bluuebunny/crossref_metadata_2025 huggingface dataset:
Characteristics and outcomes of catheter ablation of ventricular arrhythmias originating from the left ventricular summit
Authors: Sanchez Millan P J , Sanchez Moreno J M , Constan De La Revilla E , Cabrera Borrego E , Tercedor Sanchez L , Alvarez Lopez M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) of the left ventricular summit (LVS) arrhythmias is a challenging procedure due to the inherent complexity anatomy of that region. Different anatomical approaches are usually performed for mapping this area including deep intramural location. The objective of this study is to investigate the procedural outcomes of ablation of LVS arrhythmias.

Methods

Retrospective analysis of 32 consecutive patients (mean age 58±12 years old) who underwent CA of LVS arrhythmia in a single center. Baseline characteristics, procedural parameters and clinical outcomes were analyzed.

Results

All LVS arrhythmias had inferior and vertical axis (positive inferior leads with negative aVR and aVL leads). LBBB pattern was found in 25/32 (78%) and RBBB pattern in 7/32 (22%). 14/32 (44%) patients presented a "w" morphology in DI lead. 18/32 (56%) cases showed abrupt V3 transition. 13/32 (41%) patients had a previous failed ablation. Direct mapping of the intramural septum, through the septal perforator veins, was performed using a wire or a multipolar 2Fr catheter in 19 patients (59%). The earliest activation area was recorded in LCC-RCC in 13 patients (41%) followed by a septal perforator vein in 9 patients (28%). Most patients required multisite sequential ablation for achieving success (20 patients, 62%). Acute arrhythmia suppression was achieved in 22 patients (69%) and only 1 patient presented a complication (pericardial tamponade). Late success was noted in 3 patients (9%). During a median follow up of 9,79±8,6 months, 23 patients (72%) maintained a sustained acute success (80% reduction of PVC burden at least) None of the 9 patients without sustained acute success needed to repeat ablation.

Conclusions

Ablation of LVS arrhythmias is a challenging procedure with frequent previous ablation attempts. The earliest activation area is commonly found between LCC-RCC junction and in the intramural septum. Multisite non-conventional anatomical mapping and ablation steps are required to obtain a sustained success.
A method to identify which patients will have VT substrate ablation targets prior to ablation procedure
Authors: Burg M , Anderson R D , Gonna H , Al-Shaheen A , Niri A , Shapira E , Ben-Dor A , Hayam G , Baron T , Masse S , Nanthakumar K
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dr Nanthakumar is a recipient of the Mid-career Investigator Award from the Heart & Stroke Foundation of Ontario

Background

Recent trials in ventricular tachycardia (VT) ablation suggest that early ablation could reduce VT burden. A method to predict which patients will have substrate ablation targets based on non-invasive testing prior to the procedure does not exist and could be of value in selecting ideal patients for early VT substrate ablation. Decrement-evoked potential (DeEP) mapping is used to identify VT substrate ablation targets.1 A method for predicting which patients would have DeEP targets on a pre-ablation 12-lead ECG has not yet been developed.

Objective

To develop a metric to predict the presence of physiological substrate VT ablation targets from the 12-lead ECG.

Method

22 electrophysiology (EP) lab VT cases that had undergone DeEP mapping were extracted from the CARTO® 3 system and were analysed retrospectively. For each case, DeEP was calculated by subtracting last component of the nearfield evoked response in the pacing train (S1) from the latest component of the nearfield evoked decremented response of the extra stimulus (S2). By inference, 12-lead ECG prediction was calculated by subtracting the width of the 12-lead surface ECG envelope of S1 from the width of the 12-lead ECG envelope of S2. Cases were divided into three categories:

- Cases displaying intracardiac DeEP between 0-10ms – no ablation targets

- Cases displaying intracardiac DeEP between 10-50ms – DeEP positive

- Cases displaying intracardiac DeEP >50ms – prominent DeEP present

Results

Out of the 22 cases, 8 were characterised as no ablation targets, 12 as DeEP positive, and 2 as prominent DeEP present. The 12-lead surface ECG measurement means were 3.5±4.6ms for the no ablation target group, 23.2±9.1ms for positive DeEP group, and 80.9±8.1ms for prominent DeEP group. The surface ECG decrement was significantly different P<0.0001 between the three groups. Consequently, we propose that ECG QRS widening of envelope width of 20ms or more may indicate the presence of DeEP targets during invasive mapping.

Conclusion

It may be possible to detect which patients will have substrate ablation targets based on 12-lead ECG, prior to the VT ablation procedure. Additionally, this prediction rule, based on its association with arrhythmogenic potentials, may be able to predict which ambulatory patients who have not had manifest VT, may be prone to develop VT thus help identify early VT ablation candidates. This concept should be validated in larger data sets and is ideal for training and testing using surface ECG envelopes with artificial intelligence algorithms.
Efficacy and safety of catheter ablation of VT using the QDOT Micro catheter: a propensity-matched dual-center comparison with the thermocool SmartTouch catheter
Authors: Compagnucci P , Dello Russo A , Bergonti M , Cipolletta L , Parisi Q , Volpato G , Santarelli G , Valeri Y , Carboni L , Stronati G , Guerra F , Marini M , Sarkozy A , Natale A , Casella M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation is an increasingly used treatment option for patients with recurrent ventricular tachycardia (VT) or electrical storm (ES). The QDOT Micro (QDOT) Catheter (Biosense Webster) is a novel radiofrequency ablation catheter that was found to allow rapid and effective pulmonary vein isolation among patients with atrial fibrillation. There is no published data on the safety and efficacy of catheter ablation for VT using the QDOT catheter, and few data allow a direct comparison of different technologies in this setting.

Purpose

to assess outcomes of CA for VT among patients with structural heart disease using the QDOT catheter, and compare them to those observed with the Thermocool Smarttouch (TC-ST, Biosense Webster) catheter.

Methods

we conducted a dual-center, observational, prospective study enrolling patients with structural heart disease and recurrent VT/ES undergoing catheter ablation with the QDOT catheter. For comparison, we performed a 1:1 propensity score matching to identify patients who underwent VT CA with the TC-ST catheter, using the nearest neighbor method. Propensity score was based on gender, age, etiology of structural heart disease, left ventricular ejection fraction, electrical storm, and number of previous CAs for VT. The primary efficacy outcome was freedom from recurrent VT, as assessed by implantable defibrillator (ICD) interrogation; the primary safety outcome was in-hospital complications.

Results

Forty propensity-matched patients were included in the analysis (QDOT, n=20; TC-ST, n=20); baseline clinical characteristics are resumed in Table. After a median follow-up of 7 months, survival free from any recurrent VT measured 74 (95% CI, 57-97)% and 69 (95% CI, 51-93)% in the QDOT and TC-ST groups, respectively (log-rank p=0.54, Figure A), while survival free from ICD shocks was 95 (95% CI, 86-100)% versus 84 (95% CI, 69-100)% (log-rank p=0.26, Figure B). There were no major complications in the QDOT group, while three patients (15%) in the TC-ST had a primary safety event (p=0.23; femoral pseudoaneurysm, n=1; cardiac tamponade, n=1; aortic cusp perforation, n=1).

Conclusion

In a cohort of patients with structural heart disease and recurrent VT or ES, the novel QDOT ablation catheter had similar efficacy and safety compared to the TC-ST catheter. Interestingly, no major procedural complications were observed with the QDOT catheter, suggesting that this device may be safe even in most challenging patients.
Safety and efficacy of bipolar radiofrequency catheter ablation in ventricular arrhythmias of mural vs non-mural origin
Authors: Caixal G , Waight M , Pinto A , O Neill C , Grimster A , Li A , Saba M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Bipolar radiofrequency catheter ablation (B-RFA) has shown promising results in refractory ventricular arrhythmia (VA) of septal origin and underlying non-ischemic cardiomyopathy (NICM). However, its efficacy and safety in other locations such as the free wall and papillary muscles (PM) has not yet been fully determined.

Purpose

To describe and analyse the procedural data, safety and efficacy results of B-RFA in a cohort of patients with VA of different locations and underlying substrate.

Methods

We enrolled 21 patients with recurrent VA after prior failed ablation into this study, of whom 16 patients required B-RFA for effective ablation. Seven of the patients had ventricular ectopy (VE) and 9 presented with ventricular tachycardia (VT). During B-RFA, a contact-force-sensing, saline-irrigated catheter was connected to the ablation catheter connection on the radiofrequency generator and a second ablation catheter (saline-irrigated in 6 of the cases) was connected to the ground patch terminal through a custom-made switch box. This allowed visualization of both catheters on the 3D mapping system and acquisition of electrograms from both simultaneously. Procedure data, related complications and acute and long-term outcomes during follow-up were assessed.

Results

The VA distribution was septal (31.3%, n=5), PM (31.3%, n=5), right ventricle free wall (18.8%, n=3), left ventricle (LV) free wall (12.5%, n=2) and LV summit (6.3%, n=1). Compared to septal ablation, contact force obtained during B-RFA ablation was significantly lower in PM ablation (p=0.01), as was the impedance drop (p=0.03). There were no significant differences in the number of energy applications, their mean duration, the total ablation time, the power and the temperature among locations. Acute success was achieved in 15 patients (93.6%). Long-term success, defined as no recurrence of sustained VT or less than 1% VE burden on 24-hour Holter at 12-month follow up, was achieved in 11 patients (68.8%), and another 2 patients (12.5%) had partial success. Papillary muscle VA had lower acute and long-term success (80% and 60%, respectively) after B-RFA. On the other hand, patients with NICM appeared to have superior outcomes (figure 1). No steam pops or major peri-procedural complications were observed. However, the use of a non-irrigated indifferent electrode resulted in char formation.

Conclusions

B-RFA can be used successfully and safely in NICM involving the septum and free walls but has limited use for PM arrhythmias. This could be related to a lack of catheter stability and reduced energy transfer. In addition, when using B-RFA, any catheter in the circulatory system should be irrigated.
Audit of urgent pacing therapy in nonagenarian patients and their follow up over one year
Authors: Saint-Joy V , Dagher-Hayeck Y , Bellemain-Appaix A , Frattini F , Jacq L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction and objectives

The aging of the population in the world and particularly in developed countries is changing the panorama of patients who are treated both on the socio-demographic level and on the indications for the care of elderly subjects. Antibes is the sixth region in France with the most nonagenarians. A study had already been carried out in our center on the management of coronary emergencies in people over 90 years old and this time we are interested in the management of rhythmic emergencies in the latter with a focus on permanent cardiac stimulation in emergency.

Methods

This 5-year retrospective descriptive study runs from 2016 to 2020 and analyzes the records of 156 nonagenarians hospitalized in the intensive care unit and 1322 planned visits of patients over 90 years old to the electrophysiology unit.

Results

Nonagenarians represent 16.6% of patients admitted for cardiac arrhythmias requiring intensive and / or invasive management. 65% of patients hospitalized in cardiac critical care unit (CCU) benefited from the implantation of a pacemaker, with 13% of them presenting non-severe complications related to the procedure. 2% died in the CCU. After their hospital stay 60% came for follow-up at 3 months and only 19.6% at 1 year.

Conclusion

This study highlights the need to make invasive cardiology practitioners aware of the growing proportion of this geriatric subgroup of very old patients (>90). There were no serious complications limiting the eligibility of nonagenarians. It seems necessary to develop a close collaboration of cardio-geriatricians and telecardiology in this subset of frail patients.
Autocapture algorithm behaviour in left bundle branch pacing
Authors: Sola Garcia E , Molina Lerma M , Tercedor L , Alvarez M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Autocapture algorithms allow remote monitoring of patients, reducing the need for face-to-face hospital consultations and increasing patient safety. These algorithms are widely validated in patients with conventional pacing and are not recommended in His bundle pacing, but there is no information on its behaviour in left bundle branch pacing (LBBP).

Purpose

The objective was to analyse the autocapture algorithm behaviour in LBBP and its differences with conventional pacing and manual thresholds during device first programming (acute phase), after 1-7 days (subacute phase) and 1-3 months later (chronic phase).

Methods

Prospective non-randomised single-centre comparative study. Consecutive patients with an indication for cardiac pacing were included. The implant was performed in the left bundle branch area or in the right ventricle endocardium (outflow tract or apex) at the discretion of the operator. LBBP was considered according to published criteria. Autocapture algorithm was activated in both groups whenever allowed by the device. The thresholds manual measurement was performed with the intracavitary electrogram and the surface electrocardiogram.

Results

Sixty patients were included, 40 with LBBP and 20 with conventional pacing. Baseline characteristics of patients are shown in Figure 1. The feasibility of the autocapture algorithm was more frequent in late phases, with a favourable trend toward bipolar pacing (Figure 2A). The failures in the activation of the algorithm were mainly due to the absence of adequate safety margins (90.9% in conventional pacing and 86.6% in LBBP), the rest were attributable to atrial tachyarrhythmias (9.1 and 6.7%, respectively) and electrical noise (remaining 6.7% in LBBP). In LBBP group, there were not statistically significant differences between manual and automatic thresholds except in subacute phase (unipolar) (Figure 2B), and both remained stable during follow-up (average increase of 0.46V).

Conclusions

Autocapture algorithm is feasible in LBBP, with a favourable trend toward bipolar pacing. Automatic thresholds are similar to manual in patients with LBBP, and they remain stable during follow-up.
Conduction system pacing guided by 3d-electroanatomic mapping system preserves systolic function in paediatric patients
Authors: Silvetti M S , Saputo F A , Mizzon C , Tamburri I , Campisi M , Battista V , Silvetti G , Cazzoli I , Raimondo C , Drago F
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Paediatric transvenous permanent pacing from alternative ventricular sites including conduction system pacing may prevent ventricular dyssynchrony and systolic dysfunction. These procedures may be difficult and require higher fluoroscopic exposures. The use of three-dimensional-electroanatomic mapping system (3D-EAM) may guide lead implantation toward these alternative sites and reduce fluoroscopic exposure.

Purpose

of this study is the outcome of 3D-EAM-guided alternative sites pacing in paediatric patients.

Methods

Retrospective analysis of children and young patients with congenital or acquired complete atrioventricular block (CAVB) with or without other congenital heart disease (CHD) who underwent 3D-EAM-guided transvenous pacing in alternative sites of the subpulmonary ventricle, to perform non-selective His bundle pacing (NSHBP), pacing of ventricular septum close to conduction system (VS-CSP) or outflow tract (OT). 3D-pacing map guided stylet-directed screw-in lead implantation toward septal sites with narrower paced QRS. Procedure and follow-up data were recorded. Parameters of ECG (QRS duration, left ventricular activation time, LVAT), echocardiogram (3D ejection fraction, EF, global longitudinal strain, GLS, of the systemic ventricle) and lead (threshold, sensing) were registered and compared at baseline (pre-implantation) and during follow-up (1-3-year). Data are reported as median (25th-75th centiles). P<0.05 was significant.

Results

64 patients (47 females) with CAVB, of whom 11 with CHD, underwent 3D EAM-guided pacing (31 VVIR, 33 DDD) at age 12 (8-15) years, weight 44 (27-57) kg. Prior pacing (RV apex, RV and LV free wall, also biventricular) was present in 27 patients. Pacing sites were: 10 NSHBP, 5 RVOT, 49 VS-CSP (Figure 1). Procedure time was 175 (146-200) min, fluoroscopy exposure was: 3.0 (1.2-5.0) mGy and 90 (33-146) microGy/m2. Echographic parameters at baseline and follow-up are reported in Table 1. Baseline QRS duration 85 (80-130) ms, increased after implantation, 115 (100-120) ms (P=0.002), with LVAT 80 (70-81) ms (Figure 1). In patients with prior pacing, QRS shortened post-implantation: QRS 130 (120-160) vs. 120 (110-125)ms (P=0.004). Lead parameters were good post-implantation and at 3-year follow-up: threshold 0.5 (0.4-0.7) vs. 0.9 (0.7-1.2)V/0.5 ms; R-wave sensing 9 (6-12) vs. 7 (4-9)mV. Four NSHBP patients showed lead dislodgement requiring lead repositioning.

Conclusions

3D-EAM-guided alternative site pacing was accomplished with low fluoroscopic exposure. Paced QRS duration was significantly broader than in junctional rhythm but it was significantly narrower than prior epi/conventional site endo pacing. This pacing approach preserved ventricular systolic function in paediatric patients with CAVB at mid-term follow-up.
Intermuscular two-incision technique for implantation of the subcutaneous implantable defibrillator: 3-year follow-up
Authors: Migliore F , Pittorru R , Dall'aglio P , Falzone P , Bertaglia E , De Lazzari M , Iliceto S , Corrado D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

data on long-term outcome of the intermuscular (IM) two-incision implantation technique for the subcutaneous implantable cardioverted defibrillator (S-ICD) are lacking.

Purpose

the aim of the present study was to evaluate the outcome of patients underwent S-ICD implantation with the IM two-incision technique during 3-year follow-up.

Methods

the study population consisted of 105 consecutive patients (79 male; median 50 [13-77] years) underwent S-ICD implantation with the IM two-incision technique.

Results

according to the PRAETORIAN score, the risk of conversion failure was classified as low in 99 patients (94.3%), intermediate in 6 (5.7%).Ventricular fibrillation was successfully converted at ≤65 J in 97.4% of patients. During a median follow-up of 39 (16-53) months, 10 patients (9.5%) experienced device-related complications and 9 (8.5%) patients reported inappropriate shocks (IAS). Lead-associated complications were the most common (4.7%), including 2 cases of lead failure (1.9%). Pocket complications were reported in 2 patients (1.9%). Extra-cardiac oversensing (3.8%) represented the leading cause of IAS. No T-wave oversensing episodes were recorded. Twelve patients (11.4%) experienced appropriate shocks. Eight patients (7.6%) died during follow-up. IAS or device-related complications did not impact on mortality (HR 0.5; 95%CI 0-4.3; P=0.5; HR 0.7; 95%CI 0.1-6.0; P=0.8, respectively).

Conclusions

according to our findings, the IM two-incision technique allows for optimal positioning of the device achieving a low PRAETORIAN score with a high conversion rate. IM two-incision technique allows low incidence of pocket complications, shifting the type of complications towards lead-related complications, which represent the most common complications. The IM two-incision technique would not seem to impact the occurrence of IAS. Management of complications are safe without impact on the outcome.
Beneficial effects of high output His bundle pacing in patients with heart failure, narrow QRS
Authors: Katsouras G , Stavrakis S , Guida P , Duni N , Dentamaro I , Perniciaro V , Sgarra L , Quadrini F , Galgano G , Grimaldi M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac Resynchronization Therapy (CRT) decreases heart failure (HF) hospitalizations and mortality and increases left ventricular Ejection Fraction (EF) in patients with dilated cardiomyopathy, left bundle branch block and QRS>130msec1. However, CRT is not beneficial in HF patients with narrow QRS3.

Purpose

We performed His Bundle Pacing (HBP) with high output (3.5V/1msec) in HF patients with dilated or ischemic cardiomyopathy and narrow QRS to prove hemodynamic benefit independently of the QRS duration or AV delay shortening.

Methods

9 male patients with dilated cardiomyopathy (EF<35%) and narrow QRS (<110ms) were referred for implantation of a defibrillator. We implanted an ICD- HBP system, and we collected clinical, echocardiographic, and electrocardiographic data.

Results

We obtained HBP in all 9 patients successfully. Basal mean EF was 31±4% and increased to 43±6% (P<0.001) after a median follow-up of 116 days. Left ventricular end-diastolic diameter and left ventricular end-diastolic volume decreased from 62±5 to 59±6ml (P=0.014) and from 188±87 to 144±35ml (P=0.095), respectively. Left ventricular end-systolic volume decreased from 139±78 to 85±29 (P=0.035). NYHA class decreased by one class in every patient after only one month. Baseline QRS duration remained stable after pacing from 107±7 to 118±15ms. In one patient an iatrogenic right bundle branch block was created which was corrected partially by His bundle pacing. PQ after implantation was shorter (from 167±23 to 121±14 (P=0.030) so as to pace the ventricle. HBP threshold was 1.24V±0.50/1msec, the impedance was 529±116 Ohms while R-wave was 3.8±1.7mV. In one out of 9 patients, threshold increased from 1 to 2V/1msec in 6months and then remained stable. In the other eight patients, threshold remained stable.

Conclusions

HBP in HF patients with dilated cardiomyopathy and narrow QRS improves hemodynamic function and decreases NYHA class. This benefit appears to be produced by a higher stimulation output. We cannot exclude that a very short AV delay could be favorable. To our knowledge these are the first cases of beneficial HBP in HF patients with narrow QRS. There is urgent need for large, randomized clinical trials.
Biventricular or conduction system pacing for cardiac resynchronization therapy: a proposed treatment algorithm based on interventricular conduction delays
Authors: Carmine Marallo C M , Federico Landra F L , Claudia Baiocchi C B , Maria Barilli M B , Nicolo Sisti N S , Antonio Pagliaro A P , Cristina Tavera C T , Andrea Stefanini A S , Andrea Pica A P , Matteo Cameli M C , Santoro A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac resynchronization therapy (CRT) is usually performed with biventricular pacing (BiVP), but recently conduction system pacing (CSP) has been proposed as an alternative in case of unsuccessful coronary sinus lead implantation. CSP was performed as His Bundle pacing or Left bundle branch pacing(1). However, further evidence is needed to determine when CSP should be used in lieu of BiVP to improve clinical benefit.

Purpose

To assess the clinical benefit of a treatment algorithm based on interventricular conduction delays (IVCD) to choose between BiVP or CSP in candidates to CRT(figure1).

Methods

Consecutive patients presenting at our Institution from January 2018 to December 2020 with an indication to CRT were prospectively enrolled in the study group (delays-guided resynchronization group, DRG). IVCD were measured after left ventricle (LV) lead positioning in a lateral or posterior-lateral cardiac vein, when feasible, using endocavitary electrogram(2). Treatment algorithm based on IVCD was used to decide whether to leave LV lead to perform BiVP or pull it out and perform CSP. Outcomes from the DRG group were compared to a historical cohort of CRT patients (resynchronization standard guide group,SRG). The primary endpoint was a composite of cardiovascular mortality, heart failure (HF) hospitalization, or HF event at 1 year after the date of intervention.

Results

Study population consisted in 292 patients, of which 160 (54.8%) in the DRG and 132 (45.2%) in the SRG. In the DRG 41 of 160 patients underwent CSP based on treatment algorithm (25.6%). The primary endpoint was significantly reduced in the DRG (35/160, 21.8%) compared to SRG (48/132, 36.4%) (hazard ratio(HR):1.72;95% confidence interval(CI):1.12-2.65;p=0.013)(figure2).

Conclusion

A treatment algorithm based on IVCD shifted 1 patient every 4 from BiVP to CSP, with consequent reduction in cardiovascular deaths, HF hospitalizations or HF event after implantation. Therefore, its application could be useful to determine whether to perform BiVP or CSP in CRT candidates.
Baseline creatinine level and long-term outcomes in patients with heart failure undergoing cardiac resynchronization therapy
Authors: Mazurek M , Jedrzejczyk-Patej E , Kotalczyk A , Gumprecht J , Lenarczyk R , Sokal A , Pruszkowska P , Szulik M , Kowalski O , Kowlaczyk J , Kalarus Z
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Renal dysfunction has been shown as an independent predictor of mortality in patients with heart failure (HF). However, data on the long-term outcomes of cardiac resynchronization therapy (CRT) in patients with chronic kidney disease is scarce due to underrepresentation of such patients in clinical trials on CRT.

Aim

To determine outcome and mortality predictors in patients with HF and elevated creatinine level treated with cardiac resynchronization therapy.

Methods

Study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in a tertiary care university hospital, in a densely inhabited, urban region of Poland (949 subjects [89.6%] with CRT-D; 110 patients with CRT-P [10.4%]; 832 men [78.6%]).

Results

The median creatinine level before CRT implantation was 96 umol/L (10th and 90th percentile: 67-160). We divided all CRT patients into quartiles per creatinine level: I <79 umol/L, II 79 to less than 96 umol/L, III 96 to less than 118 umol/L, and IV ≥118 umol/L. During the median follow-up of 1661 days (10th and 90th percentile: 323-3995), mortality rates for quartiles I-IV were 36.8, 44.9, 60.1, and 71.7%, respectively (P<0.05) [Figure 1]. The creatinine level ≥118 umol/L (quartile IV) appeared to be an independent risk factor for death (HR 1.004, 95%CI 1.003-1.006, P<0.001). On multivariable analysis, lower left ventricular ejection fraction (HR 0.97, 95%CI 0.95-0.99, P=0.04), higher NT-proBNP level (HR 1.00, 95%CI 1.0001-1.0005, P=0.04), and diabetes treated with insulin (HR 1.64, 95%CI 1.07-2.53, P=0.02) were independent risk factors for death in quartile IV. The mortality rate in those with creatinine level ≥118 umol/L and left ventricular ejection fraction ≤ 20% was 88% during the observation.

Conclusions

Compared to patients without renal dysfunction prior to CRT implantation, mortality rates of those with creatinine level ≥118 umol/L are significantly higher and reach 70% in 4.5 years of median observation. Almost 9 out of 10 CRT recipients with creatinine level ≥118 umol/L and left ventricular ejection fraction ≤ 20% die within 4.5 years since CRT implantation.

Figure 1. Kaplan-Meier curves for survival of patients treated with cardiac resynchronization therapy as a function of creatinine level
Prognostic value of nutritional status in post-implant CRT outcomes in patients with chronic heart failure
Authors: Brochado L , Santos E , Rosas F , Brandao M , Manuel A M , Almeira J G , Goncalves H , Oliveira M , Primo J G , Fonseca P , Fontes-Carvalho R , Leite-Moreira A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

There’s a close relationship between chronic heart failure (CHF) and malnutrition, and their main pathophysiological modifications are well known. Cardiac resynchronization therapy (CRT) has proven to be a promising therapy in symptomatic heart failure (HF) patients with broad QRS complexes and impaired systolic function with optimized medical therapy. However, there is still a considerable amount of non-responder patients. The role of nutritional status in CRT therapy response has yet still not been well assessed.

Purpose

Assess the prognostic value of nutritional status in post-op outcomes in patients with Chronic Heart Failure and (CRT)

Methods

Single-center retrospective study of patients submitted to CRT implantation between January 2007 and march 2021. Inclusion criteria were patients meeting criteria for CRT implantation, QRS duration ≥ 120ms, FEVE ≤ 35%, NYHA class II–IV and no adverse events during the follow up. Primary outcomes measured were all-cause mortality, cardiovascular mortality, and hospitalizations due to HF in a 1-year follow-up. To evaluate patient's nutritional status the CONUT score was used with patients being categorized in 2 groups: Low CONUT (Score 0-4: normal/low malnutrition) and Hight CONUT (Score 5-12: moderate/severe malnutrition).

Results

198 patients (83%) exhibited Low CONUT status, and 41 patients (17%) exhibited High CONUT status. Patients with Hight CONUT were older (72.9 yrs vs 65.9 yrs, p<0.001), and exhibited higher percentage of chronic obstructive pulmonary disease (43.9% vs 27.3%, p=0.004), atrial fibrillation (72.9%, vs 25.3%, p<0.001), hypertension (78.1% vs 60.6%, p=0.038), chronic kidney disease (39.1% vs 21.2%, p=0.016) and NYHA IV (19.5% vs 5.1%, p<0.001). Cardiovascular mortality was 3.7% in the low CONUT group vs 29.3% in the Hight CONUT group (p<0.001; HR, 0.12; 95% CI, 0.05-0.29) and total HF hospitalizations were 16 and43, respectively (p=0.013; HR, 0.482, 95% CI, 0.27 to 0.86). The nutritional status prior to CRT assessed by the CONUT score showed to be an independent predictor of cardiovascular mortality (p=0.007; HR, 0.16 95% CI, 0.04-0,60).

Conclusion

Malnutrition was a common condition in our CRT patients showing that deficient nutrition status remains highly underdiagnosed. Patients with worse nutritional status before CRT device implantation presented higher morbidity and were more prone to worst outcomes such as cardiovascular mortality and mortality by all causes as well as higher incidence of hospitalizations secondary to HF decompensation. Assessment of nutritional status using screening tools may provide additional prognostic information in patients with HF and help early identification of those who may benefit from further assessment and nutritional intervention.
Effects on the timing of left ventricular pressure rise when pacing the right ventricular free wall in cardiac resynchronization therapy
Authors: Marciniak M , Albatat M , Hammersboen L E , Stugaard M , Frostelid V C , Finstad E , Remme E , Odland H
Published: May 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian Research Council.

Background/Introduction

The timing of left ventricular pressure rise (Td) is associated with dispersion of regional work distribution and prolongs with dyssynchrony and dyssynergistic contractions. Synergistic contractions shorten Td and result from effective biventricular pacing (BIVP). Attempts have been made to optimize right ventricular (RV) lead position with septal lead placement away from the apex. In this study we attempted to study the effects from RV free wall (RVfw) compared to septal/ apical RV (RVsept) lead positioning on Td.

Purpose

RVfw pacing results in activation of RVfw before LV activation with a delay that may hamper the myocardial synergy resulting from biventricular pacing. This effect has not yet been demonstrated and may play an important role to understand non-response to CRT.

Methods

9 mongrel dogs were included in the study and handled according to ethics committee approved protocol/GLP. Pacing electrodes were placed epicardial on the left atrial appendage, the RVfw and LV, and endocardial in the septum. Pressure was measured with a Micro-tip pressure sensor (Millar Inc.) in the LV. BIVP was performed from LV combined with RVsept or RVfw. Td was measured from 10 consecutive beats. Mixed models were utilized for the repeated measurements.

Results

The average Td with BiVP-RVfw, BIVP-RVsept and LV pacing only was 116ms (95% CI: 110, 122), 114ms (95% CI: 108, 120), and 118ms (95% CI: 112, 124) respectively (p<0.001). BiVP with RVsept shortened Td by 4.1 ms (95% confidence interval (CI): -5.3, -2.9, p<0.001), whereas BiVP with RVfw pacing location shorten Td by 1.8 ms (95% CI: -2.8, -0.8, p<0.001), compared to LVP. The SD from 10 beats was on average 0.8ms (range 0-1.6ms).

Conclusion(s)

Myocardial Synergy with shortening of Td compared to LV only pacing was demonstrated with BIVP regardless of RV position. The synergistic effect from BIVP is more pronounced with BIVP-RVsept than from BIVP-RVfw. RV lead position may play an important role in cardiac resynchronization therapy that can be revealed when measuring the time-course of LV pressure rise.
Short term outcome of different lower pacing rates in patients with recently implanted CRT
Authors: Ragab A H M E D , Abdelwahab A M I R , Hassanien N O H A , Sharaf Y A S S E R , Eldamaty A H M E D
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac Resynchronization Therapy (CRT) is a well-established treatment for patients with congestive heart failure, impaired ejection fraction and QRS duration more than 130 msec. Around one third of patients remains to be non-responders. Several parameters have been tested aiming at improving the response rate.

Purpose

We aim at comparing the effect of two bi-ventricularly base pacing rates (DDD 60 Bpm vs DDD 80 Bpm) on the composite endpoint of mortality and hospitalization due to heart failure.

Methods

We included patients with recently implanted CRT, all patients had LBBB, QRS duration more than 130 msec and ejection fraction less than 35%. Patients were randomized using randomization table into two groups (DDD 60 bpm and DDD 80 bpm). Patients with atrial fibrillation, active coronary artery disease and those who refused to sign a consent were excluded from the study. Patients were followed 3 months after randomization and then every 6 months thereafter.

CRT programming was done, the following pacing parameters were standardized for all patients as per protocol: Mode of pacing was set at DDD, sensor was set as passive, VV delay at 0msec, sensed AV delay at 120ms and paced AV delay at 150ms. Dynamic AV and VV delay optimization algorithms were intentionally turned off.

Results

Fifty-one patients were enrolled, 45 patients were included in the final analysis (one died before the randomization, two patients were excluded due to average heart more than 80 beats/min at the time of randomization and three were lost to follow up). Mean age was 51.67 ± 11.1 years, 23 patients (51.1%) were females. Thirty-seven patients (82.2%) had dilated Cardiomyopathy, 16 patients (35.6%) had New York heart association (NYHA) functional class (FC) III heart failure (HF) and 29 patients (64.4%) had NYHA class IV (ambulant) HF. At baseline, Minnesota living with heart failure questionnaire score was (52.56 ± 14.3), six minutes-walk distance was 242 ± 95.9 meters and EF was 24.6± 7.4%. Patients were followed for mean duration of 23.2 ± 11.5 months. More patients reached the primary endpoint of death or hospitalization due to heart failure in the DDD 80 bpm group [ 3 (13.6%) vs 13 (56.5%), P=0.003]. This was driven mainly by hospitalization due to heart failure. Death was numerically higher in the DDD 80 group but this was not statistically significant [1 (4.5%) vs 4 (17.4%), P=0.18]. Patients in DDD 60 group had significant improvement in the 6MWD, NYHA functional class, EF % and Minnesota living with heart failure score compared to non-significant improvement in the DDD 80 group. (Table 1)

Conclusions

In CRT recipients, Base pacing rate 60 beats/min shows less incidence of the composite endpoint of mortality and hospitalization due to heart failure and base pacing rate 80 beats/min could potentially be harmful.
Appropriate and inappropriate therapies in remotely monitored patients with cardiac implantable devices long-term experiences of a tertiary centre
Authors: Dyrbus M , Pyka L , Kurek A , Niedziela J T , Adamowicz E , Ostrega M , Sokola K , Pres D , Gasior M , Tajstra M
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The evidence supporting the implantation of implantable cardioverter-defibrillator (ICD) in the primary prevention of sudden cardiac death (SCD) comes mostly from the times when optimal management of heart failure was not as effective as at present. Moreover, the detailed data on the long-term risk of arrhythmias in patients with ICD are scarce.

Purpose

To present the long-term results of the remote monitoring (RM) of patients with ICD from a large, tertiary cardiovascular centre registry.

Methods

The clinical data from the time of device implantation were derived from the COMMIT-HF registry, while the follow-up data were obtained from the investigator-initiated RM registry. In brief, the registry encompasses data regarding the types of the transmissions and their contents, with particular emphasis on the occurrence of arrhythmic episodes, device interventions, as well as the data on the causes of other alert transmissions.

Results

In total, 1,299 patients were included in the analysis. The median follow-up duration of RM was 4.4 years, and the primary indication for implantation was ischemic cardiomyopathy (60.3%). Appropriate antitachycardia pacing (ATP) and high-voltage therapy for ventricular arrhythmias occurred in respectively 25.3% and 26.1% of patients, while inappropriate ATP and HV in respectively 11.5% and 8.7%. The prevalence of AF was 40.8%.

Conclusions

In a large real-life cohort of continuously remotely monitored patients with ICDs, the percentage of patients with appropriate therapies for ventricular arrhythmias exceeded 25%. Further analyses are necessary to stratify the risk of ventricular arrhythmias in the contemporary practice.
Leadless pacemaker implantation following transvenous lead extraction: data from i-LEAPER registry
Authors: Mitacchione G , Schiavone M , Arabia G , Gasperetti A , Mazzone P , Rovaris G , Dello Russo A , Biffi M , Pisano E , Della Bella P , De Asmundis C , Saguner A , Tondo C , Curnis A , Forleo G B
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

transvenous (TV) pacemakers are negatively associated with local and systemic device-related infections, often requiring transvenous lead extraction (TLE). Moreover, patients reimplanted with a TV device following TLE, exhibit substantial mortality and reinfection rates during the subsequent follow-up (FU). In this setting, leadless pacemakers (LPMs) are appealing as a first choice for TLE patients requiring a pacemaker reimplantation. To date, limited data on real-world safety and efficacy of LPMs in patients who underwent TLE are available.

Purpose

The present study aims to assess long-term safety and efficacy of LPM implantation in patients who previously underwent TLE of a transvenous pacemaker, compared to LPM de novo implant patients.

Methods

Consecutive patients who underwent LPM implantation in 12 centers joining the International LEAdless PacemakEr (i-LEAPER) registry were enrolled. Patients receiving LPM following TLE (n=184) were compared with patients with de novo implant (n=995). The primary endpoint was LPM-related major complications rate at implant and during FU. Additionally, differences in electrical performance were assessed between the two groups. Completion of 12-months FU was obtained in all patients.

Results

1179 patients were enrolled in this study and followed for a median of 12 [IQR 11-14] months. Baseline clinical characteristics resulted balanced among the two groups, apart from a higher prevalence of heart failure among recipients of LPM following TLE (16.8% vs. 9.4%, p=0.013). As reported in the Table, LPM related major complications and all-cause mortality did not differ among the two groups (1.6% TLE group vs. 2.2% de novo group, p=0.785, and 5.4% TLE group vs. 7.8% de novo group, p=0.288, respectively). Pacing threshold (PT) resulted higher in the TLE group throughout the FU (Figure-Panel A). Higher PTs were recorded in LPMs implanted at same location from where the previous transvenous lead was removed, as far as 12-months postimplant (Figure-Panel B), with a higher proportion of patients with high PT (>1 to 2V @0.24ms) in the first group at implant, 1-month, and 12-month FU (Figure-Panel C).

Conclusion

In this real-world registry, LPMs showed a satisfactory safety and efficacy profile after TLE. In the post-TLE cohort, better electrical parameters were obtained when LPMs were implanted at a different location from where the previous transvenous lead was extracted.
Procedural outcome and risk prediction in young patients undergoing transvenous lead extraction. A GALLERY subgroup analysis
Authors: Chung D , Rexha E , Pecha S , Burger H , Naegele H , Reichenspurner H , Gessler N , Willems S , Butter C , Hakmi S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The prevalence of young patients with cardiac implantable electronic devices (CIED) is continuously rising. Along with this development there is a concomitant increase in the incidence of CIED-related complications, such as device-related infections and lead failure. Transvenous lead extraction (TLE) has evolved into an indispensable therapeutic option for such cases.

Aim

The aim of this study was to analyze patient characteristics and procedural outcomes of young patients undergoing TLE and to identify independent risk factors for adverse events.

Methods

We performed a subgroup analysis of all patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) who were 45 years or younger at the time of enrollment. Predictor variables for all-cause mortality, procedural complications and procedural failure were assessed via multivariate analyses.

Results

We identified 160 patients (6.3% of the GALLERY) aged 45 years or younger with a mean age of 35.3±7.6 years and 42.5% (n=68) female patients. Mean body mass index was 25.6±5.4 kg/m2 and the proportion of patient with highly reduced ejection fraction (LVEF <30%) was 11.3%. Comorbidities, such as arterial hypertension (AHT), diabetes mellitus (DM) and chronic kidney disease (CKD) were present in 23.8%, 6.3% and 5.0% of patients, respectively. Leading extraction indication was lead dysfunction in 51.3% of cases, followed by local infections in 20.6% and systemic infections in 16.9%. The most common device to be extracted were implantable cardioverter-defibrillators (ICD) with 52.5%. Mean number of leads per patient was 2.2±1.0. Median age of the oldest indwelling lead was 91.5 [54.75-137.5] months. Median procedural time was 88 [65-151.75] minutes. Overall complication rate was 3.8% with 1.9% minor and 1.9% major complications. Complete procedural success was achieved in 90.6% of cases. Clinical procedural success rate was 98.1%. Procedure-related mortality was 0.0%. All-cause in-hospital mortality was 2.5%, which was mainly due to septic shock. Multivariate analysis revealed CKD as independent predictor for all-cause mortality (OR: 51.48; 95% CI: 1.98-1340.0; p=0.018). Lead age ≥10 years (OR: 14.58, 95% CI: 1.36-156.2; p=0.027) was identified as sole independent risk factor for procedural complication.

Conclusion

Transvenous lead extraction in young patients is safe and effective with a procedure-related mortality rate of 0.0%. All-cause mortality was mainly driven by patients succumbing to CIED-related sepsis, despite successful extraction. Chronic kidney disease and lead age ≥10 years are relevant risk factors in young patients undergoing TLE.
Self-taught ultrasound-guided axillary vein access for pacemaker implantations - complication rates and outcomes
Authors: Kong Q G , Ang D T Y , Peat E , Hood S , Lau Y
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac implantable electronic devices (CIEDs) are the mainstream therapy for advanced atrioventricular block or sustained ventricular arrhythmia. EHRA survey (1) showed that cephalic vein dissection and blind subclavian vein puncture are the preferred techniques for the implantation of CIED leads in European centres. Ultrasound (US) guided axillary puncture has emerged as feasible alternative for safe and rapid venous access for lead implantation. However, insufficient evidence to support its widespread adoption.

Aim

To compare the complication rates and clinical outcomes of CIED implantations utilising self-taught US guided axillary puncture versus non-US guided venous access (Subclavian puncture and fluroscopy guided axillary puncture). Assess the mean time to gain venous access and overall success rate in US guided technique.

Methods

Retrospective , observational study across two sites involving all CIED implantations of four experienced implanters over the year from January 2021 - June 2022. Patient's demographics, venous access time, complications and clinical outcomes were extracted from electronic database. US axillary access technique was self-taught.

Results and Outcomes

Venous access was obtained by US Guided axillary puncture in 146 patients, non-US guided in 208 patients. Successful axillary venous access by ultrasound guidance is 97%(146/151) with mean time to venous access of 2.1 minutes.

Baseline demographics (age, gender) and comorbidities (hypertension, diabetes, cardiomyopathy, coronary artery disease, dyslipidemia, renal failure, oral steroid use, nicotine use) were similar between both US-guide and non-US guided groups, usage of oral anticoagulations (32.9% vs 39.4%,p=0.208) and antiplatelet agents(28.1% vs 35.1%,p=0.164) were not statistically different.

Greater proportion of dual chamber pacemakers were implanted in US guided access group versus non-US guided (39.7% vs 27.9%,p=0.015).

US Guided axillary access resulted in lower overall complication rate (2.1% vs 8.9%, p=0.0196): lower risk of pneumothorax (0% vs 3.8%,p=0.0236), lower risk of haemathoma (0% vs 3.4%,p=0.0448). No difference in short term pocket/lead infection or lead displacement. Severe vascular complications remains low in both groups.

Stepwise binary regression analysis demonstrated US guidance as independent predictor of lower overall complication rate, odd-ratio 0.195 (95% CI 0.054 - 0.706).

Summary: This multi-centered, retospective observational study demonstrated that US guided axillary access has high overall success rate, not time consuming and resulted in lower complication rates (especially pneumothorax and pocket haemathoma), despite the US access technique being self-taught and have greater proportion of dual chamber device implantations. US guided axillary access is demonstrated to be independently associated with 5-fold lower risk of complications.