bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of myocardial revascularization on long-term outcomes in a nationwide cohort of first acute myocardial infarction survivors
Authors: De Luca Leonardo , D’Errigo Paola , Rosato Stefano , Mureddu Gian Francesco , Badoni Gabriella , Seccareccia Fulvia , Baglio Giovanni
Published: May 2022

The long-term clinical benefits of myocardial revascularization in a contemporary, nationwide cohort of acute myocardial infarction (AMI) survivors are unclear. We aimed to compare the mortality rates and clinical outcomes at 8 years of patients admitted in Italy for a first AMI managed with or without myocardial revascularization during the index event. This is a national retrospective cohort study that enrolled patients admitted for a first AMI in 2012 in all Italian hospitals who survived at 30 days. The outcomes of interest were all-cause mortality, major cardio-cerebrovascular events (MACCE), and re-hospitalization for heart failure (HF) at 8 years. Time to events was analysed using a Cox and Fine and Gray multivariate regression model. A total of 127 431 patients with AMI were admitted to Italian hospitals in 2012. The study cohort consisted of 62 336 AMI events, of whom 63.8% underwent percutaneous or surgical revascularization ≤30 days of the index hospital admission. At 8 years, the cumulative incidence of all-cause death was 36.5% (24.6% in revascularized and 57.6% in not revascularized patients). After multiple corrections, the hazard ratio (HR) for all-cause mortality in revascularized vs. not revascularized patients was 0.61 (P < 0.0001). The rate of MACCE was 45.7% and 65.8% (adjusted HR 0.83; P < 0.0001), while re-hospitalizations for HF occurred in 17.6% and 29.8% (adjusted HR 0.97; P = 0.16) in AMI survivors revascularized and not revascularized, respectively. In our contemporary nationwide cohort of patients at their first AMI episode, those who underwent myocardial revascularization within 1 month from the index event compared to those not revascularized presented an adjusted 39% risk reduction in all-cause mortality and 17% in MACCE at 8-year follow-up.
ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes
Authors: De Luca Leonardo , Rubboli Andrea , Lettino Maddalena , Tubaro Marco , Leonardi Sergio , Casella Gianni , Valente Serafina , Rossini Roberta , Sciahbasi Alessandro , Natale Enrico , Trambaiolo Paolo , Navazio Alessandro , Cipriani Manlio , Corda Marco , De Nardo Alfredo , Francese Giuseppina Maura , Napoletano Cosimo , Tizzani Emanuele , Nardi Federico , Roncon Loris , Caldarola Pasquale , Riccio Carmine , Gabrielli Domenico , Oliva Fabrizio , Massimo Gulizia Michele , Colivicchi Furio
Published: May 2022

Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.
ANMCO position paper: 2022 focused update of appropriate use criteria for multimodality imaging: aortic valve disease
Authors: Nardi Federico , Pino Paolo Giuseppe , De Luca Leonardo , Riccio Carmine , Cipriani Manlio , Corda Marco , Francese Giuseppina Maura , Gabrielli Domenico , Oliva Fabrizio , Gulizia Michele Massimo , Colivicchi Furio
Published: May 2022

This document addresses the evaluation of the Appropriate Use Criteria (AUC) of multimodality imaging in the diagnosis and management of aortic valve disease. The goal of this AUC document is to provide a comprehensive resource for multimodality imaging in the context of aortic valve disease, encompassing multiple imaging modalities. Clinical scenarios are developed in a simple way to illustrate patient presentations encountered in everyday practice.
Long-term remodelling and arrhythmogenicity after myocardial infarction using a novel image-based estimator: the Scar Maturation Score
Authors: Nunez Garcia M , Finsterbach S , Ly B , Lorenzi M , Cochet H , Sermesant M
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Council

Introduction

Post-infarction scar remodelling may start and evolve at a different pace across patients, often requiring years until the affected tissue becomes arrhythmogenic. Current risk stratification strategies lack sensitivity and specificity, and therefore more knowledge is required (e.g. new biomarkers and insights about the appropriate time point to evaluate them).

Purpose

We introduce a model of scar maturation and a novel estimator of scar remodelling based on fully automated analysis of cardiac computed tomography (CT).

Methods

We retrospectively included patients with history of myocardial infarction and available cardiac CT at the scarring stage (i.e. >6 months post-infarction). A fully automated pipeline was introduced including LV wall segmentation, reformatting to short-axis view, and LV wall thickness (WT) computation. 4 biomarkers representing moderate to severe LV wall thinning were considered (i.e. WT < {5, 4, 3, 2} mm). A statistical approach based on Bayesian Gaussian Process regression was used to model the biomarkers’ evolution. The Scar Maturation Score, a subject-specific parameter encoding the maturation stage relatively to the group-wise model was introduced, and its relationship with sustained ventricular arrhythmia (VA) was analysed.

Results

A total of 428 patients were included (age: 73±8 years, 83% males, LVEF: 46±11%), comprising 58 with 2 CT studies available (median scan delay: 2.1 years). The model estimated a progressive LV wall thinning over the years following the infarction. Patients without VA were typically assigned to low Scar Maturation Scores (i.e. early maturation stage), while VA patients were frequently associated with higher Scores. Scar Maturation Score, LVEF, area of wall thinning, and scar age were all significantly associated with VA (p < 0.0001), the Scar Maturation Score showing the higher correlation ratio.

Conclusion

Fully-automated LV thickness measurements from CT allow for a plausible modelling of scar maturation that, together with the patient-specific Scar Maturation Score, may be useful to improve patient treatment (e.g. determine optimal time point for patient screening) and risk stratification.
Description of flecainide usage from 2005-2018 in the Danish population
Authors: Krogager E , Lock-Hansen M , Vibe-Rasmussen P , Dalgaard F , Ruwald M , Zoner C , Toennesen J , Schjerning AM , Gislason G , Pallisgaard JL
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Flecainide is an antiarrhythmic class 1C agent used to treat cardiac arrhythmias. Due to the risk of pro-arrhythmia and 1:1 conduction with flecainide, concomitant treatment with atrioventricular nodal blocking (AVNB) agents is advised. However, little data exist pertaining to the real-world use of flecainide and concomitant AVNB therapy.

Purpose

We sought to investigate the change over time in the use of flecainide and AVNB agents in relation to patient characteristics.

Methods

Using the Nationwide Danish registers, all Danish patients above 18 years with a redeemed prescription for flecainide between January 1st, 2005, and December 31st, 2018, and included at the date of the first prescription. The use of AVNB agents was identified in the period from 180 days prior to and 180 days after the inclusion date. Individual AVNB agents were divided into beta-blockers, class IV calcium channel blockers, and digoxin.

Results

The study cohort consisted of 6,594 patients with a median [IQR] age increasing from 59 [53-65] years in 2005 to 63 [56-69] in 2018, 59 % were men, and the most frequent arrhythmia diagnosis was AF (90.1%). In total, there were 297 patients starting flecainide in 2005 and 491 in 2018, with the highest number of patients in 2011, with 613 new users (Figure 1). Compared to the 144,215 patients with prevalent atrial fibrillation in Denmark in 2018, the number of patients using flecainide was only 0.3% this year.

The percentage of patients on concomitant AVNB treatment was high throughout the study period, with 93% in 2005 and 95% in 2018, giving an average increase of 0.3% per year over time. The most frequently used AVNB was beta-blockers, and the least frequently used were the class IV calcium channel blockers. (Figure 2)

Over time, the number of patients with concomitant AVNB treatment to flecainide decreased from 94% the first year in flecainide treatment to 90% between the second and third years. Between the firth and sixth year in flecainide treatment, the number was down to 86%.

The number of patients with a diagnosis of ischemic heart disease was 10% in 2005, dropping to 6% in 2018

Conclusions

Flecainide use increased from 2005 to 2018. The use of AVNB was high in patients prescribed with flecainide and increased over time, with beta-blocker as the most frequent.
Comparison between oral procainamide and mexiletine for the treatment of recurrent and refractory ventricular tachyarrhythmias
Authors: Toniolo M , Burelli M , Mugnai G , Rebellato L , Daleffe E , Bilato C , Muser D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The antiarrhythmic therapy of recurrent ventricular arrhythmias in patients having undergone catheter ablation and in whom amiodarone and/or beta blockers were ineffective or contraindicated, is a controversial issue.

Purpose

The present study sought to compare the efficacy and tolerability of oral procainamide and mexiletine in patients with recurrent ventricular arrhythmias, when the standard therapy strategy failed.

Methods

All patients with an implantable cardioverter defibrillator (ICD) treated with oral procainamide or mexiletine for recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) in 2 Cardiology Divisions between January 2010 and January 2020 were enrolled. The patients were divided in group A (oral procainamide) and group B (mexiletine) and the 2 groups were compared to each other. The primary endpoint was the efficacy of therapy; the secondary endpoint was the discontinuation of therapy. All the events occurring during procainamide or mexiletine treatment were compared with a matched duration period before the initiation of the therapy. Antiarrhythmic therapy was considered effective when an ≥80% reduction of the sustained ventricular arrhythmias (SVA) burden recorded by the ICD was achieved.

Results

A total of 68 consecutive patients (61 males, 89.7%; mean age 74 ± 10 years) were included in this retrospective analysis. In 27 (39.7%) patients catheter ablation of VT was attempted before therapy initiation. A concomitant therapy with amiodarone was present in 25 (36.8%) patients. The mean dose of procainamide was 1207±487 mg/die. The mean dose of mexiletine was 576±66 mg/die. After a median follow-up of 19 months, 38 (56%) patients had a significant reduction in the SVA burden. After multivariable adjustment (Table 1), therapy with procainamide was independently associated with an almost 3-fold higher efficacy on VA suppression compared to mexiletine (HR 2.54, 95% CI 1.06-6.14, p=0.03). Similar results (HR 2.89, 95% CI 1.26-6.62, p=0.01) were found after adjustment using inverse probability weighting by a propensity score including age, gender, left ventricular ejection fraction, ischemic heart disease and concomitant amiodarone therapy. Only 3 patients (9%) treated with procainamide presented severe side effects (dyspnea or hypotension) requiring discontinuation of therapy against 6 patients (18%) treated with mexiletine who interrupted therapy because of severe side effects (p=0.47).

Conclusions

Compared to mexiletine, oral procainamide has a higher efficacy for the treatment of recurrent and refractory VAs and shows a good profile of tolerability

Table 1. Multivariable Cox Proportional Hazards Analysis of Baseline Covariates in Relation to effective VAs suppression.
Dielectric-based tissue thickness measured during radiofrequency ablation catheter
Authors: Schillaci V , Stabile G , Arestia A , Shopova G , Agresta A , Salito A , De Simone A , Solimene F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

A new dielectric-based method of KODEX-EPD mapping system (EPD Solutions) for measuring tissue thickness at the catheter-tissue interface has recently been developed. We reported preliminary data on real-time catheter-based measuring myocardial wall thickness in vivo, during typical atrial flutter (AFL) RF ablation.

The Kodex version used to perform this type of analysis is a version not commercially available yet but only for case replay and research purpose, not used in clinical practice.

The study population consisted of 12 consecutive patients, suffering from symptomatic paroxysmal or persistent cavo-tricuspid isthmus (CTI) dependent. The Wall Viewer (WV) function is measured by assessing a series of dielectric signals derived directly from real-time local interrogation of the catheter-tissue interface. WV is displayed in millimeters, with either high or low confidence levels per met or unmet prerequisite acquisition criteria respectively and it is displayed as a color code scale (Fig. 1, A).

The anatomy of the CTI was identified using the 4mm MAP-iT irrigated ablation catheter. A suitable starting point for the ablation, in the proximity of the tricuspid valve, and a final location in the junction between the inferior vena cava and the right atrium, were precisely defined based on electrograms recorded. Subsequently, "point by point" CTI ablation was performed delivering RF energy with 30/40 Watts for 20-40 seconds with an interlesion distance ≤6 mm.

9 patients had paroxysmal common AFL, 3 persistent common AFL. The mean age was 64±9 years, 10 (83%) were male. The mean body mass index was 30±6, 9 (75%) patients had hypertension, and 1 (8%) had coronary artery disease. The mean procedure time was 37±13 min, the mean fluoroscopic time was 690±378 s, the mean RF time 763±205 s, with a mean number of RF pulses of 28±7. The mean cavo-tricuspid isthmus length was 29.5±2.6 mm. The atrial wall thickness was significantly higher close to the tricuspid annulus than close to the inferior vena cava (3.6±0.5 mm vs 2.4±0.3 mm, p<0.001) and a trend towards a progressive decrease of atrial wall thickness was observed moving the mapping catheter from the tricuspid valve to the inferior vena cava (Fig. 1, B). Acute bidirectional cavo-tricuspid isthmus block was achieved in all patients without any complications.

We first describe a new mapping technology that allows atrial wall thickness measurement and, as expected, the wall thickness was higher close the tricuspid annulus and lower towards the inferior vena cava. The possibility to calculate the substrate thickness before RF delivery could deeply change the way to perform RF ablation, allowing a tailored energy delivery thus increasing the efficiency of the procedures and potentially reduction of the risk of complications.
Noise reduction in electrophysiological signals using transfer machine learning
Authors: Ruiperez-Campillo S , Deb B , Feng R , Ganesan P , Clopton P , Rogers AJ , Narayan SM
Published: May 2022

Funding Acknowledgements

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

Background/Introduction

Reducing electrophysiological signal noise is essential for diagnosis, mapping and ablation, yet most approaches are suboptimal. Template matching requires libraries of known signal types, that are difficult to obtain. Beat averaging can reduce noise, yet cannot be applied to single beats and obscures beat-to-beat variations. Beat smoothing can lose critical and subtle signal features. We set out to use neural networks (NN) based on encoder-decoders, which are able to extract key signal features and hence reconstruct them without noise and artifact.

Purpose

We hypothesised that electrograms with varying sources of artifact can be denoised using autoencoder neural networks. We further hypothesised that this could be achieved in a small data set by developing the method in a larger dataset of related signals, then using transfer learning. We tested this approach for atrial monophasic action potentials (MAPs) that have verifiable shapes.

Methods

The NN was first trained with 5706 left and right ventricular MAPs from 42 patients with ischemic cardiomyopathy (age 65±13y; fig 1.A): 60% for training, 20% (validation) and 20% (testing). Transfer learning and parameter-tuning were then used to apply this NN to a smaller sample of atrial MAPs (N=641, 21 patients, 67±5y, 13 women; fig D,F,H).

Results

The autoencoder was able to learn key features of MAPs, and hence reconstruct them without artifacts. NN learned ventricular MAPs with similarity coefficient 0.91±0.16, Pearson correlation 0.99± 0.01 (fig A) and learned key features (upstroke, triangular descent, terminus) to reduce noise (fig B-C). Applying this trained NN to atrial MAPs, the approach automatically eliminated ventricular artifact (fig E), high frequency noise (fig G), truncation (fig I), saturation and other artifacts. After fine-tuning, the NN reconstructed atrial MAPs with Pearson correlation = 0.99±0.01 (p<0.001).

Conclusions

Machine learned encoder-decoders are powerful tools that can automatically eliminate diverse types of noise in single beats by learning essential signal features. Transfer learning makes this possible without large datasets for training, even from signals in a different cardiac chamber. This approach may have far-reaching applications for mapping and ablation.
Incident arrhythmias, heart failure and cardiovascular outcomes with SGLT-2 inhibitor use in diabetic patients: Insights from a global federated electronic medical record database
Authors: Fawzy AM , Rivera-Caravaca JM , Fauchier L , Lip GYH
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Sodium-glucose co-transporter 2 inhibitor (SGLT-2i) use has been associated with improved outcomes in patients with prevalent heart failure (HF), regardless of whether or not they have diabetes.

Purpose

We aimed to investigate the impact of SGLT-2i use on the risk of incident HF and adverse cardiovascular outcomes in patients with diabetes.

Methods

All diabetic patients between January 2018 and December 2019 were identified from a federated electronic medical record database (TriNetX), and followed up for 2 years. A 1:1 propensity score matched (PSM) analysis was performed to balance SGLT-2i and non-SGLT-2i cohorts. The primary outcome was incident HF and secondary outcomes included all-cause mortality, cardiac arrest, ventricular tachycardia/fibrillation (VT/VF), incident atrial fibrillation (AF), ischaemic stroke, a composite of arterial and venous thrombotic events, and a composite of incident VT/VF and cardiac arrest.

Results

A total of 115,749 diabetic patients who were on SGLT-2i and 2,316,638 who were not on SGLT-2i were identified. After PSM, 115,749 patients remained in each group. In the PSM analysis, the risk of incident HF was significantly lower in patients who were on SGLT-2i, compared to patients who were not on SGLT-2i (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.65-0.70). SGLT-2i use was also associated with a significantly lower risk of all-cause mortality (HR 0.62, 95% CI 0.59-0.65), cardiac arrest (HR 0.62, 95% CI 0.55-0.69), incident AF (HR 0.78, 95% CI 0.75-0.81), ischaemic stroke (HR 0.93, 95% CI 0.88-0.96), composite arterial and venous thrombotic events (HR 0.93, 95% CI 0.90-0.95), and composite of incident VT/VF and cardiac arrest (HR 0.74, 95% CI 0.68-0.79), compared to SGLT-2i non-use. There were no significant differences between the two groups for VT/VF (HR 0.94, 95% CI 0.88-1.01).

Conclusion

SGLT-2i use was associated with a significant decrease in the risk of incident HF, all-cause mortality, cardiac arrest, incident AF, ischaemic stroke, thromboembolic events and VT/VF/cardiac arrest, when compared to the non-use of SGLT-2i.
Shift work and incident atrial fibrillation in younger and older individuals
Authors: Zwartkruis VW , Lochen ML , De Boer RA , Mathiesen EB , Njolstad I , Wilsgaard T , Sharashova E , Rienstra M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Shift work is associated with myocardial infarction and stroke. However, comparatively little is known about the association between shift work and atrial fibrillation (AF).

Purpose

We aimed to study if shift work is associated with incident AF, and if this association differs depending on sex and age.

Methods

We studied 22 339 participants (age 37±10 years, 49% women) with paid work and without prevalent AF from the third (1986-1987), fourth (1994-1995), fifth (2001), and sixth (2007-2008) survey of the population-based Tromsø Study. AF was ascertained by searching participants’ hospital records for AF events, which were further adjudicated by an endpoint committee. All AF was ECG-confirmed. Follow-up for AF was available through 2016. Shift work status was assessed by questionnaire at each survey. If participants attended multiple surveys, the first attended survey was considered the baseline visit. We used Cox regression models (unadjusted, age- and sex-adjusted, and multivariable-adjusted) to study the association of shift work at baseline with (1) incident AF during the first 10 years of follow-up and (2) incident AF during the total follow-up period (through 2016). Interactions with sex and age were tested in the multivariable model. Analyses were stratified when a significant interaction (p for interaction <0.10) was present.

Results

Shift work was reported by 21% of participants at baseline. Participants with shift work were younger and had a lower average education level, lower prevalence of hypertension, higher BMI, and higher prevalence of smoking than those without shift work. During the first 10 years of follow-up, 129 participants (0.6%) developed AF. Shift work was not significantly associated with 10-year incident AF in any of the models. There was no interaction between shift work and sex (p for interaction = 0.687). However, there was a significant interaction between shift work and age (p for interaction = 0.059). In participants aged <40 years, shift work was significantly associated with 10-year incident AF in the unadjusted model (HR 2.65, 95% CI 1.05-6.71) and age- and sex-adjusted model (HR 2.71, 95% CI 1.07-6.88), but not in the multivariable model (HR 2.37, 95% 0.91-6.17). In participants aged ≥40 years, shift work was not associated with 10-year incident AF (Table 1). During the total follow-up (22±10 years), 1244 participants (5.6%) developed AF. When considering the total follow-up duration, shift work was not significantly associated with AF in any model, and none of the interaction terms with age or sex were significant.

Conclusions

In the total study population, shift work was not associated with incident AF. However, our results indicate that shift work may be associated with 10-year risk of AF in younger individuals.
Safety of pulsed-field ablation in patients with cardiac implantable electronic devices. A single-center pilot study
Authors: Winkelmann SJ , Lemoine MD , Wuerger T , Schleberger R , Rottner L , Dinshaw L , Moser JM , Muenkler P , Nikorowitsch J , Reissmann B , Ouyang F , Toennis T , Kirchhof P , Metzner A , Rillig A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulsed-field ablation (PFA) is a novel energy source to perform pulmonary vein isolation (PVI) in patients with atrial fibrillation or cavo-tricuspid isthmus ablation (CTI) in patients with atrial flutter. Whether strong electrical fields generated by PFA could change the function and integrity of cardiac implantable electronic devices (CIED) is not known.

Aim

To assess the function and integrity of implanted devices before and after pulsed-field ablation.

Methods

This study included consecutive patients with CIED undergoing PFA at a large single center. Real-time CIED electrograms were recorded during PFA applications. CIED were interrogated before and after PFA assessing function (threshold, sensing), integrity (impedance), and arrhythmia episodes.

Results

We performed PFA in six patients (age 69±12 years, 1/6 female, left atrial diameter was 44±3 mm, left-ventricular ejection fraction 40±14%) for PVI in five patients with atrial fibrillation and CTI ablation in one patient with atrial flutter. All patients had CIEDs (one cardiac resynchronization device, two implantable cardioverter-defibrillators, three two-chamber pacemakers). Each patient undergoing PVI received 32 PFA applications of 2.5 s. (4x basket configuration and 4x flower configuration at each pulmonary vein), amounting to a total ablation time of 80 s and resulting in complete PVI in all five patients. For CTI ablation we applied 8 PFA applications of 2.5 s (20 s total ablation time) resulting in CTI blockade. Real-time intracardiac electrograms (iEGM) during PFA applications revealed sensing of single PFA application impulses in three patients and blanking of the iEGM in three patients. Postinterventional device testing revealed no changes in impedance, stimulation threshold or sensing. No leads were dislocated or damaged. No other device malfunctions occurred during the procedure, as well as no other major periprocedural complications occurred.

Conclusion

The function and integrity of pacemakers and defibrillators is not affected by PFA in our patient sample. Larger series are needed to confirm the apparent safety of PFA in patients with CIED.
Gastrointestinal bleeding preceding new-onset atrial fibrillation - results from the nationwide FinACAF study
Authors: Jolkkonen S , Aro A , Haukka J , Halminen O , Putaala J , Linna M , Mustonen P , Hartikainen J , Airaksinen J , Lehto M
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District Funding The Finnish Foundation of Cardiovascular Research

Introduction

Initiation of oral anticoagulation (OAC) in case of a new-onset atrial fibrillation (AF) requires assessment of bleeding history. Gastrointestinal (GI) bleedings are among the most common bleeding events.

Purpose

We aimed to assess clinical characteristics and initiation of OAC in patients with new-onset AF and a history of previous GI bleeding.

Methods

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. The study population consists of all patients diagnosed with AF between the years 2010-2018 and with laboratory data available. Patients were identified from nationwide primary care and reimbursement registries and hospitalization records. OAC purchases at 90 days from cohort entry were obtained from the National Prescription Register upheld by the Social Insurance Institution of Finland.

Results

134 242 patients from the initial FinACAF cohort were included in this substudy. Of these, 6543 (4.9%) patients had a history of GI bleeding. Those with GI bleeding were more often male (52.6%), older (mean age 76.6 ± 11.4 vs 72.4 ± 13.1 years), and had more comorbidities. They also had lower blood hemoglobin (mean 124.9 ± 21.3 vs 135.8 ± 18.4 g/l) and higher serum creatinine (mean 99.7 ± 75.8 vs 87.5 ± 52.7 µmol/l) levels than patiens without preceding GI bleeding. Furthermore, initiation of OAC medication was less frequent in the GI bleeding group (46.9% vs 58.6%).

Patient characteristics of the study population including age, sex, comorbidities, OAC medication and laboratory findings are shown in Figures 1 and 2.

Conclusions

Patients with AF and preceding GI bleeding are vulnerable to rebleeding events. This may affect decision-making of clinicians, leading to more infrequent initiation of OAC medications.
First clinical experience with cardiac magnetic resonance guided typical atrial flutter ablation with the integration of active catheter tracking and electro-anatomical mapping
Authors: Bijvoet GP , Nies HMJM , Holtackers RJ , Vernooy K , Wildberger JE , Linz D , Mihl C , Chaldoupi SM
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

In our university hospital, we previously implemented cardiac magnetic resonance (CMR) guided typical atrial flutter ablation in a pre-existing MRI suite which was transformed into an interventional cardiac MRI (iCMR) suite.

Purpose

To describe our first clinical experience with integration of active catheter tracking and dedicated electro-anatomical mapping (EAM) system for the treatment of typical atrial flutter in a transformed pre-existing MRI suite.

Methods

Between February 2021 and December 2021, all consecutive patients planned for CMR guided typical atrial flutter ablation were included in this analysis. The procedure was performed under general anaesthesia. Feasibility and safety of active catheter tracking and the integration with a dedicated EAM was evaluated. All patients provided written informed consent.

Results

In total, nine patients underwent CMR guided atrial flutter ablation. Procedural characteristics are presented in Table 1. In all patients, both active catheter tracking and the integration with EAM were performed successfully. Bidirectional cavo-tricuspid isthmus block was achieved in eight out of nine patients and confirmed by differential pacing using intracardiac electrograms and EAM. In one of these eight patients, the registration of intracardiac electrograms was not possible due to technical problems and the patient was transferred to a conventional electrophysiology lab to complete the ablation following our predefined bailout procedure. Seven out of nine patients were in sinus rhythm at the start of the procedure, one in nodal rhythm with atrial bigeminy, one patient required electrical cardioversion for atrial fibrillation prior to the procedure. No periprocedural complications occurred.

Conclusion

CMR guided typical atrial flutter ablation in a transformed pre-existing MRI suite using active catheter tracking and a dedicated EAM system is feasible and safe based on this small population. It allows for detailed visualisation of catheters and individual patients anatomy. Further studies in larger patient populations are required to evaluate whether iCMR is cost effective and can improve clinical outcome of typical atrial flutter ablation and other arrhythmias.
Procedural safety, short and long-term follow up after pacemaker implantation in nonagenarians
Authors: Meynet I , Tricomi L , Ferraro A , Maggio R , Mazza A , Ceci R , Minniti D , Varbella F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Permanent cardiac stimulation is increasingly necessary in very old patients, due to the augmented life expectancy. This raise concerns in physicians, patients and caregivers, because pacemaker (PM) implantation can be perceived as too invasive for frail patients with significant comorbidities.

Purpose

The aim of the present study is to provide data about peri-operative complications, short and long-term survival and their predictors in this specific setting.

Materials and methods

All consecutive patients aged ≥90 years undergoing pacemaker implantation in our Centre from 2008 to 2020 were enrolled in the registry. Their baseline and follow up data were recorded in a specific database.

Results

Among the 2437 patients undergoing PM implantation in a 13-year period, 153 were nonagenarians (6.3%). Mean age was 92.7±2.3 years. Most of the patients (66.7%) received a ventricular single chamber PM. High-degree atrio-ventricular block was the first indication for implant (59.5%), followed by sick sinus syndrome or atrial fibrillation with slow ventricular response (30.1%). 15.7% patients needed temporary pacing at presentation. 4 patients (2.6%) experienced acute complications: 3 pneumothorax, 1 ventricular lead displacement with need of repositioning. Mean follow up duration was 2.5±2.0 years. 117 patients (78.5%) died during the follow up. Death occurred after a mean of 2.47 years after PM implantation (range 1-3272 days). Survival rates were 70.0%, 35.3% and 10.0% at 1, 3 and 5 years respectively. No pacemaker-related long-term complication was recorded during the follow up. 2 patients underwent generator replacement due to battery end of life. Chronic kidney insufficiency (p = 0.030) and congestive heart failure (p = 0.021) but not age were predictors of precocious mortality (within 1 month). Age at implant and longer length of hospital stay before PM implantation were predictors of long-term death (p = 0.001 and p = 0.043 respectively).

Conclusions

Extremely old age should not discourage PM implantation, when indicated; age is obviously predictor of long-term death but is not predictor of precocious mortality. Acute periprocedural complication rate is low and generally comparable to that of younger populations.
Recurrences after stereotactic arrhythmia radioablation for refractory ventricular tachycardia
Authors: Herrera Siklody C , Schiappacasse L , Jumeau R , Le Bloa M , Ozsahin M , Teres Castillo C , Moeckli R , Porretta AP , Pascale P , Domenichini G , Bourhis J , Pruvot E
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Stereotactic arrhythmia radioablation (STAR) has been recently introduced for the management of ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter ablation (CA). VT recurrences have been reported after STAR but the mechanisms remain poorly known. We analyzed recurrences in our patients (pts) after STAR for refractory VT.

Methods

From 09.2017 to 01.2020, 12 pts (66±8y, LVEF 40±14%) suffering from refractory VT were enrolled. The underlying cardiopathy was ischemic in 3, inflammatory in 3 and idiopathic in 6 pts. Nine out of 12 pts had a history of at least 1 electrical storm. Before STAR, an invasive electro-anatomical mapping of the VT substrate (VT-sub) was performed. A mean dose of 22±2Gy was delivered to the VT-sub using the Cyberknife system.

Results

The ablation volume was 24±7cc and involved the basal interventricular septum (IVS) in 10 pts. During the first 6 months after STAR, VT burden decreased by 95% (mean value, from 930 to 46 VT/semester). After a median follow-up of 14±10 months, 10/12 (83%) developed a recurrence as a sustained VT and underwent a redo CA. VT recurrence was located at the border zone (BZ) of the treated VT-sub in 6 cases, involved both the BZ and a larger substrate in 2 cases, and occurred remote from the VT-sub in 2 cases (see Table). The dose delivered at sites of VT recurrence was 9.9±8.6 Gy with a large heterogeneity ranging from 0.11 to 28.37 Gy, for some patients due to dose constraints near critical structures. Importantly no pts developed an AV block after STAR.

Conclusion

STAR appears to be an efficient tool for the management of IVS refractory VT, leading to a strong VT burden reduction and no AV block. Recurrences were nevertheless common, often at the border zone of the irradiated volume.
Determinants of mortality after stereotactic radio-ablation for ventricular tachycardia. Results from the international MUSIC consortium
Authors: Cochet H , Maury P , Whitaker J , Woods C , Gandjbakhch E , Bredfeldt J , Mak R , Sauer W , Juhoor M , Sermesant M , Sacher F , Bogun F , Zei P , Jais P , Tedrow U
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Council

Background

SBRT is currently restrained to the most severe patients with drug- and catheter ablation-refractory VT, often associated with advanced heart failure.

Purpose

To analyze the determinants of mortality after SBRT for VT.

Methods

Patients with drug- and catheter ablation-refractory VT underwent imaging prior to SBRT. The inHEART technology was used to create image-based 3D models of substrate, cardiac anatomy, and organs at risk (coronaries, phrenic nerve, GI tract, AV node). In MUSIC software (IHU Liryc-Inria), 3D models were fused with prior EP maps, and SBRT targets were interactively drawn in 3D by the referring EP cardiologist. Transmural target volumes and organs at risk were fused with a 4D planning CT and used to plan SBRT in Eclipse (Varian). SBRT was delivered with either Truebeam or Edge systems (Varian), at a total dose of 25 Gy in a single session. The determinants of adverse outcomes after SBRT were analyzed.

Results

30 pts from 7 centers were included (age 70±10, 90% men). Mean LVEF was 26±9%. The VT etiology was ischemic in 67%, and non-ischemic or mixed in 47%. Patients had undergone a mean of 1.7±1.2 prior failed catheter ablation procedures. SBRT was delivered on median planning treatment volumes (PTVs) of 96[63-149] mL. Complications attributed to SBRT were observed in 2/30 (7%), none of which were fatal (heart failure and pneumonitis, both managed with steroids). Over a median FU of 4[2-8] months, death or heart transplant occurred in 11(37%) pts, attributed to VT recurrence in 4(13%), and heart failure in 7(23%). On univariate analysis, patients experiencing death or transplant after SBRT were older (77±6 vs. 66±9 years, P=0.001) and showed lower LVEF (22±6 vs. 29±10%, P=0.03). In contrast, mortality or transplant did not relate to the underlying VT etiology (P=0.30), the number of prior catheter ablations (P=0.20), the pre-SBRT VT burden (P=0.20) and the SBRT treatment volume (P=0.18).

Conclusion

In patients with severe drug- and catheter ablation-refractory VT undergoing cardiac SBRT, mortality is most often due to non-arrhythmic causes, and is more driven by age and LV dysfunction than by the VT substrate, pre-SBRT arrhythmia burden, and SBRT treatment volume.
Implantable cardioverter defibrillator in arrhythmogenic cardiomyopathy: which role for antitachycardia pacing?
Authors: Spadotto A , Toniolo S , Bartoli L , Statuto G , Angeletti A , Massaro G , Martignani C , Ziacchi M , Diemberger I , Galie N , Biffi M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmogenic Cardiomyopathy (ACM) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden cardiac death. Implantable cardioverter defibrillator (ICD) remains the only proven therapy to reduce mortality in ACM.

Purpose

The objective of this study was to identify characteristics of ventricular arrhythmias and treatment in patients with ACM.

Method

Retrospective analysis of the data of consecutives patients with confirmed diagnosis of ACM based on the proposed Padua Criteria, who underwent implantation of transvenous ICD from January 1992 and October 2021. The clinical data and information about appropriate and inappropriate ICD therapies were obtained from medical records with the review of the available intra-cardiac electrograms (EGMs).

Results

We enrolled 52 patients (69% males, mean age at implant 48.9 ±14.8 years), 27 (52%) were implanted for primary prevention, 25 (48%) for secondary prevention. After a median follow-up of 7.52 years [IQR: 4.37 - 12.0], 32 patients (61.5%) had 914 sustained episodes of ventricular arrhythmias (VA). 25 patients (48%) had 309 episodes of life-threatening arrhythmias (LT-VA), defined as sustained ventricular tachycardia ≥200 beats/min. In 29/32 patients (91%) ATP treated at least one episode of VA and in 14/25 (56%) at least one episode of LT-VA. Ventricular tachycardia (VT) detection was programmed at least 20 seconds, while VF detection was at least 7 seconds. Among patients with appropriate ICD activation, the first treated episode was a LT-VA in 50% of cases. Out of 914 VA episodes, 735 (80.4%) were treated with ATP and 179 (19.6%) with shocks. Considering LT-VA (cycle length 248 ± 25 ms), 201/309 (65%) and 108/309 (35%) episodes were treated with ATP and shocks, respectively. In 13 patients (25%) there was an inappropriate ICD activation, mostly caused by atrial fibrillation, while in 8 patients (15%) there was a complication needing reintervention (in 3 cases there was a loss of ventricular sensing dictating lead revision).

Conclusions

ACM patients are at risk of VA and LT-VA. The majority of VA at follow-up are monomorphic at rate <200 beats/minute, however the first treated VA episode is a LT-VA in half of cases. ATP is highly successful in terminating VT and even LT-VA, which questions the use of non-transvenous ICD in this young patient population. Nevertheless, transvenous ICDs are burdened by a relevant rate of lead complications which should be weighed in the choice of the ICD type.
Leadless pacemaker implantation in patients with a previous transvenous device
Authors: Jelisejevas J , Regoli F , Hofer D , Conte G , Saguner AM , Caputo ML , Grazioli L , Steffel J , Auricchio A , Breitenstein A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Leadless pacing has been established as an alternative approach to transvenous devices for selected patients suffering from bradycardias. While in the majority of cases leadless pacemaker implantation represents a de novo procedure, in an increasing number of patients such a device is used after a previously implanted transvenous pacemaker.

Purpose

Retrospective analysis of the efficacy and safety outcome in patients who underwent leadless pacemaker implantation in the context of a previously implanted conventional pacemaker.

Methods and Results

In this retrospective analysis from two large Swiss implantation centres, 257 consecutive patients undergoing leadless pacemaker implantation were included. Of the total cohort, 233 patients were diagnosed with new-onset bradycardias, while in 24 patients a prior transvenous device was present. Out of these 24 patients, 20 subjects required lead extraction of the previous system due to infection (70%, 14 patients), malfunction or other reasons (Table 1). In 3 patients with device-related infection, lead extraction and leadless pacemaker implantation were performed as a single procedure, while in the remaining 11 cases a time window between the two procedures was present (median of 11.5 days with a range of 2 to 186 days). In the population with a previous device, mean age at implantation was 81 ± 9 years which did not differ compared to the de novo cohort. Mean implantation duration was 57 ± 31 minutes in the cohort with a previous device versus 48 ± 191 minutes in the de novo population without a significant difference (P=NS) and with a successful implantation rate of 100% versus 98.7% in the de novo population (P=NS). Electrical device parameters (sensing, impedance, threshold) at implantation and during follow-up (mean 12.5 ± 9.3 months) were similar between the two groups. Eight major periprocedural complications (3.1%) were encountered (4 pericardial effusions, 3 femoral bleedings and 1 intra-abdominal bleeding) in the entire cohort within a 30 days period, of which the majority occurred in the de novo cohort (75 %, 6 of 8). A total of 4 pericardial effusions occurred, which could be managed without the need for cardiac surgery. The were no reinfections registered after leadless pacemaker implantation during follow-up.

Conclusions

Implantation of a leadless pacemaker in patients with a prior conventional system (with or without extraction of the previous device) was effective and safe in our population of patients.
Leadless pacemaker implantation after transcatheter aortic valve replacement
Authors: Jelisejevas J , Regoli F , Hofer D , Conte G , Saguner AM , Caputo ML , Grazioli L , Steffel J , Auricchio A , Breitenstein A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Impairment of the conduction system may occur in 9-30 % of patients undergoing transcatheter aortic valve replacement (TAVR). Since this is typically an elderly and frail patient population, leadless pacing potentially offers benefits over conventional transvenous pacemaker devices. However, available efficacy and safety outcome data of leadless pacing in a population who underwent a TAVR procedure is still limited.

Purpose

Retrospective analysis of efficacy and safety outcome data in patients who underwent leadless pacemaker implantation after TAVR due to relevant bradycardias.

Methods and Results

In this retrospective analysis from two large Swiss implantation centres, 257 consecutive patients undergoing leadless pacemaker were included. Of the total cohort, 26 subjects had a previous TAVR complicated by early (within 30 days)- or late-onset (after 30 days) bradycardias (Table 1). The TAVR group did not differ compared to the non-TAVR with regard to age, gender and left-ventricular ejection fraction (LVEF). Median duration between valve intervention and leadless pacemaker implantation was 8 days (range 0 to 368 days). After a TAVR procedure, left femoral access was chosen in 30.8% (8 of 26 of cases) for the leadless pacemaker implantation as compared to 5.2% (12 of 231 of the cases) in the remaining population (P < 0.01). Mean implantation duration was 56 ± 22 min in the TAVR group compared to 48 ± 20 min (P = NS) and a successful implantation rate of 100.0 % in the TAVR group vs 98.7% in the remaining population (P = NS). There were no significant differences in pacing parameters (sensing, impedance and threshold, respectively) between the two groups. A total of eight major periprocedural complications (3.1%) were encountered in the entire cohort within 30 days, of which one (pericardial effusion) occurred in the TAVR population (P = 0.04), which was managed conservatively with pericardiocentesis.

Conclusions

Leadless pacemaker implantation appears to be safe and effective in patients after TAVR in need of antibradycardia pacing.
Patient characteristics, predictors and outcome of pacemaker patients upgraded to an implantable cardioverter defibrillator
Authors: Baldinger SH , Burren D , Noti F , Servatius H , Seiler J , Madaffari A , Asatryan B , Tanner H , Reichlin T , Haeberlin A , Roten L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pacemaker (PM) patients may require a later upgrade to an implantable cardioverter-defibrillator (ICD). Limited data exists on this patient population. We sought to characterize this population, to assess predictors for ICD upgrade, and to report the outcome.

Methods

From our prospective PM and ICD implantation registry, all patients who underwent PM and/or ICD implantations at our center were analyzed. Patient characteristics and outcome of PM patients with subsequent ICD upgrade were compared to age- and sex-matched patients with de novo ICD implantation, and to PM patients without later upgrade.

Results

Of 1’301 ICD implantations, 60 (5%) were upgrades from PMs. Median time from PM implantation to ICD upgrade was 2.6 years (IQR 1.3-5.4) Of 2’195 PM patients, 28 patients underwent subsequent ICD upgrade, corresponding to an estimated annual incidence of an ICD upgrade of at least 0.33%. Lower LVEF (p=0.05) and male sex (p=0.038) were independent predictors for ICD upgrade. Transplant- and LVAD-free survival was worse both for upgraded ICD patients compared to matched patients with de novo ICD implantation (p=0.05; Figure, panel A), as well as for PM patients with later upgrade compared to matched PM patients not requiring an upgrade (p=0.036; Figure, panel B).

Conclusions

One of twenty ICD implantations are upgrades of patients with a PM. At least one of 30 PM patients will require an ICD upgrade in the following 10 years. Predictors for ICD upgrade are male sex and lower LVEF at PM implantation. Upgraded patients have worse outcome.