bluuebunny/crossref_metadata_2025 huggingface dataset:
Low haemoglobin is associated with increased risk of complications in left atrial appendage closure patients
Authors: Zweiker D , Sieghartsleitner R , Toth G , Stix G , Vock P , Schratter A , Fiedler L , Aichinger J , Steinwender C , Binder R.K , Barbieri F , Ablasser K , Verheyen N , Zirlik A , Scherr D ,   the Working Group on Rhythmology, Austrian Council for Cardiology
Published: October 2021

Introduction

Left atrial appendage closure is associated with a relevant procedural complication rate. Baseline risk factors, such as pre-procedural lab results, may identify patients that develop acute complications.

Methods

We performed a retrospective analysis of the impact of baseline characteristics and preprocedural lab results on the acute procedural outcome in patients undergoing left atrial appendage closure from the Austrian Left Atrial Appendage Closure Registry between 2010 and 2019. The endpoint for procedural complications was defined as death, stroke, major bleeding, necessity for intensive care, other complications requiring invasive interventions or failure to implant the device. We also evaluated a modified endpoint with the exclusion of bleeding events. Logistic regression was performed using stepwise approach (backward method with p_out = 0.1) and forced inclusion of age, left-ventricular function and kidney function.

Results

A total of 320 consecutive patients from 9 centres with a median age of 75 years (36.6% female) were included. Seventy-eight percent had a history of bleeding and 35% had a history of stroke. Median CHA2DS2-VASc score was 5 (interquartile range, 3–5) and median HAS-BLED score was 3 (2–4). Procedural complications occurred in 15.3% of cases. Low haemoglobin and low activated partial thromboplastin time were associated with an increased complication rate. Other significant baseline factors were liver disease, absence of intracranial haemorrhage and severe aortic stenosis. In multivariate analysis, low haemoglobin remained a significant predictor, even after adjustment for age, left-ventricular function and kidney function (Table). In the modified procedural complication endpoint excluding major bleeding events (14.1%), low haemoglobin remained a significant predictor (haemoglobin 11.9±2.0 vs. 12.8±2.0 g/dL in patients with vs. without modified endpoint, p=0.013). A baseline haemoglobin lower than 12 g/dL was present in 39.4% and it increased relative risk of procedural complications by 89% (21.4 vs. 11.3% in patients with reduced vs. normal haemoglobin), and risk of complications without bleeding by 92% (19.8 vs. 10.3%).

Conclusion

Low baseline haemoglobin is independently associated with a higher complication rate after left appendage closure compared to patients with normal haemoglobin levels, even in a modified endpoint excluding bleeding and requirement for transfusion.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific - unrestricted grant Table 1
Adherence to the 4S-AF Scheme in the Balkan region: insights from the BALKAN-AF survey
Authors: Koziel M , Mihajlovic M , Nedeljkovic M , Pavlovic N , Paparisto V , Music L , Trendafilova E , Rodica Dan A , Kusljugic Z , Dan G.-A , Lip G , Potpara T ,   BALKAN-AF Investigators
Published: October 2021

Background

Current European Society of Cardiology guidelines on atrial fibrillation (AF) propose a structured characterization of AF in order to facilitate the evaluation of patients by physicians at all healthcare levels. The 4S-AF structured scheme includes four domains: stroke risk, symptoms, severity of AF burden and substrate severity.

Purpose

To evaluate the adherence to the 4S-AF scheme in patients with high risk of stroke (CHA2DS2-VASc score ≥3 in females or ≥2 in males) in the post-hoc analysis of the BALKAN-AF dataset.

Methods

Prospective enrolment of consecutive patients with electrocardiographically documented AF was conducted in seven Balkan countries.

Results

Of the 2,712 enrolled patients, 2,712 (100.0%) had data on CHA2DS2-VASc score. 162 (6.0%) had truly low risk of stroke (CHA2DS2-VASc score of 0 in males and 1 in females). 2099 (77.4%) of patients had high risk of stroke and 613 (22.6%) individuals had low or intermediate risk of stroke (CHA2DS2-VASc score <3 in females or <2 in males). 75 (46.3%) of patients with truly low stroke risk and 1555 (74.1%) of patients with high risk of stroke were offered oral anticoagulants (OAC).

Of the 2,712 patients, 2,677 (98.7%) had data on European Heart Rhythm Association (EHRA) symptom score. Among 2,099 patients with high risk of stroke, 703 (33.4%) individuals had EHRA symptom score of 3 or 4. 207 (29.4%) of patients with EHRA symptom score of 3 or 4 and high risk of stroke were offered rhythm control strategy.

620 (55.2%) of patients with first diagnosed AF or paroxysmal AF with high risk of stroke were offered rhythm control strategy.

1927 (91.8%) of patients with high risk of stroke had ≥2 comorbidities. Mean left atrial diameter in patients with high risk of stroke was 46.5±7.8 mm.

Conclusions

OAC overuse was seen in patients with truly low stroke risk, whist OAC underuse was evident in patients with high risk of stroke. The proportion of highly symptomatic patients (EHRA 3 or 4) with high risk of stroke who were offered rhythm control strategy was low. The proportion of patients with first diagnosed AF or paroxysmal AF with high risk of stroke who received rhythm control was small. The majority of AF patients with high risk of stroke had ≥2 comorbidities. Overall, treatment decision-making was not based on the 4S-AF scheme.

Funding Acknowledgement

Type of funding sources: None.
A new electrophysiological triad for atrial flutter critical isthmus identification and localization
Authors: Adragao P , Nascimento Matos D , Galvao Santos P , Costa F.M , Rodrigues G , Carmo J , Carmo P , Cavaco D , Morgado F , Mendes M
Published: October 2021

Introduction

In a previous retrospective study it was demonstrated that an electrophysiological triad was able to identify critical isthmus in atrial flutter (AFL) patients. This triad is based in the Carto® electroanatomical mapping (EAM) version 7, which displays a histogram of the local activation times (LAT) of the tachycardia cycle length (TCL), in addition to the activation and voltage maps. This study aimed to prospectively assess the ability of an electrophysiological triad to identify and localize the AFL's critical isthmus.

Methods

Prospective analysis of a unicentric registry of individuals who underwent left AFL ablation with Carto® EAM. All patients with non-left AFL, lack of high-density EAM, less than 2000 collected points or lack of mapping in any of the left atrium walls or structures were excluded. Ablation sites of arrhythmia termination were compared to an electrophysiological triad constituted by: areas of low-voltage (0.05 to 0.3mV), sites of deep histogram valleys (LAT-Valleys) with less than 20% density points relative to the highest density zone and a prolonged LAT-Valley duration that included 10% or more of the TCL. The longest LAT-Valley was designated as the primary valley, while additional valleys were named as secondary.

Results

A total of 12 patients (9 men, median age 72 IQR 67–75 years) were included. All patients presented with left AFL and 67% had a previous atrial fibrillation and/or flutter ablation. The median TCL and number collected points were 250 (230–290) milliseconds and 3150 (IQR 2340–3870) points, respectively. All AFL presented with at least 1 LAT-Valley in the analysed histograms, which corresponded to heterogeneous low-voltage areas (0.05 to 0.3mV) and encompassed more than 10% of TCL. Eleven of the 12 patients presented with at least 1 secondary LAT-Valley. All arrhythmias were effectively terminated after undergoing radiofrequency ablation in the primary or the secondary LAT-Valley location.

Conclusion

In a prospective analysis, an electrophysiological triad was able to identify the AFL critical isthmus in all patients. Further studies are needed to assess the usefulness of this algorithm to improve catheter ablation outcomes.

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of heart rate reserve during dipyridamole stress echocardiography in patients with abnormal chronotropic response to exercise
Authors: Cortigiani L , Carpeggiani C , Landi P , Raciti M , Bovenzi F , Picano E
Published: October 2021

Aim

To assess the prognostic meaning of HRR during dipyridamole stress echocardiography (DSE) in patients with abnormal chronotropic response to exercise.

Methods

From 2004 to 2019, we prospectively acquired and retrospectively analyzed 379 patients (age 62±11 years; ejection fraction 60±5%) with suspected (n=243) or known (n=136) chronic coronary syndromes, referred to DSE for chronotropic incompetence during upright bicycle exercise-electrocardiography test defined as HRR used [(peak HR − rest HR) / (220 − age) − rest HR] <80% in patients off and <62% in patients on beta-blockers. All patients were in sinus rhythm and underwent DSE (0.84 mg/kg) within 3 months of exercise testing. During DSE, age-independent HRR (peak/rest HR) <1.22 was considered abnormal. All patients were followed-up. All-cause death was the only outcome measure.

Results

HRR during DSE was normal in 275 (73%) and abnormal in 104 patients (27%). During a follow-up of 9.0±4.2 years, 67 patients (18%) died. The 15-year mortality rate was 23% in patients with normal and 61% in patients with abnormal HRR (p<0.0001) (Figure). At multivariable analysis a blunted HRR during DSE was an independent predictor of outcome (hazard ratio 2.01, 95% confidence intervals 1.23–3.29; p=0.005) with age and diabetes, while neither inducible ischemia nor ongoing beta-blocker therapy were significant predictors.

Conclusion

A blunted HRR during DSE predicts a worse survival in patients with chronotropic incompetence during exercise test. HRR during DSE is an appealingly simple biomarker of cardiac autonomic dysfunction independent of imaging, exercise and beta-blocker therapy.

Funding Acknowledgement

Type of funding sources: None.
Endocardial pacing compared to epicardial left ventricle pacing and right ventricle pacing: a single center long term experience in a pediatric population
Authors: Gatti P , Eliasson H , Gadler F
Published: October 2021

Introduction

Complete atrioventricular block (CAVB), either congenital or post heart surgery, are the main indications for cardiac pacing in the pediatric population.

Epicardial pacing is preferred in small infants or for specific cardiac anomalies and some studies highlight a superior contraction pattern when pacing epicardially from the left ventricular apex region [1–3]. Endocardial pacing is more frequently used in children with a weight >20 kg and is less invasive [4].

Paced QRS duration seems to be independently associated with ventricular dysfunction irrespective of location or age at device implantation [5].

Purpose

Describe the echocardiographic and electrocardiographic changes after switch from epicardial to transvenous pacing in a pediatric population with CAVB.

Methods

Children (0–18 years), who underwent a switch from left- (LV) or right ventricle (RV) epicardial pacing to transvenous pacing at our center, were retrospectively studied. Clinical, ECG- and echocardiographic parameters before and after the switch of the PM-system were collected as well as the most recent FU data. Left ventricular end-diastolic diameter (LVDD) and fractional shortening (FS) values were transformed to a body surface-related and age-related z-score (z), respectively.

Results

Fifteen patients with CAVB who received an epicardial pacemaker (60% congenital, 40% post-cardiac surgery) were converted to a transvenous system at our center (2005–2021). The median age at the switch was 6.8 (2–13) years with a median weight of 21 (9–62) kg. The epicardial lead location was more frequently the RV wall (60%) than the LV wall (40%). The RV outflow tract and interventricular septum were the most common locations (73%) for the endocardial leads. The mean QRS duration during epicardial stimulation was 150 (IQR 26) ms vs. a median QRS duration with the transvenous system of 136 (IQR 19) ms and a median delta QRS duration of 13ms. A detailed comparison between RV and LV epicardial pacing are reported in Figure 1. Children with post-surgical AV block had a broader median QRS duration, both with epicardial and endocardial stimulation. Before the switch, there was only one abnormal observation of FS less than −2 z with normal LVDD. At the last available follow-up (mean time 7 years), all the children had normal LVDD and only one had FS less than −2 z.

Conclusions

Our report of pediatric patients after switch from epi to endo pacing, shows good results in terms of QRS duration with no significant echocardiographic or clinical evidence of deterioration of the cardiac function. Due to the small sample size the results could serve as a hypothesis generator, but larger prospective studies are needed to evaluate the electrocardiographic and echocardiographic impact of transvenous - compared to epicardial pacing.

Funding Acknowledgement

Type of funding sources: None. Comparison of QRS duration
Speckle tracking during stress echocardiography using high frame rate imaging
Authors: Orlowska M , Ramalli A , Bezy S , Voigt J.-U , D'hooge J
Published: October 2021

Background

As many cardiac diseases do not lead to symptoms under resting conditions, subjecting the patient to a stress (e.g. exercise) test is clinical routine to reveal disease. Quantification of cardiac function using speckle tracking echocardiography (STE) during such stress test remains a challenge not only as overall image quality typically drops but also as the heart rate increases which results in an unfavourable heart-rate-to-frame-rate ratio as required for robust tracking. Moreover, conventional STE runs at relatively low frame rate thereby under-resolving peak strain rate (SR) values – which is particularly true at high heart rates – while this biomarker has been shown to better disclose stress-induced disease than strain using Tissue Doppler Imaging (TDI)-based strain methodologies.

Purpose

The aim of this study was therefore to test whether HFR STE could reveal the strain / SR response described previously in the TDI literature.

Methods

Stress echocardiography was performed in 25 healthy volunteers at four different stress levels (baseline, 25%, 50% and 66% of maximum workload) using a supine bike. Apical 4-chamber views were recorded using the ULA-OP 256 experimental scanner running a HFR sequence based on the compounding of 6 diverging wave transmits to achieve a frame rate of 833Hz. A myocardial contour was manually drawn on the reconstructed images and tracked during the cardiac cycle by a custom-made 2D HFR STE algorithm (DOI: 10.1109/TUFFC.2020.2985451). Then, strain and strain rate curves were computed from which systolic (S) and diastolic (early (E) and late (A)) peak values, as well as the short-lived isovolumic relaxation peak (IVR) were extracted. Finally, these values were compared amongst the different stress levels using a single factor ANOVA.

Results

Some datasets had to be discarded as the contour was not properly tracked at a visual assessment of an expert cardiologist. Tracking was feasible in 92%, 98%, 80% and 64% of cases, for baseline, 25%, 50% and 66% of maximum workload, respectively. The decreasing feasibility with exercise level is in line with what is seen clinically, as volunteers' breathing is faster and heavier with increasing exercise level making the imaging more challenging. The extracted strain and SR curves showed a physiological pattern (Fig. 1a). As shown in Fig. 1b, the global systolic strain response was biphasic, showing a significant increase at low stress level but then reaching a plateau. In contrast, all SR indices linearly increased at each stress level.

Conclusion

Strain rate clinical markers extracted with HFR STE are concordant with what was reported in TDI literature. These findings show that HFR STE allows to assess cardiac function adequately during stress echocardiography.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): FWO - Research Foundation Flanders
Idiopathic ventricular arrhythmias ablating from different subregions in the aortic sinus cusps: anatomic distribution, electrocardiography, and electrophysiology characteristics
Authors: Weng S.X , Zhai Z.Q , Tang M , Zhang S ,   fuwai hospital
Published: October 2021

Background

Previous studies had described the electrocardiographic or electrophysiological characteristics of ventricular arrhythmias (VAs) from 3 aortic sinus cusps (ASC) as a whole, while little is known about the differences among VAs ablated in different subregions of the ASC.

Objective

To investigate the distribution, specific precordial electrocardiographic sign, and bipolar electrogram characteristics of VAs ablated in different subregions of the ASC.

Methods

We divided the right coronary cusp (RCC) and the left coronary cusp (LCC) into 6 subregions and studied 51 idiopathic VAs ablated successfully in the ASC.

Results

Fifty-one VAs inhomogeneous distributed in the 6 subregions, which rarely located in the lateral RCC (L-RCC; 2%). The fractionated potential was dominant (39/51, 76%) in the three kinds of target electrograms. From the L-RCC to the lateral LCC (L-LCC), the percentage of fractionated potential gradually decreased from 100% to 59%. A precordial rebound notch in V3–4 or V4–5 had a sensitivity of 90.9%, a specificity of 85.0%, and a negative predictive value (NPV) of 97.1% to predict VAs ablating from the anterior RCC (A-RCC). A precordial rebound notch in V2–3 had a sensitivity of 50.0%, a specificity of 94.9%, and a NPV of 86.0% to predict VAs ablating from the L-LCC.

Conclusion

The targets of the ASC-VAs mainly distributed in the anterior ASC and the L-LCC. Fractionated potential is common among target bipolar electrograms especially in the anterolateral RCC. Precordial electrocardiographic rebound notch has a high predictive accuracy for identifying different subregions of the ASC-VAs.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Predictors of survival and ICD shocks in a population submitted to ventricular tachycardia ablation
Authors: Alves Da Silva P , Rodrigues T , Brito J , Silverio-Antonio P , Cunha N , Couto-Pereira S , Valente-Silva B , Carpinteiro L , Cortez-Dias N , Pinto F.J , De Sousa J
Published: October 2021

Introduction

Sustained monomorphic ventricular tachycardia (VT) is associated with an increased risk of mortality and morbidity in patients with ischemic heart disease (IHD). While implantable cardiac defibrillators (ICD) have been shown to reduce mortality in patients with IHD and are effective in terminating VT, they are unable to prevent recurrent VT. Also, recurrent ICD shocks have been associated with an increase in all-cause mortality, hospitalizations for heart failure and are painful, resulting in impaired quality of life. Therefore, strategies to prevent ICD shocks are needed.

Aim

To evaluate risk factors associated to all cause Mortality and ICD shocks

Methods

We conducted a prospective, observational, single-centre and single-arm study involving patients with IHD, referred for Radiofrequency catheter ablation (RCA) procedure for VT using high-density mapping catheters. Variables selected from the univariate analyses (p<0.10) were entered into multivariable Cox proportional hazards regression models to estimate predictors of ICD shocks recurrence and overall mortality. All analyses were 2-sided and a P-value <0.05 was considered statistically significant. Statistical analysis was performed by using IBM SPSS Statistics 26™.

Results

From June 2015 to June 2020, a total of 64 consecutive patients were referred to our centre for a first RCA procedure using high density mapping for VT. The mean age was 68±9 years, 95% were male. 83% of patients were in NYHA functional class II or I and mean LV ejection fraction was 33±11%. All-cause mortality was 23.4%, an age higher than 70 years (p=0.01) and chronic kidney disease (CKD) were associated with reduced survival on univariate analysis. On multivariate analysis, CKD shown a tendency to reduced survival (HR 0.22; CI95%: 0.41–1.22, p=0.08). No risk factors for ICD shocks were found (table 2).

Conclusions

In our population, age and chronic kidney disease were associated with reduced survival, however no risk factors were associated with ICD shocks.

Funding Acknowledgement

Type of funding sources: None.
Comparison of mortality prediction scores in elderly patients with ICD for heart failure with reduced ejection fraction
Authors: Hayiroglu M.I , Cinar T , Cinier G , Pay L , Yumurtas A.C , Tezen O , Eren S , Kolak Z , Cetin T , Ozcan K.S , Turkkan C , Ozbilgin N , Tekkesin A.I , Alper A.T , Gurkan K
Published: October 2021

Background

This investigation aimed to examine and compare the predictive value of MADIT-II, FADES, PACE and SHOCKED scores in predicting 1-year and long-term all-cause mortality in implantable cardioverter-defibrillator (ICD) implanted patients who were 75 years and over since there has been an area of uncertainty about the utility and usefulness of available risk scores in such cases.

Methods

In this observational, retrospective study, ICD implanted 189 geriatric patients are divided into two groups according to the presence of long-term mortality in follow-up. The baseline characteristics and laboratory variables were compared between the groups. MADIT-II, FADES, PACE and SHOCKED scores were calculated at the time of ICD implantation. 1-year and long-term predictive value of these scores were compared by a receiver operating curve (ROC) analysis.

Results

A ROC analysis showed that the best cut-off value of the MADIT-II score to predict 1-year mortality is 3 with 87% sensitivity and 74% specificity (AUC: 0.83; 95% CI: 0.73–0.94; p<0.001) and long-term mortality is 2 with 83% sensitivity and 43% specificity (AUC: 0.68; 95% CI: 0.60–0.76; p<0.001) The predictive value of MADIT-II was superior to FADES, PACE and SHOCKED scores in ICD implanted patients who are 75 years and over.

Conclusion

MADIT-II score has a significant prognostic value compared to FADES, PACE and SHOCKED scores for the prediction of 1-year and long-term follow-up in geriatric patients implanted ICD for heart failure with reduced ejection fraction.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
High incidence of inappropriate alarms in patients with wearable cardioverter-defibrillators: findings from the swiss WCD registry
Authors: Kovacs B , Burri H , Reek S , Sticherling C , Linka A , Ammann P , Mueller A.S , Kobza R , Haegeli L , Mayer K , Eriksson U , Reichlin T , Steffel J , Saguner A.M , Duru F ,   Swiss WCD Registry
Published: October 2021

Introduction

The wearable cardioverter defibrillator (WCD) uses surface electrodes built into the vest to detect underlying arrhythmia before initiating a treatment sequence. However, it is also prone to inappropriate detection due to artefacts.

Purpose

The aim of this study was to assess the alarm burden in patients and its possible impact on clinical outcomes.

Methods

The Swiss WCD Registry is a nationwide, retrospective, observational registry. Patients were included from December 2011 until February 2018. Clinical characteristics and data from the WCDs, including alarm burden were analysed. Recordings ≥30 seconds of length were analysed and categorized as VT/VF, atrial fibrillation (AF), supraventricular tachycardia or artefact.

Results

A total of 10'653 device alarms were documented in 324 of 456 patients (71.1%) over a mean WCD wear-time of 2.0±1.6 months. Among these, the episode duration was 30 seconds or more in 2996 (28.2%). One hundred and eleven (3.7%) were VT/VF episodes. The remaining recordings were inappropriate arrhythmia detections (2736 (91%) due to artefacts; 117 (3.7%) AF; 48 (1.6%) supraventricular tachycardia). Two-hundred and seven patients (45.0%) had 3 or more alarms per month, whereas 49 patients (10.7%) had 1 or more alarms per day. Body mass index (BMI) was significantly higher in patients with 3 or more alarms per month (p=0.002, 25.6 vs. 27.3 kg/m2) High alarm burden was not associated with a lower average daily wear time (20.8 hours vs 20.7 hours, p=0.785) or a decreased implantable cardioverter defibrillator implantation rate after stopping WCD use (48% vs 47.3%, p=0.156).

Conclusions

In patients using WCDs, alarms emitted by the device and impending inappropriate shocks were frequent and most commonly caused by artefacts. A high alarm burden did not lead to a decreased adherence, as determined by average daily wear-times. Obesity was significantly associated with a higher alarm burden.

Funding Acknowledgement

Type of funding sources: None.
Stability of pacemaker parameters in cardiac amyloidosis patients
Authors: Wang J.Q , Yang D.Y , Fang Q
Published: October 2021

Cardiac amyloidosis is a rare disease due to the deposition of amyloid fibrils in the heart. Clinical manifestation of the heart includes restrictive heart failure and arrhythmia, when myocardium and conduction system are involved respectively. Arrhythmia can present as atrioventricular block (AVB), and sick sinus syndrome (SSS), therefore cardiac amyloidosis may require permanent pacemaker implantation. However, the stability of pacemaker parameters in cardiac amyloidosis patients remains unknown.

We conducted an observational retrospective study of patients diagnosed with cardiac amyloidosis who underwent permanent pacemaker implantation from January 1, 2011 to December 31, 2019. Base-line data were obtained via Medical Record System. Data of pacemaker parameters were obtained via pacemaker programming at the time of implantation and last follow-up at the clinic.

A total of 10 patients were included in our study, among which 5 patients underwent cardiac biopsy and showed positive result, 4 patients showed positive biopsy result of other tissue and characteristic echocardiography result of restrictive diastolic dysfunction, 1 patient was diagnosed with primary systematic amyloidosis (AL) involving kidney and advanced atrioventricular block. Amyloidosis type of the 10 patients were primary systemic amyloidosis (AL). Among the 10 patients, 3 were female (30.0%), and the mean age was 61.3±3.9. All patients met the indication for permanent pacemaker implantation, including 9 SSS and 1 advanced AVB. 9 patients were implanted with DDD, and 1 with VVI. The middle survival time was 446 (331, 728) days from the time of implantation to last follow-up (June 30, 2020). Two patients died due to disease progression. As for the 7 patients whose baseline and follow-up data were both obtained, pacemaker parameters at baseline were as followed: Atrial Impedance 477.8±115.0 Ω, Atrial P Wave 1.30±0.70 mV, Atrial Threshold 0.75±0.16 V@0.4ms, Ventricular Impedance 551.3±233.4 Ω, Ventricular R Wave 7.99±4.66 mV, Ventricular Threshold 0.76±0.15 V@0.4ms. Pacemaker parameters at follow-up were as followed: Atrial Impedance 426.2±93.2 Ω, Atrial P Wave 1.34±0.71 mV, Atrial Threshold 1.59±1.51 V@0.4ms, Ventricular Impedance 405.8±41.6 Ω, Ventricular R Wave 10.69±6.53 mV, Ventricular Threshold 1.80±1.88 V@0.4ms.

Most patients relieved from cardiac symptoms and severe cardiac complications. A relatively short-term follow-up indicated elevation of Ventricular Threshold (P=0.028), and analysis of other parameters showed insignificant results. Elevation of Ventricular Threshold may be explained by the progression of amyloid fibrils deposition in the heart. Ventricular Threshold of one patient significantly increased from 1.0 V to 6.0 V at 3-month follow-up. Since all patients underwent chemotherapy for the primary amyloidosis, stability of pacemaker parameters may be another way for evaluation. Long-term follow-up is needed for further evaluation.

Funding Acknowledgement

Type of funding sources: None.
Single- vs dual-chamber ICDs to prevent from inappropriate shocks: the debate is still alive
Authors: Briongos Figuero S , Estevez A , Perez M.L , Martinez Ferrer J.B , Garcia E , Vinolas X , Arenal A , Alzueta J , Munoz Aguilera R
Published: October 2021

Background

The efficacy of dual-chamber implantable cardioverter defibrillators (ICDs) in preventing from inappropriate shocks (IS) is still a matter of debate.

Purpose

To compare the risk of IS among single- and dual-chamber ICDs in a cohort of heart failure (HF) patients carrying a prophylactic device. We aimed to focus on the relationship between programming and discriminators, and the risk of IS in a large cohort.

Methods

All HF patients with left ventricle ejection fraction <35% undergoing a prophylactic ICD-only implant were collected from the multicentre, prospective and nationwide UMBRELLA study. ICD programming was performed according to regular clinical practice at each site and. ICD setting and arrhythmic events occurring during the study period were automatically stored through the remote monitoring system. An experts committee analysed in a blinded manner all electrograms coming from the arrhythmic events.

Results

From 2006 to 2015, 782 patients implanted with an ICD were analysed (537 patients (68.7%) with single-chamber ICDs and 245 patients (31.3%) with dual-chamber ICDs). During a mean follow-up of 4.35±2 years, 109 IS were delivered in 49 patients. IS occurred in 7.8% (n=42) of patients carrying single-chamber ICDs and in 2.9% (n=7) of dual-chamber carriers (p=0.001). A propensity score matched analysis was performed. The matched cohort was composed by 110 well-balanced (regarding baseline characteristics and programming) patients. In the weighted sample, dual-chamber ICDs were related to lower rates of IS (Figure 1) as compared to single-chamber devices (0.9% vs. 11.8%, p≤0.001).

Among programming the following ICD settings correlated to lower risk of IS: ≥30 of 40 intervals detection within ventricular fibrillation (VF) zone (HR=0.47; p=0.018), a programmed ATP-capable zone enabled through VF zone (HR=0.54; p=0.038), morphology discriminator (Wavelet®) (HR=0.42; p=0.032), and the specific dual-chamber discriminator (PR Logic®) (HR=0.28; p=0.004). After multivariable Cox regression analysis including clinical variables and device settings, PR Logic® discriminator was the only programming parameter independently related to a lower risk of IS (HR=0.18, CI 0.06–0.48, p=0.001).

Conclusions

In our nationwide cohort of primary prevention ICD-only patients, dual-chamber devices were associated with a lower risk of IS. ICDs equipped with PR Logic® discriminator might be useful to prevent from IS.

Funding Acknowledgement

Type of funding sources: None. Programming in the matched populationFigure 1
New York Heart Association class change on heart failure patients with implantable devices: does it matters?
Authors: Duarte F , Barradas M.I , Oliveira L , Serena C , Dourado R , Fontes A , Monteiro A , Machado C , Santos E , Pelicano N , Tavares A , Pacheco M , Martins D
Published: October 2021

Background

Chronic heart failure (CHF) is a pathology with high prevalence and an important cause of morbidity and mortality. Benefits of implantable devices have been demonstrated in selected groups of patients with benefits on symptoms and heart failure hospitalization.

Purpose

To determine the clinical impact of New York Heart Association class change (NYHA) in patients with CHF and Cardiac Implantable Electric Devices (CIEDs).

Methods

We retrospectively enrolled 178 consecutive patients with CHF and CIEDs between November 2003 and January 2021, during a follow-up period of 51±43,9 months. Patients demographic characteristic and NYHA class change impact on occurrence of arrhythmic events, heart failure hospitalization (HFH) or long-term admission in an emergency department were assessed. Patients with NYHA class change were considered responders to therapy.

Results

Out of 178 patients enrolled in this study, sixty-seven (37,6%) had a reduction ≥1 in NYHA functional class and in this group, 61 patients (91,0%) had a cardiac resynchronization therapy (CRT) and 9% had an implantable cardioverter defibrillator. Mean age 68±11,3 years, 44 (65,7%) patients were male, 33 (49,2%) were in NYHA class II, 30 (44,8%) NYHA class III and 4 (6%) NYHA class IV. Mean QRS width 129,9±63,1 ms before CIEDs. Fifty-eight patients (86,6%) had an improvement in one NYHA functional class and 9 patients (13,4%) in two NYHA functional class.

Fourty NYHA responders patients (59,7%) had paroxistic or permanent atrial fibrillation and 31,9% had an epicardial coronary artery disease, that was a negative predictor of NYHA response (p=0,012).

A total of 35 (19,7%) enrolled patients experience non-sustained ventricular tachycardia (NSVT) and 74,3% were non-responders (p=0,019).

There was fifteen and twenty HFH at 2 and 5 years of follow-up, respectively, and we observed that an improvement in NYHA class was associated with a reduction in HFH at 2 years of follow-up (p=0,043; OR 0,029, 95% CI 0,050–1,06) and 5 years of follow-up (p 0,027, OR 0,252; 95% CI 0,069 – 0,915). Emergency department (ED) admission related to HF decompensations was significantly reduced at 2 years of follow-up (p=0,035, OR 0,22, 95% CI 0,048 – 1,0) and at 5 years of follow-up (p=0,001, OR 0,15, 95% CI 0,044 – 0,55).

There was no difference on cardiovascular or all-cause mortality.

Conclusion

CHF patients with CIEDs and improving on NYHA class have less NSVT episodes, HFH and HF decompensations with ED admission, both at 2 and 5 years of follow-up.

Funding Acknowledgement

Type of funding sources: None.
The effect of QRS area in predicting survival benefit following cardiac resynchronization therapy: a systematic review and meta-analysis
Authors: Tokavanich N , Prasitlumkum N , Mongkonsritragoon W , Cheungpasitporn W , Trongtorsak A , Chokesuwattanaskul R
Published: October 2021

Background

QRS area, three-dimensional QRS complex, is among novel vectorcardiographical methods of measuring the magnitude of electrical forces generated by the heart. Hypothetically, greater QRS area portrayed higher dyssynchronous electrical activation, possibly deriving significant cardiac resynchronization therapy (CRT) benefit. Previous studies suggested a positive correlation between QRS areas and the degree of CRT responses. Nevertheless, its clinical use has remained premature. We hence performed a systematic review and meta-analysis of QRS area in predicting survival benefit following CRT.

Method

We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to March 2021. Included studies with prospective and retrospective cohort design. Studies those report QRS area before implantation of CRT and outcome of total mortality. Data of each study were combined with random effects model. The results were reported in hazard ration (HR) with 95% confidence intervals.

Result

Four observational studies, including 4,931 patients, were identified. The cut-off values between large and small QRS areas ranged from 102–116 μVs. Our analysis showed larger QRS area was statistically associated with survival benefit in patients implanted with CRT with follow up time up to 5 years (Pooled hazard ratio 0.46, 95% confident interval 0.38–0.55, I2=42%). More QRS areas changes (pre and post implantation) were associated with lower total mortality rate (Pooled hazard ratio 0.45, 95% confident interval 0.38–0.52, I2=0%).

Conclusion

Patients with pre-implantation larger QRS area were strongly associated with survival benefit after CRT implantation. QRS area may potentially become additional selection criteria for CRT implantation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Forest plot of pooled hazard ratioTable 1. Study characteristics
HeartLogic algorithm for heart failure monitoring in the era of CoViD-19 pandemic and remote monitoring/telemedicine
Authors: Ebrille E , Amellone C , Lucciola M.T , Suppo M , Antonacci G , Gotta F , Birolo M , Favro E , Orlando F , Giammaria M
Published: October 2021

Background

Due to the current CoViD-19 pandemic, the number of outpatient hospital visits has significantly decreased, creating a fundamental need for telemedicine. Remote monitoring of implantable cardiac devices has emerged as a powerful and well-validated tool to follow patients with heart failure (HF) and cardiac resynchronization therapy (CRTs) devices.

Purpose

The aim of our study was to evaluate the CRT HeartLogic algorithm performance in the detection of HF episodes in a real-life population followed with remote monitoring.

Methods

Fifty-four patient (mean age 73±7 years, 72% males) with HF and reduced left ventricular ejection fraction were implanted with a HeartLogic-enabled CRT device and were enrolled in the Boston Scientific Latitude remote monitoring platform. Remote data were reviewed every month and at the time of an alert. The HeartLogic nominal value of 16 was used to trigger an alert episode. Patients were then contacted by phone and actions were taken to manage the potential HF condition detected by the alert.

Results

During a median follow-up of 12 (6–18) months, the HeartLogic alert was triggered in 9 patients (9/54, 17%). The median time between threshold crossing and a HF clinical event was 11 (2–19) days. The maximum HeartLogic index value was 43 (mean 29±8). Three events occurred after inappropriate discontinuation of HF therapy. All the events required clinical action. Four out of 9 patients required diuretic dosage increase, 1/9 electrical cardioversion for new onset atrial fibrillation, 3/9 hospitalization for i.v. therapy. One patient showed only mild HF symptoms but was found to have concomitant CoViD-19 infection.

Conclusion

The HeartLogic algorithm is useful to detect HF worsening and undertake appropriate clinical actions. Telemedicine and device remote monitoring are very helpful tools allowing early detection of HF-related clinical conditions. This is of utmost importance in the era of CoViD-19 pandemic, when scheduled access to the hospital for routine follow-up appointments might be limited.

Funding Acknowledgement

Type of funding sources: None.
Patients with transthyretin amyloid cardiomyopathy may have preserved, mildly reduced, or reduced ejection fraction
Authors: Garcia-Pavia P , Fine N , Weissman N.J , Castano A , Gundapaneni B , Sultan M.B , Shah S.J
Published: October 2021

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an often-overlooked form of heart failure with preserved ejection fraction (HFpEF). Previous studies have demonstrated that relatively high proportions of older patients with HFpEF have underlying ATTR-CM. However, while ATTR-CM should not be overlooked as a cause of HFpEF, it also should not be assumed that all patients with ATTR-CM present with HFpEF.

Purpose

To categorise patients with ATTR-CM from a large clinical trial by left ventricular ejection fraction (LVEF) at enrolment in order to describe the prevalence of HFpEF, HF with mildly reduced EF (HFmrEF), and HF with reduced EF (HFrEF).

Methods

The Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) enrolled 441 patients with ATTR-CM, including both hereditary (ATTRv) and wild-type (ATTRwt) patients. In ATTR-ACT, all patients underwent echocardiography at enrolment using a standardised protocol, and all images were reviewed and analysed at an independent central laboratory. In this analysis of patient data at enrolment, all patients in ATTR-ACT were categorised by LVEF as: HFpEF (LVEF ≥50%), HFmrEF (LVEF 41–49%), or HFrEF (LVEF ≤40%). The proportions of patients in these LVEF categories in the sub-groups of race, sex, genotype, and disease severity (by NYHA class) were assessed, together with myocardial contraction fraction (MCF) in each category.

Results

In ATTR-ACT, there were 220 (50.5%) patients with HFpEF, 119 (27.3%) with HFmrEF, and 97 (22.3%) with HFrEF (Table). Five subjects with missing LVEF at enrolment were not categorized. Asian patients had the highest proportion with HFpEF, followed by White, then Black patients. The ATTRwt group had a higher proportion of patients with HFpEF than the ATTRv group. There were significant differences (as assessed by Chi-square test; P=0.0001) in the proportion of patients in each EF category between NYHA class I or II and NYHA class III patients. Median MCF was higher in NYHA class I/II (16.6%) than NYHA class III (14.8%) patients, and higher in patients with HFpEF compared with HFmrEF and HFrEF.

Conclusions

Not all patients with ATTR-CM have HFpEF. In this analysis of patients at enrolment in ATTR-ACT half had mildly reduced or reduced LVEF, with even higher proportions of reduced EF observed in Black patients, ATTRv patients, and patients with worse functional class (NYHA class III). These data demonstrate that ATTR-CM should be considered as a possible diagnosis in all patients with HF regardless of EF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Table 1
Interleukin-6 and outcomes in patients recently hospitalized with heart failure and preserved ejection fraction
Authors: Mooney L , Jackson C.E , McConnachie A , Myles R , McMurray J.J.V , Petrie M.C , Jhund P.S , Lang N.N
Published: October 2021

Introduction

Inflammation may play a role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). Interleukin-6 (IL-6) is an important inflammatory mediator but information about its prognostic relevance in HFpEF is lacking.

Purpose

To examine the association between IL-6 and outcomes in patients with HFpEF.

Methods

We assessed the relationship between IL-6 tertile (T1–3) and all cause death, cardiovascular (CV) death and first HF hospitalisation (HFH) in 340 patients admitted to hospital with HFpEF. The association between log IL-6 and outcomes was examined in a Cox regression model adjusted for MAGGIC risk score and log B-type natriuretic peptide (BNP).

Results

Range of IL-6 (pg/ml) was: T1 (0.71–4.27), T2 (4.28–7.91) and T3 (7.94–236.32). Patients with higher IL-6 were older (73.9 versus 70.3 years), more commonly male (58.4% versus 39.5%) and had higher serum creatinine (117.6 versus 106.5 μmol/l), C-reactive protein ([CRP] 17.4 versus 4.4mg/l), troponin I (6.2 versus 5.0μg/l) and BNP (331.0 versus 254.5pg/ml). Rates of CV death and all-cause mortality, but not HFH, remained significantly higher in T3 versus T1 after adjustment. When modelled as a continuous variable, one log unit increase in IL-6 was associated with higher risk of CV death (HR 1.34 [1.05–1.70]), p=0.02) and all cause death (HR 1.41 [1.13–1.75], p=0.002).

Conclusion

In patients recently hospitalised with decompensated HFpEF, IL-6 is an independent predictor of CV death and all-cause mortality after adjusting for the MAGGIC risk score and BNP. The potential utility of IL-6 as a therapeutic target in HFpEF warrants investigation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Scottish Executive Chief Scientist Office [project grant entitled, “Microvolt T-Wave Alternans in Chronic Heart Failure: A Study of Prevalence and Incremental Prognostic Value” (Ref CZH/4/439)]
Exercise-induced changes of ventricular function in male and female amateur marathon runners as assessed by three-dimensional echocardiography
Authors: Lasocka Z.B , Dabrowska-Kugacka A , Kaleta-Duss A , Lewicka-Potocka Z , Faran A , Danilowicz-Szymanowicz L , Nowak R , Kaufmann D , Raczak G , Lewicka E
Published: October 2021

Introduction

The long-term endurance training is associated with an increased risk of both right (RV) and left ventricular (LV) dysfunction. However, males and females exhibit different cardiac adaptation to exercise. The aim of our study was to evaluate three-dimensional (3D) echocardiographic parameters of ventricular function before and after the marathon in male and female amateur athletes, and compare them between sexes.

Methods

The study included 40 male (39±8 years) and 27 female (40±7 years) amateur athletes. Echocardiography was performed 2–3 weeks before (Stage 1) and immediately after (Stage 2) the marathon run. RV and LV area and function were assessed using standard and 3D echocardiography.

Results

After the marathon, there was a significant increase in the RV size (indexed RV end-diastolic volume, 51.1±12.0 vs. 59.0±9.1 ml/m2, p=0.003 in males; 48.8±11.0 vs. 60.0±11.1 ml/m2, p<0.001 in females), with a decrease in the LV dimensions (indexed LV end-diastolic volume, 57.1±11.9 vs. 53.0±9.4 ml/m2, p=0.026 in males; 66.2±7.9 vs. 60.1±9.5 ml/m2, p=0.001 in females). RV systolic contractility, as assessed by ejection fraction (EF) and fractional area change (FAC), significantly decreased at Stage 2 in both studied groups, while post-race decrease in LVEF was observed only in males (p<0.05 for the interaction sex and stage).

Conclusions

In both male and female amateur athletes, marathon running resulted in RV dilatation and reduction in function, with concomitant decrease in LV dimensions. However, 3D analysis revealed that strenuous exercise alters LV systolic function to a greater degree in men relative to women.

Funding Acknowledgement

Type of funding sources: None.
Comparing the central arterial stiffness indices in the decompensated and compensated states of heart failure: a cohort study
Authors: Youssef G , El Fol A , Ammar W , Sharaf Y
Published: October 2021

Background

Arterial stiffness is strongly linked to the pathogenesis of heart failure (HF), and development of acute decompensation of patients with stable chronic HF.

Purpose

To compare the arterial stiffness indices in patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization with acute decompensated state, and then three months later after discharge during the compensated state.

Methods

One hundred patients with acute decompensated HFrEF (NYHA class III and IV) and left ventricular ejection fraction (LVEF) ≤35% were included in the study. Fifty-six patients (56%) had ischemic cardiomyopathy (ICM) and the rest had dilated cardiomyopathy (DCM). During the initial and follow up visits, all patients were subjected to full medical history taking, clinical examination, electrocardiography (ECG), transthoracic echocardiography (TTE), routine labs and non-invasive pulse wave analysis (PWA) by the Mobil-O-Graph 24h PWA device for measurement of arterial stiffness parameters.

Results

The mean age was 51.6±6.1 years and 80% were males. There was a significant reduction of the central arterial stiffness indices in patients with HFrEF during the compensated state as compared to their decompensated state values, table (1). During the decompensated state, patients with ICM showed a significantly higher PWV as compared to patients with DCM (9.2±1.1 vs 8.6±1.4 m/sec, P=0.042), patients presented with NYHA FC IV (n=64) showed higher AI (24.5±10.0 vs 16.8±8.6, p<0.001) and PWV (9.2±1.3 vs 8.5±1.2, p=0.021) than patients with NYHA FC III, and despite the relatively smaller number of females, they showed higher stiffness indices than males, table (2).

Conclusion

Central arterial stiffness indices derived from the non-invasive Mobil-O-Graph 24h PWA device in patients with HFrEF were significantly lower in the compensated state as compared to the decompensated state. Patients with ICM, NYHA FC IV and females showed higher stiffness indices in their decompensated state of heart failure.

Funding Acknowledgement

Type of funding sources: None.