bluuebunny/crossref_metadata_2025 huggingface dataset:
Bleeding risks with frailty and multimorbidity in patients with atrial fibrillation. A nationwide analysis of 1.4 million subjects
Authors: Fauchier L , Bisson A , Bodin A , Herbert J , Clementy N , Pierre B , Angoulvant D , Hanon O , Babuty D , Lip G
Published: November 2020

Background

Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (>75 yo).

Results

Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p<0.001). The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). In elderly patients (n=853,833), the c-statistics were all lower than in the whole population and were lower for the 4 scores than for the CCI and CFI scores (0.463, 0.473, 0.443, 0.445, 0.622 and 0.620 for HAS-BLED, ATRIA, ORBIT, HEMORR2HAGES, CCI and CFI, respectively).

Conclusion

Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF.

Funding Acknowledgement

Type of funding source: None
Cross sectional analytic study of the relationship between age and the distance from His bundle to slow pathway in atrioventricular nodal reentrant tachycardia (AVNRT) patients using 3D mapping
Authors: Srisakvarakul C , Boonyapisit W , Sriprom C
Published: November 2020

Background and objective

The incidence of atrioventricular nodal reentrant tachycardia (AVNRT) in elderly patients has increased due to an increased in life expectancy of the general population. Slow pathway (SPs) ablation is considered the treatment of choice for patients with AVNRT. This study is interested in the relationship of the distance from SPs to His bundle electrogram (HBEs) in various age groups because understanding of anatomy clearly could guide treatment patients by using radiofrequency ablation to be easier and safer.

Design and methods

A cross-sectional study was analyzed in patients diagnosed with AVNRT and underwent SPs ablation using EnSite NavX mapping system guided therapy. The distance from SPs to the lowest HBEs recorded was measured. Relationship between distance from SPs to HBEs and age was analyzed by Pearson correlation.

Results

A total 68 adults diagnosed with AVNRT (27.9% males, mean age 52.43 years old) were included. The mean distance from SPs to HBEs is shorter in the group older than or equal to 60 years old (n=24, mean age 70.70 years old) compared to the group younger than 60 years old (n=44, mean age 42.45 years old) (13.77 vs. 17.73 millimeter, p=0.024). Average fluoroscopy time was greater in the older group compared to the younger group (24.43 vs. 16.52 minutes, p=0.002) while the procedure time in both groups was not different (105.1 vs. 85.48 minutes, p=0.09). The distance from SPs to HBEs was negative correlation with age with the coefficient of −0.392 (p<0.001). When dividing the age group into three age groups, the group that younger than 40 years old (n=15, mean age 29.73 years old), 40 to 60 years old (n=29, mean age 49.03) and older than 60 years old (n=24, mean 70.70 age), the average distance from SPs to HBEs was 20.77, 16.15 and 13.77 millimeter respectively. The mean distance from SPs to HBEs in the group younger than 40 years old is significant statistically different to the group that is older than 60 years old (p=0.006). Slow pathway ablation was successful in all patients in this study except for one patient who was 72 years old because frequent transient atrioventricular block occurred during ablation.

Conclusion

Distance from SPs to HBEs was negative correlation with age by measuring with 3-dimentional mapping.

Distance from SPs to HBEs in each groups

Funding Acknowledgement

Type of funding source: None
The relationship between left ventricular outflow tract gradient and sudden cardiac death in childhood hypertrophic cardiomyopathy
Authors: Norrish G , Ding T , Field E , O'Mahony C , Elliott P.M , Omar R , Kaski J.P
Published: November 2020

Background

The most common mode of death in childhood hypertrophic cardiomyopathy (HCM) is sudden cardiac death (SCD). Left ventricular outflow tract obstruction (LVOTO) is an established risk factor for SCD in adults with the disease. In contrast, the prognostic implications of LVOTO in childhood disease is unclear, with recent studies suggesting that it may have an inverse relationship with the risk of SCD.

Purpose

The aim of this study was to explore the role of LVOTO and the risk of SCD in childhood HCM.

Methods

A multi-centre, retrospective, longitudinal cohort of 871 children (diagnosed with HCM <16 years of age) was used to explore the relationship between SCD and LVOTO (LVOT gradient ≥30mmHg).

Results

189 patients (23%) had LVOTO, which was mild (30–50mmHg), moderate (50–100mmHg) or severe (>100mmHg) in 58 (6.7%), 98 (11.3%) and 33 (3.8%), respectively. The risk of SCD showed an inverse relation to LVOT gradient severity compared to those with no obstruction: mild HR 1.75 (95% CI 0.89–3.44), moderate HR 1.04 (95% 0.55–1.98), and severe HR 0.7 (0.36–1.35) [figure].On univariable analysis [table] LVOTO was associated with heart failure symptoms (NYHA>1) [p <0.001], maximal wall thickness (MWT) [p <0.001], left atrial (LA) diameter [p <0.001], and future myectomy occurring during follow up [p <0.001]. The inverse relationship observed was not altered by the presence or absence of other traditional risk factors.

Conclusions

LVOTO appears to have a complex relationship with the risk of SCD in childhood HCM, with multiple contributing factors. The pathophysiological mechanisms behind this observation need further exploration, which may be limited by low patient numbers

Cummulative incidence of SCD by LVOTO

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation
Clinical aspects of pediatric Brugada syndrome
Authors: Imamura T , Makiyama T , Huang H , Aizawa T , Gao J , Kashiwa A , Wuriyanghai Y , Yamamoto Y , Kohjitani Y , Kato K , Ohno S , Sumitomo N , Horie M
Published: November 2020

Introduction

Brugada syndrome (BrS) is an inherited arrhythmia characterized by a coved-type ST elevation and sudden death, especially in middle-aged males and more common in Asia. Mutations in SCN5A are detected in 15–20% and reported to be associated with poor prognosis. Among children, BrS is rare and the risk factors in pediatric BrS are unknown, especially in Asian population.

Purpose

The purpose of this study is to elucidate the risk factors for fatal arrhythmic events in Japanese pediatric patients with BrS.

Methods

We enrolled 52 Japanese children with BrS younger than 20 years, and performed genetic analysis and collected the clinical information.

Results

The mean age of initial symptoms was 10.7±5.5 years, and the mean follow-up period was 3.9±5.5 years. Ninety percent of patients were probands. No subjective symptom was confirmed in 28 of the patients, but aborted cardiac arrest (ACA) in 4, ventricular tachycardia in 4, ventricular fibrillation in 1, and syncope in 11. We identified mutations in SCN5A in 63%. There was no significant gender difference in ≤10 years, but a significant male predominance appeared in >10 years. And no gender difference was confirmed in the incidence of severe cardiac events in ≤10 years.

Conclusion

No gender difference was confirmed in ≤10 years in this study about Asian children. And being girls did not reduce the risk in ≤10 years. The frequency of SCN5A mutations was higher than adults, but decreased from childhood (68%) to adolescence (59%). In BrS, genetical and environmental factors may be more effective in childhood and adulthood, respectively.

Funding Acknowledgement

Type of funding source: None
Atenolol is not effective in reducing ventricular arrhythmia severity on exercise stress test in patients with catecholaminergic polymorphic ventricular tachycardia
Authors: Peltenburg P , Lieve K.V.V , Van Der Werf C , Wilde A.A.M , Brugada R , Till J , Ackerman M.J , Probst V , Haugaa K , Swan H , Kammeraad J.A.E , Horie M , Sanatani S , Schwartz P , Leenhardt A
Published: November 2020

Patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) are at risk for malignant ventricular arrhythmias during exercise and emotions which may lead to sudden cardiac death. Beta-blockers (BB) are the mainstay of therapy in patients with CPVT, but studies comparing the efficacy of different types of BB are scarce. Our objective was to determine the efficacy of different types of BB in reducing the ventricular arrhythmia (VA) severity on exercise stress test (EST) in patients with CPVT.

Data was derived from the International CPVT Registry, a large retrospective cohort study. We included patients who had an EST before (pre-EST) and after start of BB (post-EST). We divided the cohort into five groups based on the first prescribed BB and compared pre-EST and post-EST.

We included 428 patients (median age 18.5 [11.7–39.6] years, 240 (56.%) female), 155 (36.2%) probands) of whom 38 (8.9%) used atenolol, 131 (30.6%) bisoprolol, 82 (19.2%) metoprolol, 124 (29.0%) nadolol and 53 (12.4%) propranolol. Sex and history of aborted cardiac arrest were similar in all groups. The age at start of BB differed (p<0,001): patients using bisoprolol were oldest (35.0 [15.7–35.3]) while patients using propranolol were youngest (12.3 [8.8–24.9]). Median daily BB dose in mg/kg was: 1.0 [0.8–2.3] for atenolol, 0.06 [0.05–0.10] for bisoprolol, 0.9 [0.6–1.5] for metoprolol, 1.1 [0.9–1.6] for nadolol and 1.5 [1.1–2.8] for propranolol. Resting heart rate on pre-EST and post-EST was similar in all groups. Patients using metoprolol had a significantly higher maximum heart rate post-EST compared to nadolol and propranolol (161±18 vs 136±19 and 130±22 bpm, p=0,002 and p=0,001, respectively). The VA severity decreased significantly after BB (147 (37.9%) (non-sustained) ventricular tachycardia ((NS)VT) and 120 (30.9%) no or isolated ventricular premature beat (iVPB) pre-EST vs 46 (11.4%) (NS)VT and 184 (45.7%) iVPB post-EST, p<0,001). Examining the different groups, the VA severity decreased significantly after BB in all but atenolol (13 (40.6%) (NS)VT and 8 (25.0%) iVPB pre-EST vs 9 (25.0%) (NS)VT and 15 (41.7%) iVPB post-EST, p=0,103).

Based on these results we conclude that all beta-blockers except atenolol are effective in reducing the VA severity on EST in patients with CPVT.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): E-Rare Joint Transnational Call for Proposals 2015 “Improving Diagnosis and Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia: Integrating Clinical and Basic Science”
Comparison of electrical characteristics between atrial and ventricular side His-bundle pacing in bradycardia patients
Authors: Liu X , Gu M , Hu Y.R , Hua W , Zhang S
Published: November 2020

Background

His-bundle pacing (HBP) is recognized as the most physiological way of pacing but with less study focused on electrical characteristics in different site.

Purpose

We aimed to evaluate the differences of pacing and echocardiographic parameters between atrial and ventricular side His-bundle pacing.

Methods

Patients who successfully underwent HBP implantation from September 2018 to August 2019 were retrospectively analyzed. All patients were assigned to atrial-side HBP (aHBP) group or ventricular-side HBP (vHBP) group according to the location of the His-bundle pacing lead, which was confirmed by two methods including postoperative echocardiography and visualization of tricuspid valve annulus (TVA). The pacing and echocardiographic parameters were compared between two groups during the procedure and at 3-month follow-up.

Results

A total of 71 bradycardia patients who successfully underwent HBP implantation and confirmed lead position were included. Among them, twenty-seven were assigned to aHBP group and the other 44 were assigned to vHBP group with no significant differences in baseline clinical characteristics between two groups. During the procedure, the proportion of selective HBP was significantly higher (77.8% vs. 11.4%; P<0.01) and the intra-procedural HV intervals was significantly longer (50.85±6.53 ms vs. 42.95±6.02 ms, P<0.01) in aHBP group than in vHBP group. The capture threshold in vHBP group was significantly lower than in aHBP group at implantation (0.92±0.22 V/1.0ms vs. 1.05±0.26 V/1.0ms, P=0.03) and remain significantly difference after 3-month follow-up (0.98±0.23 V/1.0ms vs. 1.15±0.44 V/1.0ms, P=0.03). The R-wave amplitude was significantly higher in vHBP group than in aHBP group at implantation (5.82±2.52 mV vs. 3.74±1.81 mV, P<0.01), and these differences still persisted during follow-up (5.88±2.51 mV vs. 3.67±1.61 mV, P<0.01). During 3-month follow-up, an increase in the capture threshold >1 V/1.0ms was seen in 2 cases in aHBP group while all patients remained stable in vHBP group. One patient developed a pocket hematoma in aHBP group compared to none in vHBP group. None of deterioration of tricuspid regurgitation and other procedure-related complications were observed during 3-month follow-up.

Conclusions

Ventricular side His-bundle pacing can achieve favourable pacing parameters including a lower pacing threshold and a higher R-wave amplitude than atrial side His-bundle pacing, which may be an ideal pacing strategy for patients in need of ventricular pacing.

Funding Acknowledgement

Type of funding source: None
Usefulness of lead delivery catheter system for true right ventricular septal pacing
Authors: Miyajima K , Urushida T , Ito K , Kin F , Okazaki A , Takashima Y , Watanabe T , Kawaguchi Y , Wakabayashi Y , Naruse Y , Maekawa Y
Published: November 2020

Background

Right ventricular (RV) septal pacing is often selected to preserve a more physiologic ventricular activation. But the pacing leads are not always located in true septal wall, rather in hinge or free wall in some cases with the conventional stylet-guided lead implantation. In recent years, new guiding catheter systems has attracted attention as a solution to that problem.

Objective

The aim of this study is to investigate that true ventricular sepal pacing can be achieved by use of the new guiding catheter system for pacing lead.

Methods

We enrolled 198 patients who underwent RV septal lead implantation and computed tomography (CT) after pacemaker implantation. 16 cases were used delivery catheter (Delivery), and 182 cases were used stylet for targeting ventricular septum (Conventional). We analyzed the lead locations with CT, and evaluated capture thresholds, R-wave amplitudes, lead impedances and 12-lead electrocardiogram findings one month after implantation.

Results

All cases of delivery catheter group had true septal lead positions (Delivery; 100% vs Conventional; 44%, p<0.01). Capture thresholds and lead impedances had not significant differences between between two groups (0.65±0.15V vs 0.60±0.15V, p=0.21, 570±95Ω vs 595±107Ω, p=0.39, respectively). R-wave amplitudes were significantly higher in delivery catheter group (13.0±4.8mV vs 10±4.6mV, p<0.01). Paced QRS durations were shorter in delivery catheter group (128±16ms vs 150±21ms, p<0.01).

Conclusions

The delivery catheter system designated for pacing lead can contribute to select the true ventricular septal sites and to attain the more physiologic ventricular activation.

Funding Acknowledgement

Type of funding source: None
Leadless pacemaker implant in patients with a history of open heart surgery: experience with the Micra transcatheter pacemaker
Authors: Garweg C , Iacopino S , El-Chami M.F , Veltmann C , Clementy N , Grubman E , Johansen J.B , Knops R , Schalij M.J , Piccini J.P , Soejima K , Stromberg K , Fagan D.H , Roberts P.R
Published: November 2020

Background

The Micra transcatheter pacemaker has demonstrated a favorable safety and efficacy profile relative to transvenous pacing. Patients with a history of open heart surgery have a higher risk of complications with transvenous pacemakers during follow-up. The experience with leadless pacemakers among a large cohort of patients with a history of open heart surgery has not been reported.

Objective

To report outcomes in patients with a history of open heart surgery undergoing Micra implant.

Methods

Patients undergoing Micra implant from the Micra Transcatheter Pacing Post-Approval Registry (PAR) were included in the analysis. Baseline and procedural characteristics, major complications, and electrical performance were compared among patients with vs. without history of cardiac surgery.

Results

A total of 331 out of 1815 (18.2%) patients had a history of open heart surgery, underwent Micra implant, and were followed for 19.4±10.4 months. The mean age was 74.6±13.5 years, 40% were female. The most common cardiac surgery was aortic valve surgery (71%) followed by mitral valve surgery (39%). Patients with prior open-heart surgery were more likely to have contraindications to transvenous pacing, were more likely to be on oral anticoagulants, and had more co-morbidities including atrial fibrillation, heart failure, and coronary artery disease (all p<0.005). Implantation was successful in 327 of 331 patients (98.8%) with a median procedure time of 29 minutes. Mean pacing capture thresholds (PCTs) at implant were 0.66±0.51V and remained stable through follow-up. There were 11 major complications in 10 cardiac surgery patients, with no device or procedure-related infections reported. The major complication rate was 3.1% (Figure) and was not significantly different than that of patients without a history of open heart surgery (HR: 0.85, P=0.640). There was 1 cardiac perforation (with no intervention required) in the open heart surgery group (0.3%) and there were 14 cardiac perforations (0.94%, P=0.332) in the non-open heart surgery group of which 10 required intervention.

Conclusion

The Micra transcatheter pacemaker can be safely implanted in patients with a history of open heart surgery, with a similar long-term safety profile to patients without a history of open heart surgery. Importantly, there were no device-related infections reported in either group.

Risk of Major Complication

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic, Inc.
A randomised, double-blind, controlled trial on patients undergoing cardiac implantable electronic device implantation with local anaesthesia and sedation with and without pectoral nerve block
Authors: Wang Y , Chandran R , Woon K.L , Chang S.S , Quek H.Y , Singh P.A , Tan P.T , Yeo C , Wong K , Tong K.L , Tan V.H
Published: November 2020

Background

Implantation of cardiac implantable electronic devices (CIED) are generally carried out with local anaesthesia (LA) and sedation. However, peri-procedural hypoxaemia and hypotension are well recognised complications of this technique primarily due to sedation effect. The pectoral nerves block (PECs) targets the lateral and median pectoral nerves at interfascial plane between pectoralis major and minor muscles. This technique potentially lower sedation usage and therefore lower sedation-related complications. There is, however, no randomised study to date comparing CIED procedure with and without PECs block.

Methods

We randomly assigned 64 patients undergoing CIED implantation procedure with LA (subcutaneous lignocaine 1%) and sedation (intermittent bolus of intravenous midazolam and fentanyl according to pain score) with (32 patients) and without (32 patients) PECs. Those received PECs with be given 10 mls of 0.25% ropivacaine. Primary endpoint was total dose of sedation used. Secondary endpoints were perioperative incidence of hypoxia, hypotension and hypopnea, perioperative pain scores, proceduralists' and patients' satisfaction scores.

Results

Overall, majority were male (64.1%), mean age of 67.9±10.7 years, mean BMI of 25.7±5.5 kg/m2 and mean lignocaine 1% dosage was 15.3±3.1mL. Compare to those with and without PECs, there was no significant difference in baseline characteristics. The mean fentanyl [25.3±25.0 mcg (95% CI: 16.3–34.3) vs 32.2±26.7 mcg (95% CI: 22.6–41.8), p=0.29] and midazolam dosage [0.7±0.7mg (95% CI: 0.4–0.9) vs 0.8±0.8 (95% CI: 0.6±1.1), p=0.36] were trended lower in PECs compared to without PECs. PECs group had lower pain score at recovery (OR: 1.7, 95% CI: 0.38–7.93, p=0.48). Proceduralists' and patients' satisfaction score were trended higher in PECs compare to non-PECs group. There was no hypoxia, hypotension or hypopnea in both groups.

Conclusion

Patients underwent CIEDs implantation procedure with PECs received lower sedation dosage and lower periprocedure pain score as compare to non-PECs group. Satisfaction score for both proceduralists and patients were trended higher in PECs group compare to non-PECs group.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Changi General Hospital Research Grant
Pacemakers capable of monitoring sleep-disordered breathing: impact on sleep apnea detection in real life
Authors: Bidegain N , Garcia R , Degand B , Christiaens L , Bouleti C , Le Gal F , Tavernier M
Published: November 2020

Background

Pacemaker recipients are at high-risk of sleep apnea (SA). New generation of pacemakers allow day by day, sleep-disordered breathing (SDB) monitoring. These devices measure variations in thoracic impedance and can detect apnea and hypopnea.

Purpose

The aim was To compare the rate of SA detection in patients implanted with and without pacemaker capable of monitoring (SDB).

Methods

This retrospective study included all consecutive patients implanted with a pacemaker between 2013 and 2016 at Poitiers university hospital. Pacemaker recipients allowing SDB monitoring (SDB monitoring group) and pacemaker recipients not allowing SDB monitoring (control group) were compared in terms of SA diagnosis, continuous positive airway pressure (CPAP) therapy initiation, newly AF discovered and stroke occurrence.

Results

Among the 1442 patients included (mean age 79 years, 39% of women, BMI = 27 kg/m2). 653 were in the SDB monitoring group and 789 in the control group. The 2 groups were not different in terms of age, body mass index, cardiovascular risk factor, cardiac function, and medication. Indication for cardiac pacing was atrioventricular block and sinus dysfunction in 56% and 23% of patients respectively. Mean follow-up was 24.7 months. 40 patients (7.5%) have been diagnosed with SA in the SDB monitoring group and 18 (2.7%) in the control group (p<0.001). CPAP therapy was initiated in 33 (5%) patients in SDB monitoring group and in 16 (2%) patients for the control group (p=0.01). The rate of newly diagnosed AF was 15% in SDB monitoring and 7% in control group (p<0.001). The incidence of stroke was 16 (2.4%) in the SDB monitoring group and 18 (3.4%) in the control group (P=0.45).

Conclusion

In real life conditions, pacemakers capable of monitoring SDB improve the diagnosis of SA and CPAP therapy rate.

Monitoring of sleep apnea after at least

Funding Acknowledgement

Type of funding source: None
Valsartan improves left ventricle contractility and prevents its remodeling in patients with dual chamber pacemaker
Authors: Tomasik A , Radzik E , Pigon K , Banasik G , Jachec W , Romuk E , Birkner E , Kawecki D , Wojciechowska C , Kalarus Z , Gasior M , Nowalany-Kozielska E
Published: November 2020

Introduction

Permanent right ventricle pacing leads to left ventricle dyssynchrony, systolic dysfunction, remodeling, and symptomatic heart failure in the long run. Valsartan is well known for its preventive anti-remodeling function in the post infarction heart remodeling.

Objectives

To assess the effect of valsartan on left ventricle contractility, measured as global longitudinal stain, and its remodeling in patients with second and third degree atrioventricular block with first-time implantation of dual chamber pacemaker.

Methods

This was a randomized, double-blind, placebo controlled single center study. One hundred eligible patients were assigned in a 1:1:1 fashion to receive placebo, valsartan 80mg or 160mg once daily, respectively. Echocardiographic assessment of left ventricle geometry, its systolic and diastolic function was performed at baseline and at twelve months. Global longitudinal strain (GLS) was measured off-line with EchoPac software. One patient from placebo group suffered stroke. We present the baseline date for 100 enrolled patients and follow-up data for 88 patients who have completed the study. Data in valsartan arms are pooled in one group.

Results

Results are presented in table. Data are presented as mean and standard deviation.

Valsartan alleviates diastolic dysfunction, left ventricle dilation and protects from loss of systolic function.

Conclusion

Valsartan has protective effect of left ventricle contractile function and remodeling. It may be useful in prevention of pacing induced heart failure. (ClinicalTrials Identifier NCT01805804)

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Medical University of Silesia
The back-up lead in his bundle pacing: evolution over the years
Authors: Zanon F , Marcantoni L , Pastore G , Baracca E , Picariello C , Lanza D , Maddalozzo A , Roncon L
Published: November 2020

Background

His bundle pacing (HBP) can be affected by high thresholds and low sensing. Thus, in selected patients including a back-up lead is advisable.

Objective

Single-centre retrospective analysis of a large HBP experience, focusing on the back-up lead utilization over the years.

Methods

677 pts (76±8 years; 433 males) were implanted with HBP from 2004 to 2019 July. The pts received S-HBP (67%) or NS-HBP by the 3830 lead. The pacing indications were AV block 54%, sinus node disease 17%, slow atrial fibrillation 23%, heart failure 6%. Ischemic cardiopathy was found in 26%; hypertension in 83%, diabetes in28% pts. Baseline QRS duration was 123±32 ms and EF 56±12%.

Results

266 (39%) pts received the back-up lead. In sinus rhythm we implanted 3-chamber PM (His lead:LV port; VV delay 80 ms: His pulses and apical pacing during the refractory period). 30 pts (11%) received a particular type of 3-chamber PM which provides back-up pacing only if His capture fails, thus saving energy. In atrial fibrillation 2-chamber PM was implanted (His lead: atrial port, DVI). We recorded a significant decrease of back-up lead use over the years, strictly related to operators/centre experience (>70% during the first years, nearly 10% during the last year). The C315 fixed curve sheath, strongly contributed to the rapid reduction of back-up lead use thanks to better lead fixation and stability.

Conclusion

The back-up lead utilization is progressively decreasing. It is strictly related to the operator/centre experience. The presence of the back-up lead could strengthen the Hisian pacing reliability, potentially impacting pacing indication even in advanced conduction disturbances and saving device longevity.

Funding Acknowledgement

Type of funding source: None
The mortality outcome after implantable cardioverter-defibrillator implantation according to indication for implantation and underlying etiology: a Nationwide Cohort study
Authors: Yang P.S , Kang Y , Park H.D , Sung J.H , Joung B
Published: November 2020

Background and objectives

There are few nationwide data about the mortality outcome after implantable cardioverter-defibrillator (ICD) implantation. The aim of this study was to evaluate the mortality outcome after ICD implantation according to indication for implantation (primary vs. secondary prevention) and underlying etiology (non-ischemic vs. ischemic heart disease) with a nationwide cohort data of Korea.

Methods

During the period from January 1, 2008 to December 31, 2017, 3,558 patients (mean age, 67.7±11.4 years) with newly-implanted ICD who were aged 19 years or older were identified by 50-percents random sampling from the Korean National Health Insurance Service database.

Results

Patients with primary and secondary prevention ICD were 1,097 (30.8%) and 2,461 (69.2%), respectively. Patients with non-ischemic and ischemic heart disease were 2,487 (69.9%) and 1,071 (30.1%), respectively. Overall all-cause mortality was 20.4% during the follow-up period (mean 24 months). The mortality rates in patients with primary and secondary prevention ICD were 26.2% and 17.9%, respectively. The mortality rates in patients with non-ischemic and ischemic heart disease were 16.1% and 30.4%, respectively. In Kaplan-Meier estimates of survival according to both indication for implantation and underlying etiology, the best prognostic group was patients with secondary prevention ICD and having non-ischemic etiology. The worst prognostic group was patients with primary prevention ICD and having ischemic etiology. The survival probability was below 50% (45.2%) 5 years after ICD implantation in patients with primary prevention ICD and having ischemic etiology.

Conclusions

In Korean nationwide data, patients with primary prevention ICD and having ischemic etiology show the worst prognosis. About half of these patients died of any cause within five years.

Funding Acknowledgement

Type of funding source: None
Echocardiographic assessment of CRT candidates. Does it work equally well in intermediate QRS duration?
Authors: Duchenne J , Cvijic M , Aalen J.M , Larsen C.K , Galli E , Penicka M , Fehske W , Hopp E , Stankovic I , Smiseth O.A , Donal E , Voigt J.U
Published: November 2020

Background

The presence of mechanical dyssynchrony – such as apical rocking (ApRock) and septal flash (SF) – on echocardiography is associated with favourable outcome after cardiac resynchronization therapy (CRT). Myocardial scar on the other hand, has a considerable negative impact on CRT response. There is growing evidence that a visual echocardiographic assessment of mechanical dyssynchrony by ApRock, SF and scar predicts CRT response. Little is known however if this works equally well in patients with intermediate QRS duration (120–150ms), where guideline recommendation for CRT is weaker.

Methods

A total of 400 unselected patients referred for CRT, who fulfil the contemporary guidelines, were enrolled in this multicentre study. Echocardiographic images were visually assessed before CRT implantation, focussing on the presence of ApRock, SF and location and extent of scar segments in the left ventricle (LV), resulting in a CRT response prediction (i.e. Reader Interpretation). Readers were blinded to all patient information other than ischaemic aetiology of heart failure. CRT response was defined as ≥15% reduction in LV end-systolic volume on echocardiography, on average 15 months after device implantation.

Results

Overall, 321 (80%) patients had a left bundle branch block (LBBB), with an average QRS duration of 166±25ms. Ischemic aetiology of heart failure was found in 131 (33%) patients. Before CRT, ApRock and SF were present in 254 (64%) and 244 (61%) patients, respectively. ApRock and SF alone predicted CRT response with an area under the curve (AUC) of 0.79 (95% CI: 0.74–0.84) and 0.78 (95% CI: 0.73–0.83) (Figure A), while the echocardiographic Reader Interpretation had an AUC of 0.85 (95% CI: 0.81–0.89), with a sensitivity of 89% and a specificity of 82% for the prediction of CRT response (Figure B) (p<0.0001 vs. ApRock and SF alone). A total of 92 patients had a QRS duration of 120–150ms, and 48 of them responded to CRT. In these patients, the AUC of Reader Interpretation was comparable to that of the entire study cohort [0.83 (95% CI: 0.75–0.92)], as was sensitivity and specificity (90% and 79%, respectively, p=0.717 vs. the AUC of the entire cohort) (Figure C).

Conclusions

A visual assessment of LV function, by means of mechanical dyssynchrony and scar, has an excellent predictive value for CRT response, and requires only apical echocardiographic images. Responders were identified equally well in the challenging subgroup of patients with a QRS duration of 120–150 ms.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): KU Leuven
Essential role of PET-CT in the management of patients with severe infectious complication CIEDS: multicentre study
Authors: Taborsky M , Latal J , Fedorco M , Skala T , Novak M , Kozak M , Krivan L , Gloger V , Schee A
Published: November 2020

Background

With the increasing number of implanted cardiac pacemakers, ICDs and CRTs, the number of serious infectious complications of these procedures increases significantly, especially in the longer term from the primary implantation. The systematic solution is in most cases endovasal extraction of these systems.

Methods

In a multicenter, prospective, randomized, controlled trial evaluating the benefit of CIEDS infection management in 277 patients, a conventional approach using blood cultures, microbiological examinations and TEE versus innovative management of these patients using PET-CT was compared. PET-CT examination is able to differentiate very well the infection of the implant pocket (Figure A) against bacterial endocarditis (Figure B). Thanks to this, it is possible to individualize the management of the patient and to shorten the dates of hospitalization, resp. time to re-implantation of the new system in patients without the presence of bacterial endocarditis.

Results

The results of the multicentre study are summarized in Table 1.

Conclusions

A comprehensive examination of patients with CDRIE using PET-CT significantly shortens hospital stay, time of antibiotic therapy and, as a consequence, leads to a lower incidence of serious complications of extraction procedures.

PET-CT in CDRIE patients

Funding Acknowledgement

Type of funding source: None
AIM2-driven inflammasome activation in chronic heart failure
Authors: Ruppert M , Onodi Z.S , Leszek P , Toth V.E , Koncsos G , Merkely B , Ferdinandy P , Radovits T , Varga Z
Published: November 2020

Background

Inflammation and cytokine release have been implicated in the pathogenesis of chronic heart failure (CHF). Of particular interest, Canakinumab, a monoclonal antibody against interleukin-1b (IL-1β), had provided benefit against cardiovascular events, suggesting that blockade of IL-1β secretion and signaling might be a promising new therapeutic target. Although, recent studies have provided evidence that inflammasome activation is the main contributor to IL-1β maturation, the role of inflammasome activation in CHF remains unknown.

Objective

Therefore, we aimed to assess inflammasome activation in myocardial samples from end-stage failing hearts.

Methods

Inflammasome activation was assessed by immunoblotting in left ventricular myocardial specimens harvested from patients with end-stage CHF. Furthermore, immunoblot measurements were also performed on translational animal models of CHF (e.g. rat models of permanent coronary artery ligation and transverse aortic constriction). Left ventricular monocyte and macrophage infiltration was detected by immunohistochemistry. To investigate the molecular background of inflammasome activation, a series of cell culture experiments were performed on AC16 human cardiomyocytes and THP-1 human monocytic cell lines.

Results

Out of the 4 major inflammasome sensors tested, expression of the inflammasome protein absent in melanoma 2 (AIM2) and NLR family CARD domain-containing protein 4 (NLRC4) increased in human CHF while the NLRP1 and NLRP3 (NLR family, pyrin domain containing 1 and 3) inflammasome showed no change. A similar expression pattern in AIM2 and NLRC4 was also noted in CHF animal models. Furthermore, robust infiltration of Iba1+ monocytes/macrophages was observed in human failing hearts as well as in different animal models of CHF. In vitro AIM2 inflammasome activation, as induced by transfection with double-stranded DNA [poly(deoxyadenylic-deoxythymidylic)] was reduced significantly by the pharmacological blockade of pannexin-1 channels.

Conclusions

AIM2 and NLRC4 inflammasome activation might contribute to chronic inflammation in CHF. Our findings suggest that pannexin-1 channels might be a promising novel target to reduce inflammasome activation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017
Shear wave elastography by high frame rate echocardiography can detect diffuse myocardial fibrosis after heart transplantation
Authors: Petrescu A , Bezy S , Cvijic M , Santos P , Duchenne J , Orlowska M , Van Keer J , Von Bardeleben S , Droogne W , Bogaert J , Van Cleemput J , D'hooge J , Voigt J.-U
Published: November 2020

Background

Myocardial fibrosis is fundamental in the development of cardiac failure, regardless of ethiology. In both animal models and humans it has been shown that diffuse myocardial fibrosis (DMF) contributes to functional impairment, especially to increased passive myocardial stiffness, which is an important pathophysiological determinant of left ventricular diastolic dysfunction. Histological examination is the gold standard for myocardial fibrosis quantification, however, it requires endomyocardial biopsies which are invasive and not without risk. Echocardiographic shear wave (SW) elastography, based on high frame rate imaging, is an emerging approach for measuring myocardial stiffness in vivo. Natural SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure (MVC) and their propagation velocity is directly related to myocardial stiffness, thus providing an opportunity to assess myocardial stiffness at end-diastole.

Purpose

The aim was to investigate if propagation velocities of natural SWs can be used to detect diffuse myocardial fibrosis in a cohort of heart transplant recipients.

Methods

We prospectively enrolled 22 patients (10.3±6.3 years after HTx) that underwent CMR during their annual check-up. We performed SW elastography in parasternal long axis views of the left ventricle using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2–5AC) at 1100±250 frames per second. The SW propagation velocities at MVC were measured in the basal LV septum. Native T1 and extracellular volume (ECV) were measured at the same segment to evaluate DMF. A cut-off value for native T1 of 1040 ms and for ECV of 29% was used to define DMF in our cohort.

Results

We found good correlations between SW velocities and both myocardial T1 (r=0.80, p<0.0001, Figure A) and ECV (r=0.64, p=0.003, Figure B) measured with CMR. Further, we derived reference thresholds of natural SW velocities to identify DMF in HTx patients. The optimal cut-off value of SW velocity to identify patients with nativT1>1040 ms was 4.84 m/s (AUC 0.81, sensitivity 82%, specificity 82%, Figure C). To identify patients with ECV>0.29 the cut-off value of SW velocity was 4.74 m/s (AUC 0.74, sensitivity 73%, specificity 78%, Figure D).

Conclusions

End-diastolic shear wave propagation velocities, as measure of myocardial stiffness, showed a good correlation with CMR defined diffuse myocardial injury. Values higher than 4.74 m/s could identify diffuse myocardial injury in HTX patients with a good sensitivity and good specificity. These findings thus suggest that shear wave elastography has the potential to become a valuable non-invasive method for the detection of diffuse myocardial fibrosis.

Funding Acknowledgement

Type of funding source: None
Weight loss early after discharge predicts the risk of rehospitalization in non-obese patients with heart failure preserved ejection fraction
Authors: Kamisaka K , Kamiya K , Iwatsu K , Iritani N , Iida Y , Adachi T , Yamada S
Published: November 2020

Background

Weight loss (WL) has been considered as a prognostic factor in heart failure with reduced ejection fraction (HFrEF). However, the prognosis and associated factors of WL in heart failure with preserved ejection fraction (HFpEF) have remained unclear.

Purpose

This study aimed to examine the prevalence, prognosis, and clinical characteristics of worse prognosis based on the identified WL after discharge in HFpEF.

Methods

The study was conducted as a part of a multicenter cohort study (Flagship). The cohort study enrolled ambulatory HF who hospitalized due to acute HF or exacerbation of chronic HF. Patients with severe cognitive, psychological disorders or readmitted within 6-month after discharge were excluded in the study. WL was defined as ≥5% weight loss in 6-month after discharge and HFpEF was defined as left ventricular ejection fraction (LVEF) ≥50% at discharge. Age, gender, etiology, prior HF hospitalization, New York Heart Association (NYHA) class, brain natriuretic peptide (BNP) or N-terminal-proBNP (NT-proBNP), anemia (hemoglobin; male <13g/dL, female <12g/dL), serum albumin, Geriatric Depression Scale, hand grip strength and comorbidities were collected at discharge. Patients were stratified according to their body mass index (BMI) at discharge as non-obese (BMI <25) or obese (BMI ≥25). We analyzed the association between WL and HF rehospitalization from 6 month to 2 years after discharge using Kaplan-Meier curve analysis and Cox regression analysis adjusted for age and gender, and clinical characteristics associated to worse prognosis in WL using logistic regression analysis adjusted for potential confounders in HFpEF.

Results

A total of 619 patients with HFpEF were included in the analysis. The prevalence of WL was 12.9% in 482 non-obese and 15.3% in 137 obese patients. During 2 years, 72 patients were readmitted for HF (non-obese: 48, obese: 24). WL in non-obese independently associated with poor prognosis (hazard ratio: 2.2: 95% confidence interval: 1.13–4.25) after adjustment for age and sex, while WL in obese patients did not. Logistic regression analysis chose age (odds ratio 1.02 per 1 year; 1.00–1.05), anemia (2.14; 1.32–3.48), and BNP ≥200pg/mL or NT-proBNP ≥900pg/mL (1.83; 1.18–2.86) as independent associated factors for worse prognosis of WL in non-obese patients.

Conclusion

In HFpEF, WL in early after discharge in non-obese elderly patients may be a prognostic indicator for HF rehospitalization. HF management including WL prevention along with controlling anemia is likely to improve prognosis in this population.

Kaplan Meier survival curves

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): A Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science
Correlation between procollagen propeptides end echocardiography indices in patients with ST segment elevation myocardial infarction (STEMI)
Authors: Osokina A , Karetnikova V.N , Polikutina O.M , Slepynina Y.S , Artemova T.P , Ryzhenkova S.A , Chukalenko D.A , Barbarash O.L
Published: November 2020

Objective

To investigate the correlation between Procollagen I C-Terminal Propeptide (PICP), Procollagen III N-Terminal Propeptide (PIIINP), indices of echocardiography and anamnestic data in patients with ST segment elevation myocardial infarction (STEMI) and preserved myocardial contractility.

Materials and methods

60 men and 23 women diagnosed with STEMI were examined. Echocardiographic studies were performed using SONOS 2500 Cardiac – Vascular Ultrasound (Hewlett Packard, USA). Myocardial contractility was considered to be preserved with left ventricular ejection fraction (LVEF) ≥50%. In addition to standard indices of echocardiography, mitral flow propagation velocity (FPV) was evaluated to diagnose diastolic dysfunction. Coronary angiography was performed using INNOVA 3100 Cardiovascular Imaging System (USA). All patients, during the first twelve hours of the disease, underwent percutaneous coronary intervention (PCI) with stenting of the occluded culprit infarct-related artery. On the 1st and 12th days of hospitalization, the concentrations of PICP and PIIINP were determined for all patients by enzyme-linked immunosorbent assay (ELISA) using laboratory BCM Diagnostics kits (USA). All patients at the hospital received standard therapy.

Results

The following marker values were obtained: 1st day: PICP 609 (583; 635) ng/ml, PIIINP 26 (18.9; 34.9) ng/ml; 12th day: PICP 588 (580; 561) ng/ml, PIIINP 24.2 (18.6; 30.3) ng/ml. The following significant correlations were revealed: PICP 1st day / isovolumic contraction time – IVCT (m/s) 12th day, r=−0.68, p=0.042; PICP 1st day / Tei Index 12th day, r=−0.72, p=0.028; PICP 1st day / diastolic rigidity 12th day, r=−0.74, p=0.021; PIIINP 1st day/age, r=0.55, p=0.016; PIIINP 1st day/ body mass index (BMI), r=−0.59, p=0.009; PIIINP 1st day / E (cm/s) 1st day, r=0.72, p=0.018; PIIINP 1st day / Em /FPV 1st day, r=0.78, p=0.007; PIIINP 12th day / Em / FPV 1st day, r=0.65, p=0.041; PIIINP 12th day / E (cm/s) 1st day, r=0.67, p=0.033; PIIINP 12th day / E / Em) 12th day, r=0.70, p=0.023; PIIINP 12th day / Em/FPV 12th day, r=0.73, p=0.014.

Conclusions

The data obtained indicates the correlation between serum markers of myocardial fibrosis and the indices of echocardiography, as well as age. We conclude that, all the markers listed above, are able to represent myocardial remodeling in patients with STEMI.

Funding Acknowledgement

Type of funding source: None