bluuebunny/crossref_metadata_2025 huggingface dataset:
Arrhythmic phenotypes in patients with left ventricular non-compaction cardiomyopathy
Authors: Rineiska N , Komissarova S , Chakova N , Niyazova S
Published: November 2020

Background

Identification of pts with left ventricular non-compaction cardiomyopathy (NCCM) at high risk of life-threatening arrhythmic events is focused on clinical and instrumental criteria. The genetic component is not taken into account when deciding on a strategy for preventive measures.

Purpose

To analyze life-threatening arrhythmic events in pts with the arrhythmic variant of NCCM and to identify genetic factors that may increase the risk of life-threatening arrhythmic events.

Methods

The study included 159 pts, among whom 58 had malignant ventricular arrhythmias (mean age 43.54±11.95 years, 34/24/58.6% male). The NCCM criteria were confirmed using Echocardiography and CMR. Mutation search was carried out by the next generation sequencing (NGS) in 21 pts with nonsustained ventricular tachycardia (NVT).

Results

During the follow-up period (median follow-up of 36 months), life-threatening arrhythmic events (documented sustained VT, SCD with successful resuscitation and CD implantation, SCD) were registered in 29 pts (50%), and 10 pts had CD implanted. As a result of sequencing, 23.8% (5 out of 21) of pts with NVT revealed rare genetic variants with uncertain clinical significance (VUS) in 3 genes encoding ion channel proteins: KCNQ1, KCNH2 (9.5%), RYR2 (9.5%). In 9 (42.9%) pts, 10 identified mutations were localized in the genes responsible for the synthesis of sarcomeric proteins: MYBPC3 (23.8%), MYH7 (23.8%). 12 genetic variants were found in overlapping phenotypes between NCCM, ARVC and DCM: PKP2, DSP, PLN, TRPM4 (14.3%), RBM20, LDB3 (9.5%), DPP6, DTNA, NEXN in 11 (52.4%) pts. In this group of pts, the most common (81.8% of cases) were life-threatening arrhythmic events that required surgical intervention: 6 pts were implanted with CD for primary prevention of SCD, two pts - CRT-D, two pts with systolic dysfunction were performed with OHT and one patient was implanted with the Accucinch transcatheter direct mitral valve annuloplasty system. In pts with mutations in sarcomeric protein genes, CD was implanted in 4.7% of cases, and in 14.3% of pts with mutations in ion channel genes (p<0.01).

Conclusion

The presence of mutations in genes that control the functioning of ion channels in complex overlapping genotypes is an additional risk factor for ventricular arrhythmias in patients with NCCM. Determining the genetic component opens up new opportunities for personalizing the risk stratification of pts with NCCM.

Funding Acknowledgement

Type of funding source: None
Re-do left cardiac sympathetic denervation (LCSD following breakthrough cardiac events in long qt syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT)
Authors: Bos J , Sorensen K.B , Moir C , Ackerman M.J
Published: November 2020

Background

Left cardiac sympathetic denervation (LCSD) is an effective anti-fibrillatory, minimally invasive therapy for patients with either LQTS or CPVT. As a pre-ganglionic fiber resection, re-growth or re-innervation is not possible. However, if a suboptimal CSD was performed, chances for post-LCSD breakthrough cardiac events (BCEs) are increased.

Purpose

To examine the prevalence and outcomes of patients requiring a re-do LCSD.

Methods

We performed a retrospective review of the 251 LQTS and CPVT patients who underwent CSD (mostly LCSD) at our institution to identify the subset referred for additional CSD because of recurrent BCEs after their primary LCSD that was performed elsewhere. Clinical data on symptomatic status prior to diagnosis and BCEs after first surgery as well as the surgical reports were reviewed to determine the reasons for the repeat procedure.

Results

Among the 15 patients (6% overall, 6 female; 13 LQTS, 2 CPVT) referred for additional CSD, 3 patients (20%) had a re-do LCSD performed instead of a sequential RCSD because of incomplete resection with the primary LCSD. Patient 1 is a male with Jervell-and-Lange Nielsen Syndrome (JLNS; KCNQ1-K421fs9X; KCNQ1-N365H), who first experienced syncope with torsades at age 3 after which a primary bilateral CSD was performed elsewhere. He had 2 BCEs and at age 12 underwent re-do LCSD, where his left-sided T2-T4 sympathetic chain with remnants of T1 were found to be intact. Patient 2 is a male who had 3 cardiac events prior to diagnosis (genotype negative LQTS) and LCSD at age 3. Following 3 BCEs, he underwent re-do LCSD at age 5 where scarring of T3 and intact stellate ganglion were found. Patient 3 is an adult female with CPVT (RYR2-deletion exon 3) who had multiple syncopal events, out-of-hospital arrest (leading to ICD) and 2 ICD-storms before primary bilateral CSD. Re-do LCSD was performed after identifying an intact left stellate ganglion and T2.

Conclusions

Before performing a primary bilateral CSD, proceeding to a RCSD after post-LCSD BCEs, or doing a videoscopic LCSD in the first place, it must be recognized that LCSD's success hinges on fully resecting the lower half of the stellate ganglion and the sympathetic chain through T4. Anything less is a partial denervation and likely ineffective procedure.

Funding Acknowledgement

Type of funding source: None
Left coronary cusp ablation to eliminate epicardial substrates – a novel strategy for left ventricular summit ventricular tachycardia ablation
Authors: Phanthawimol W , Komatsu Y , Hattori M , Naeemah Q.J , Shimoo S , Ota C , Ichihara N , Kimata A , Yamasaki H , Igarashi M , Nogami A
Published: November 2020

Background

Catheter ablation of LV summit VT can be challenging due to possible subepicardial or intramural site of origin and its close proximity to the major coronary vessels.

Objective

Local electrograms monitoring inside LV summit communicating vein potentially defines arrhythmogenic substrates and facilitates ablation from the adjacent anatomical structures.

Results

We experienced two cases of LV summit VT with epicardial local abnormal ventricular activities (Epi-LAVA) recorded from distal bipolar electrode of the 2F microcatheter in communicating vein close to the superior portion of LV summit. During sinus rhythm, Epi-LAVA displayed isolated late fractionated potentials in the first case but had initial fractionated potentials fused with terminal portion of far-field ventricular signals and late isolated potentials exhibiting 2:1 conduction in the second case. Epi-LAVA represented earliest ventricular signals during VT in both cases. Pace mapping at Epi-LAVA sites yielded single QRS morphology with excellent pacemap score and induced VT. Our strategy was to perform ablation at the facing site of Epi-LAVA aiming to eliminate the potentials transmurally. Radiofrequency (RF) energy was applied above and under the left coronary cusp opposite to Epi-LAVA sites using 3.5-mm tip open-irrigation catheter with a power of 30–35 W for 60 seconds under real-time intracardiac echocardiograhic guidance. VT was slowed and terminated in 1 second. Repeat ablation delayed and completely abolished Epi-LAVA followed by noninducibility of VT. Anatomical proximity of the left coronary cusp semilunar insertion and subepicardial or intramural site of origin possibly dictates successful ablation. Epi-LAVA from coronary vein mapping serve as a new landmark of the ablation target with a measurable procedural endpoint.

Conclusion

Elimination of epicardial substrates with RF energy application at the left coronary cusp can be a novel strategy for LV summit VT ablation.

Funding Acknowledgement

Type of funding source: None
Catheter ablation for ventricular tachycardia in Chagas disease
Authors: Kulchetscki R , Ferraz A.P , Gouvea F.C , Alexandre F.K.B , Mayrink M.P , Goncalves A.L.M , Dias V.H , Balbo C.P , Paucar A.D.R , Hardy C.A , Melo S.L , Chokr M.O , Pisani C.F , Scanavacca M.I
Published: November 2020

Background

Chagas disease (ChD) is a major cause of non-ischemic cardiomyopathy (NICM) in Latin America and is becoming more frequent in other parts of the world, especially due to immigration movements. Ventricular Tachycardia (VT) is more common in this type of NICM than others, and finding an effective treatment strategy still is a challenge. Catheter ablation is an option, but there is poor data regarding its efficacy and safety.

Purpose

Evaluate the outcomes after VT catheter ablation in ChD patients.

Methods

Data were collected by VT studies reports and patient record analysis, including comorbidities and clinical status at baseline and on follow-up. We analyzed all-cause mortality, one-year VT recurrence rate and procedure related major complications.

Results

Between January 2013 and December 2018, 157 catheter ablation procedures in 121 ChD patients were performed in our institution. The mean follow-up time was 22.6±22.1 (mean ± SD) months. Overall post procedure mortality was 33.1%, and mean survival time was 51.2 months (95% CI: 44.8–58. NYHA functional class (p=0.022), ejection fraction (p=0.020) and immediate ablation result (p 0.002) were predictors of all-cause mortality in the follow-up. Clinical VT inducibility after ablation was a predictor of VT recurrence at one year (p=0.04). An epicardial approach was performed in 125 (79%) procedures, and accidental right ventricle (RV) puncture occurred in 23 (18.4%), in which open-chest surgery for bleeding hemostasis was necessary in 4 procedures (3.2%).

Conclusion

Mortality and recurrence rates in ChD patients after VT ablation were high, and correlated with heart failure severity. Epicardial approach is often necessary in this subset of patients. There was a correlation between immediate ablation results and recurrence.

Kaplan-Meier of cumulative survival

Funding Acknowledgement

Type of funding source: None
Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach
Authors: Arsenos P , Gatzoulis K , Doundoulakis I , Dilaveris P , Antoniou C.K , Sideris S , Tousoulis D
Published: November 2020

Background

Although some post myocardial infarction (post-MI) and dilated cardiomyopathy (DCM) patients with mid-range ejection fraction heart failure (HFmrEF = 40–49%) face an increased risk for arrhythmic Sudden Cardiac Death (SCD), current guidelines do not recommend an implantable cardioverter-defibrillator (ICD).

Purpose

To assess the accuracy of a novel multifactorial two-step approach, with noninvasive risk factors (NIRFs) leading to programmed ventricular stimulation (PVS), for SCD risk stratification of hospitalized HFmrEF patients.

Methods

Forty-eight patients (male=83%, age = 64±14 years, LVEF = 45±5%, ischemic coronary disease = 69%) underwent a NIRF presence screening first step with ECG, SAECG, echocardiography and 24 hour ambulatory ECG (Holter). Thirty-two patients with presence of one out of three NIRFs (SAECG ≥2 positive criteria for late potentials, ventricular premature beats ≥240/24 hours, and ≥1 episode of non-sustained ventricular tachycardia on Holter) were further stratified with PVS. Patients were classified as either low (Group 1, n=16, NIRFs−), moderate (Group 2, n=18, NIRFs+ /PVS−) or high risk (Group 3, n=14, NIRFs+/PVS+). All Group 3 patients received an ICD.

Results

After 41±18 months, 9 out of 48 patients experienced the major arrhythmic event (MAE) endpoint (clinical ventricular tachycardia/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 & 2 (2/34, 5.8%). A logistic regression model adjusted for PVS, age and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618–170.887, p=0.004). Kaplan Meier curves diverged significantly (p logrank <0.001) while PVS negative predictive value was 94%.

Conclusion

In hospitalized HFmrEF post-MI and DCM patients, a NIRFs leading to PVS two-step approach efficiently detected the subgroup at increased risk for MAEs.

Funding Acknowledgement

Type of funding source: None
Electrical characteristics of deep septal vs. left bundle branch (area) pacing
Authors: Heckman L.I.B , Luermans J , Weijs B , Van Stipdonk A.M.W , Mafi-Rad M , Prinzen F , Vernooy K
Published: November 2020

Background/Introduction

Recent studies have described transvenous left bundle branch (LBB) pacing as a new conduction system pacing strategy. However, information on effect of pacing depth within the septum and the additional effect of LBB capture is unknown.

Purpose

To investigate the relation of electrocardographic characteristics with transseptal LV lead implantation depth and LBB capture.

Methods

20 consecutive patients referred for pacemaker implantation were enrolled. The right atrial (RA) lead was positioned according to routine practice. The LV septal pacing lead (Medtronic 3830) was transvenously positioned against the right side of the interventricular septum and advanced in small steps of 1–2mm towards the left side of the septum. At each depth in the septum 12-lead ECG's were recorded during pacing, from which vectorcardiograms (VCG) were calculated. QRS duration and QRS area were measured, the latter being the integral of the QRSarea in X, Y and Z directions. Successful LBB capture was defined as paced right bundle branch block (RBBB) morphology, stable and short stimulus to LV activation time (LVAT; R in V5) and recorded LBB potential.

Differences were compared among pacing conditions using repeated measures ANOVA with Bonferroni multiple comparisons procedure applied to pairwise comparisons. Statistical significance was assumed at p<0.05.

Results

LV septal lead implantation was successful in all patients. Left bundle branch capture was achieved in 10/20 patients (50%). Post-procedural LV pacing threshold, impedance and sensing was 0.7±0.1 V at 0.5 ms pulse width, 658±5 Ω and 13±10 mV, respectively. Compared to intrinsic rhythm, QRS duration was significantly increased by both RV septum (RVS; 124±5 vs. 161±3 ms) and LV septum pacing (LVS; 142±3 ms).

QRS area increased significantly during RVS pacing as compared to intrinsic rhythm but decreased when moving from RVS to LVS to values close to intrinsic rhythm (panel A & B). LVS-pacing derived QRS area was significantly lower in patients with LBB capture (36±6 mV*ms) compared to patients without LBB capture (deep septal pacing; 46±12 mV*ms).

The reduction in QRS area between RVS and LVS pacing coincided with normalization of the QRS vector in the transverse plane (panel C), which is characterized electrocardiographically by predominantly negative-to-positive inversion of the QRS complex in the precordial leads (V1-V3).

Conclusions

Compared to RV septal pacing, LV septal pacing restores ventricular electrical synchrony, as determined by QRS area, and normalizes the activation vector in the transverse plane to a level comparable to intrinsic rhythm. Differences in resynchronization between left bundle branch pacing and deep septal pacing are small.

LBBAP restores ventricular synchrony

Funding Acknowledgement

Type of funding source: None
Device-device communication stability of leadless anti-tachycardia pacemaker and subcutaneous implantable cardioverter defibrillator over 18 months
Authors: Tjong F.V.Y , Knops R.E , Swackhamer B , Koop B , Soltis B , Brisben A , Carter N , Burke M
Published: November 2020

Background

A novel modular cardiac rhythm management (mCRM) therapy approach is evaluated in this study: the performance of an anti-tachycardia pacing enabled leadless pacemaker (LP) commanded by a subcutaneous-ICD (S-ICD) via wireless, intra-body, device-device communication (DDC).

Objectives

To investigate long-term DDC performance of linked S-ICD to LP (mCRM System) and factors that impact DDC performance.

Methods

The mCRM System was implanted in 37 canine subjects: 33 with an S-ICD and an LP; 4 with an S-ICD and 2 LPs. The S-ICD was implanted using a Parsonnet pouch in the first 8 subjects. Communication thresholds were measured in three postures up to 18 months. Percent tissue encapsulation of the LP was measured at necropsy and ranged from 6% to 100% (mean: 62%). S-ICD system migration was evaluated radiographically at implant vs. at necropsy in two planes (anterior-posterior and left lateral) and evaluated 0–3 scale: none, minimal, moderate, significant. Communication thresholds were evaluated at 0 vs. 3 days using a t-test and 3 days through 18 months using a linear regression analysis. A repeated measures generalized linear model (GLM) was used to evaluate if test posture, percent tissue encapsulation of the LP, Parsonnet pouch use, or S-ICD system migration (no/ minimal migration vs. moderate/significant migration) were significant predictors of DDC performance at the subject's termination time point.

Results

DDC was successful for each tested posture and time point for all subjects (n=37), with 355 tests in Left Lateral (LL), 371 tests in Dorsal (D), and 355 tests in Right Lateral (RL). Follow up data are available up to 18 months for 19 subjects at the time of this abstract; additional follow-up data will be added to the analysis for presentation. Communication thresholds decreased between 0 days and 3 days (LL P<0.01, D P<0.01, RL P<0.05) and did not change significantly from 3 days through 18 months (LL P=0.90, D P=0.83, RL P=0.83). The GLM showed that there is no significant difference in communication thresholds for test posture (P=0.24 LL vs. D, P=0.24 RL vs. D), percent tissue encapsulation of the LP (P=0.63), Parsonnet pouch use (P=0.65), or S-ICD system migration (P=0.95).

Conclusion

Longitudinal studies demonstrate low and stable communication thresholds of a novel mCRM system over time for all three tested postures, regardless of factors such as LP encapsulation, Parsonnet pouch use, or S-ICD system migration.

Device Communication Threshold Stability

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific
Thinking about the future – data on adolescent patients with a subcutaneous ICD
Authors: Willy K , Reinke F , Rath B , Boegeholz N , Wolfes J , Frommeyer G , Eckardt L
Published: November 2020

Background

Implantable cardioverter-defibrillator (ICD) systems are established for the prevention of sudden cardiac death. Long-term data on ICD function in children and adolescents is rare and has suggested higher rates of lead failure as well as oversensing, both leading to inappropriate therapy. The present study displays a long-term single-center follow-up of young patients having received an S-ICD.

Methods and results

The present study represents a single-center experience of patients younger than 25 years who received an S-ICD (n=49). Follow-up data included regular in-house follow-up as well as unscheduled hospitalisations in our center. Mean age at implantation was 19.2±4.1 years and 33 patients (67.4%) were male. In 21 patients (42.9%) electrical heart disease or idiopathic ventricular fibrillation represented the underlying condition of ICD implantation. 15 patients suffered from HCM (30.6%). Median follow-up duration was 2 years. No patient died during the observation period. Appropriate shocks occurred in 7 patients (14.3%). Inappropriate shock delivery was recorded in 6 patients (12.3%). T-wave oversensing was the main cause for inappropriate shock delivery (5/6 patients), in the other patient myopotentials were the reason for inappropriate therapy. In one patient, operative refixation of the subcutaneous lead was necessary due to hypermobility leading to oversensing. After modification of the sensing vector as well as activation of the SMART pass filter no further oversensing episodes occurred in any patient.

Conclusion

ICD therapy in children and adolescents is effective for prevention of sudden cardiac death. Every episode was terminated by the first therapy. The rate of appropriate shock as well as inappropriate therapies was quite high compared to typical ICD cohorts. In particular T-wave oversensing seems to be challenging for the S-ICD detection algorithms also in this cohort.

Funding Acknowledgement

Type of funding source: None
RV Pacing Percentage
Authors: Cha Y.M , Metzl M.D , Canby R.C , Fruechte E.M , Duggal M , Exner D.V , Chung E.S , Singh J.P , O'Donnell D , Zimmerman P , Landman S , Lexcen D.R , Laager V , Schaber D , Cheng A
Published: November 2020

Introduction

Chronic right ventricular pacing (RVP) has been associated with dyssynchrony, leading to increased mortality. However, there have been discrepancies in previous reports in the effect of RVP levels.

Objective

To sub-stratify mortality risk by age for different RVP level groups within a large real-world ICD cohort.

Methods

Optum® de-identified electronic health records were linked to the Medtronic Carelink data to identify dual chamber ICD recipients (2007–2017). RVP level was based on median daily pacing during the first 90 days post-implant and categorized either into groups with a cutoff of 40%, or with groups of 0–9%, 10–19%, 20–29%, 30–39%, 40–49%, and 50–100%. The endpoint was death more than 90 days post-implant. Kaplan-Meier survival curves, log-rank tests, and Cox regression were used to analyze the relationship between RVP and risk of death.

Results

Among 14,832 ICD patients (median age 67; 74.0% male), there were 2,602 deaths within 10 years after implant. In unadjusted comparisons, high RVP (>40%) increased the risk of death relative to low RVP (≤40%) (p<0.001). This effect remained significant in older cohort (≥67 years old at implant) (p<0.001), but not in younger cohort (<67 years old) (p=0.955) (Figure). After controlling for age, gender, pacing mode, MI, SCA, HF hospitalization, diabetes, and renal dysfunction, similar or increased risk was associated with higher pacing groups relative to the 0–9% pacing group in the older cohort, but not in the younger cohort.

Conclusions

Our data from a large contemporaneous real-world source suggests that older age or characteristics associated with age make patients more sensitive to chronic RVP effects. These results help reconcile differences observed in prior studies.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic, Inc.
Not the pacing site but the underlying structural heart disease is a reason for wider QRS duration during right ventricular pacing
Authors: Ogano M , Tsuboi I , Tanabe J , Iwasaki Y , Shimizu W
Published: November 2020

Background

Right ventricular (RV) pacing causes changes of the electrical and mechanical activation pattern of the heart. QRS duration is reported to be a useful surrogate marker of electrical dyssynchrony, and wider QRS duration during RV pacing indicates poor prognosis. However, the mechanism of widening QRS duration during RV pacing remains to be elucidated.

Methods

A total of 211 patients who underwent catheter ablation for supraventricular tachyarrhythmias and have no bundle-branch-block on ECG were enrolled. During electrophysiological study, 3-dimensional mapping for QRS duration during RV pacing from RV outflow to RV apex was created, and the difference of QRS duration between RV outflow and RV apex was calculated. The relationship between QRS duration during RV pacing and patients' baseline characteristics including echocardiography data was analyzed.

Results

QRS duration at baseline, during RV pacing from RV outflow, and RV apex were 85.0±7.5msec, 156.2±16.1msec, and 163.7±17.1msec, respectively. The difference of QRS duration between RV outflow and RV apex among patients was only 12.5±10.4msec. The logistic multivariable regression analysis showed baseline QRS duration (odds ratio (OR) 1.24, 95% CI 1.15 to 1.34, p<0.01), interventricular septum thickness (OR 1.35, 95% CI 1.05 to 1.73, p=0.018), and E/e' (OR 1.23, 95% CI 1.12 to 1.36, p<0.01) were significant predictors for QRS duration over 160msec during RV apical pacing.

Conclusions

QRS duration during RV pacing depends largely not on the pacing site, but on the underlying structural heart disease.

QRS duration mapping during RV pacing

Funding Acknowledgement

Type of funding source: None
A novel non-invasive electrical synchrony method to improve cardiac resynchronization therapy responders
Authors: Logarzo E , Ortega D , Barja L , Paolucci A , Mangani N , Revollo G , Aboy J
Published: November 2020

Introduction

Cardiac resynchronization therapy (CRT) has emerged as an important treatment for patients with heart failure and reduced ejection fraction (EF) despite optimal pharmacological therapy. Some studies showed non-responders rate near 30%. Nowaday there is no gold standard method for selection, evaluation and follow up on this group of patients. Multiple techniques used and operator dependence made echocardiogram failed. Synchromax 2 is a device designed to evaluate non-invasive electrical synchrony. It is fast, reproducible and non-operator dependent. Synchromax was evaluated and correlated with other techniques in previous studies.

Objective

Evaluate CRT response rate guided by electrical synchrony during the device implantation and follow up.

Material and methods

43 patients were evaluated in an institution in Buenos Aires. A ICD-CRT was implanted in all patients due dilated cardiomyopathy, low EF (less than 35%) and left bundle branch block (LBBB). Non-invasive electrical synchrony evaluation (Synchromax 2) was performed in all patients in baseline condition, during device implantation and the follow up. Synchrony index and curves were analyzed. Curve type 4 and index between 0,4 and 0,7 were considered synchronous. Curve type 6 and 10 and index more than 0.7 were considered disynchronous. Interventricular intervals were modified to achieve the best curve and synchrony index. Super responders were considered when EF increased >50%. Baseline and 6 month after implantation echocardiogram were performed.

Results

Mean age 64 years. 39% females. Non-coronary dilated cardiomyopathy was main aetiology (63,1%). EF baseline average was 27%. A baseline index more than 0,7 was in 73,3% of the patients. Curve 6 was the most frequent (55,2%). Follow up average EF was 39% (increased 12%), the super responders rate was 18,6% (8 patients). Type 4 curve and index between 0,4 and 0,7 were achieved in 28 cases (65,1%). EF increased from 23% (baseline) to 42% (follow up). Average 19%. Type 4 curve was not achieved in 15 patients (34,9%). In this group, EF increased from 29% (baseline) to 34% (follow up). Average 5%.

Conclusion

Electrical synchrony evaluation using Synchromax 2 during ICD-CRT device implantation improves responders rate. When synchronous type 4 curve is achieved EF improves significantly. If type 4 curve is not found results will be unsuccessfully. Synchromax is fast, simple and non-operator dependent.

Funding Acknowledgement

Type of funding source: None
Atrial and atrioventricular resynchronization the benefit of bachmanns bundle and his bundle pacing
Authors: Wolff P , Strozik P , Gajek A , Ciesielski A , Slawuta A , Gajek J
Published: November 2020

The current treatment of patients with heart failure and concomitant atrioventricular conduction delay is difficult. Recommendations indicate the possibility to use the classic resynchronization but in the presence of narrow QRS-complex such approach could be even harmful. Without a sufficient LBBB morphology as indication for classical CRT, those patients would lose their narrow QRS complex with negative consequences for the hearts functional status.

A new therapeutic option for those patients to re-establish the physiological atrioventricular mechanical sequence is the permanent His-bundle pacing (pHBP). Advantages like physiological activation sequence of the ventricular myocardium, less affected by AF compared to classical CRT and reversal of mitral regurgitation should be enumerated to show it's beneficial effect. Additionally the use of Bachmann's-bundle pacing can correct the prolonged interatrial conduction thus further contribute to the echocardiographic and clinical improvement.

The aim of the study is to assess the influence of Bachmann's-bundle pacing and His-bundle pacing on the reversed remodeling of the heart in patients with heart failure and atrioventricular block.

The study group included 21 patients (7 women and 14 men) undergoing cardiac resynchronization using Bachmann's-bundle pacing and permanent His-bundle pacing from LV channel for atrioventricular conduction delay. All the patients had narrow QRS-complex which prevented us to use classic resynchronization. 13 CRT-D and 8 CRT-P devices were implanted according to the ejection fraction and ventricular arrhythmia risk assessment. In all patients the direct His-bundle pacing was successfully achieved, selective in 17 and non-selective in 4 patients. The mean follow-up (FU) period was 8.8 months (1–26 months). The echocardiographic, clinical and ECG results are presented in the table 1.

Conclusions

1. The correction of atrioventricular and interatrial conduction delay resulting in improvement of atrioventricular mechanical coupling can contribute to the reversed remodeling of the heart.

2. This also improves the patient's functional status.

3. In some patients this approach could lead to the normalization of echocardiographic parameters of the left ventricle.

Funding Acknowledgement

Type of funding source: None
Handling of remote monitoring alerts according to the weekday of transmission: results from the OptiLink HF study
Authors: Wintrich J , Pavlicek V.P , Brachmann J.B , Bosch R.B , Butter C.B , Oswald H.O , Rybak K.R , Mahfoud F.M , Boehm M.B , Ukena C.U
Published: November 2020

Background

Remote monitoring of patients suffering from heart failure (HF) did not result in improved clinical outcomes in the OptiLink-HF trial. However, initiation of medical intervention after transmission of telemedicine alerts triggered by fluid index threshold crossings (FTCs) was low. The relation between weekday of transmission of FTC and subsequent patient contact is unknown.

Methods

Patients enrolled in the intervention arm of the OptiLink HF trial (n=505, age 66.1±10.1, male 77.2, EF 26.7±6.1%) were analyzed according to the weekday of transmission of FTC. Transmissions of FTC on Mondays to Thursdays were categorized as TD1, Fridays to Sundays as well as bank holidays as TD2. Primary endpoint was time between transmission and telephone contact; secondary endpoints were subsequent medical intervention and hospitalizations.

Results

During a follow-up of 18 months, 1364 FTC (866 (63.5%) categorized to TD1, 498 (36.5%) to TD2) alerts occurred in 356 patients. In 46.2% of FTC same day telephone contact was performed in group TD1 compared to 18.3% in group TD2 (p<0.001). Accordingly, the median time to contact was significantly longer in TD2 compared to TD1 (2 (1–3) vs. 0 (0–1); p<0.001). Rates of no telephone contact were not different between the groups (12.1% vs. 12.4%; p=0.866). Although, signs of worsening HF were prevalent in 32.4% in TD1 vs. 32.1% in TD2 (p=0.996), initiation of a pharmacological intervention was more likely in TD1 compared to TD2 (27.9% vs. 22.9%; p=0.041). No differences existed concerning hospitalization for HF within 30 days after FTC (3.9% vs. 3.4%; p=0.636).

Conclusion

Transmission of FTC alerts during weekends and on bank holidays were less likely associated with timely patient contacts and initiation of pharmacological intervention than during the week. Telemedical centers providing 24/7 remote monitoring service might help to optimize patient care.

Funding Acknowledgement

Type of funding source: None
Permanent CIED malfunctions after oncologic radiotherapy: a multi-centre, randomized, in vitro evaluation
Authors: Di Girolamo E , Appignani M , Faustino M , Marini M , De Filippo P , Leidi C , Di Girolamo F , Delana A , Barbareschi A , Andreoli S , Genovesi D , Falco M.D
Published: November 2020

Background

Direct photon exposure of pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs) during oncologic radiotherapy may transiently or permanently affect normal device function. To evaluate potential malfunctions by direct exposure to doses up to 10 Gy in 6-MV oncologic radiotherapy, commonly considered unsafe or even not recommended, 145 PMs and 65 ICDs were observed in three different centres.

Methods

All devices had a baseline interrogation and reprogramming to VVI/40 or to DDD/40 mode, depending on type and model. Rate-adaptive function was disabled in all the devices, whereas in ICDs, even antitachycardia therapies were disabled with the ventricular tachycardia/fibrillation (VT/VF) windows left enabled. To build the corresponding treatment plan, a centring computed tomography was performed with different Treatment Plan Systems among the centres. The devices were blinded randomized to receive either 2-, 5- or 10-Gy direct exposure by a 6-MV linear accelerator (different among the three centres) in a water phantom (600 MU/min). The effective dose received was assessed by a random in-vivo dosimetry. All devices had a telemetry interrogation immediately after exposure and once monthly during a six-month follow-up.

Results

Immediately after photon exposure, no changes in device parameters or software errors were observed in 209 devices (99.5%). A non-reprogrammable reset to emergency back-up mode (VVI/65) occurred in a PM (0.5% overall; 0.7% among PMs). Seven PMs reached the Elective Replacement Indicator immediately after exposure (3.3% overall; 4.8% among PMs). Sixteen ICDs (7.6% overall; 24.6% among ICDs) had multiple VT/VF detections stored in the device memory. Two PMs (1% overall; 1.4% among PMs) reported atrial fibrillation detections.

During a six-month follow-up, a non-reprogrammable software reset (back-up to VVI/65 mode) was reported in one PM three months after a single exposure of 2 Gy (0.5% overall; 0.7% among PMs). Abnormal battery drain was observed in thirteen PMs (6.2% overall; 9% among PMs), and in one ICD (0.5% overall; 1.5% among ICDs). All events presented regardless of exposure dose of either 2, 5, or 10 Gy.

Conclusions

Last-generation devices, both PMs and ICDs, withstood direct 6-MV photon exposure up to 10 Gy, commonly considered not recommended or even unsafe by manufacturer statements and clinical guidelines. The most common failures were referred to battery issues. Malfunctions occurred solely in less recent devices, regardless of photon dose.

Funding Acknowledgement

Type of funding source: None
Performance of the padit score in patients undergoing transvenous lead extraction
Authors: Dias Ferreira Reis J.P , Valente B , Ferreira V , Castelo A , Portugal G , Monteiro A , Lousinha A , Silva Cunha P , Oliveira M , Cruz Ferreira R
Published: November 2020

Background

The PADIT trial identified 5 independent predictors of cardiac implantable electronic device (CIED) infection (prior procedure, age, chronic kidney disease, immunosuppression and type of procedure) and developed a novel infection risk score.

Aim

To assess whether the PADIT score (PS) could predict CIED reinfection and adverse events in patients (pts) submitted to transvenous lead extraction (LE) using the Pisa Technique (PT) due to CIED infection.

Methods

We conducted a single-centre prospective study of consecutive procedures (P) of LE using the PT between February 2013 and October 2019. Demographic, clinical, microbiological, device/ procedure related variables, morbidity and mortality data were retrieved during follow-up (FUP). An univariate analysis was performed to evaluate the ability of the PS to predict CIED reinfection (Re), procedural complications (C), all-cause hospital mortality (M), all-cause mortality/ hospitalization during first year of follow-up (MH1) and cardiovascular mortality (CM).

Results

A total 171 Ps including 159 pts, of which 80.7% (130 pts)were due to CIED infection: 55.1% due to pocket site infection, 18.8% to occult bacteremia with probable CIED infection and 26.1% due to both pocket site and systemic infection, with 44% of pts presenting with valvular/ lead vegetation (mean age - 70.3Y, 77.7% male, mean LVEF of 49.6%). The Rs rate was 93.1% and the clinical success rate was 99.2%. There were no deaths related to the procedure. During a mean FUP of 33 months, 11 pts had to undergo a new P, 5 of them due to pocket reinfection. The mortality rate was 24.2% (37 pts), with 8 pts dying during hospital stay, and 19 pts during the first year post-P. The mean PS was 2.9±2.5 (min- 0, max- 10). A higher PS value was associated with Re (HR - 1,43, CI95% 1.09–1.87, p=0.011), CM (HR - 1,39, CI95% 1.06–1.85, p=0.018) and MH1 (OR - 1,19, CI95% 1.03–1.38, p=0.021). There was no association between the PS and the rate of clinical success of the procedure (2.9% vs 4.5%, p=0.395), procedural complications (2.9% vs 3.3%, p=0.656) and M (4.0% vs 2.8%, p=0.192). Interestingly, a higher PS was not associated with a higher use of an antibacterial envelope during device reimplantation (3.5% vs 2.9%, p=0.371).

Conclusion

The PADIT score revealed a high predictive power for reinfection, all-cause mortality/ hospitalization during first year of follow-up and cardiovascular mortality in pts submitted to LE using the PT for CIED infection.

Funding Acknowledgement

Type of funding source: None
Leg raise can detect exercise-induced pulmonary arterial wedge pressure elevation
Authors: Nakata C , Goda A , Takeuchi K , Kikuchi H , Inami T , Soejima K , Satoh T
Published: November 2020

Background

Exercise-induced elevation of pulmonary arterial wedge pressure (PAWP) may show preclinical or exercise-induced left ventricular diastolic dysfunction. Invasive hemodynamic assessment during provocative maneuvers, like exercise and volume challenge, in these patients allows greater sensitivity to diagnose or exclude HFpEF. The aim of this study was to examine how the leg raise, which is a simple way to increase preload, can detect exercise-induced PAWP elevation.

Methods

Four hundred seventy-nine patients (60±14y.o, mean pulmonary arterial pressure (PAP) 19mmHg, PAWP 8mmHg, CTEPH /IPAH/CTD-PH/SOB unknown reason: 357/56/38/28pts) with near-normal PAP and normal PAWP at rest underwent symptom-limited exercise test using supine cycle ergometer with right heart catheter. Exercise-induced elevation in PAWP of over 20mmHg was defined as exercise-induced elevation group.

Results

ΔPAWP (after leg raise - rest) in the exercise-induced elevation group was significantly higher (6.0±4.1 vs. 2.7±3.9mmHg, p<0.001, in the older (age≥60y.o) group (n=276); 3.4±3.5 vs. 1.9±3.4mmHg, p<0.001, in the younger (age<60y.o) group (n=203)) than that in the non-elevation group after legs raise for cycle ergometer exercise. The area under the ROC curve for ΔPAWP was 0.72 (95% CI: 0.65–0.78) in the older and 0.64 (95% CI: 0.53–0.75) in the younger. In the older, the cut-off value for detect exercise-induced PAWP elevation of ΔPAWP was 4mmHg, with 72% sensitivity and 58% specificity. On the other hand, in the younger, the cut-off value was 3mmHg, with 69% sensitivity and 59% specificity.

Conclusion

Leg raise can easily detect occult left ventricular diastolic dysfunction.

Funding Acknowledgement

Type of funding source: None
Sacubitril/valsartan and circulating neprilysin hypothesis in patients with HFpEF
Authors: Santiago-Vacas E , Codina P , Domingo M , De Antonio M , Zamora E , Santesmases J , Julian M.T , Diez-Quevedo C , Troya M.I , Boldo M , Altimir S , Nunez J , Gonzalez B , Lupon J , Bayes-Genis A
Published: November 2020

Background

Neprilysin serum levels (sNEP) exhibited significant prognostic value in patients with heart failure (HF). In the PARADIGM-HF study benefit of sacubitril/valsartan was observed in patients with reduced ejection fraction (HFrEF), while in the PARAGON-HF benefit was only observed in the subgroup of patients with LVEF <57%.

Objective

To assess the prognostic value of sNEP in ambulatory patients with HF and preserved ejection fraction (HFpEF) and LVEF >57% (group 1), in comparison with patients with LVEF ≤57% (group 2).

Methods

Consecutive patients with HF attended at the Unit from May 2006 to February 2016 were considered for the study. The primary end-point was the composite of cardiovascular death or HF hospitalization. All-cause death, cardiovascular death, HF hospitalization and the composite of all-cause death or HF hospitalization were secondary end-points. Competing risk methods (R package by Bob Gray for SPSS) were used when required.

Results

sNEP was measured in 1428 patients (age 67.7±12.7, 70.3% men, LVEF 35.8% ±14, 48.9% from ischemic etiology), 144 of which had a LVEF >57% (age 70.1±15, 43.8% men, 53.5% from hypertensive or valvular etiologies). sNEP levels did not significantly differ between the two groups of patients (p=0.31). During a mean follow-up of 6±3.9 years, 856 deaths were recorded (459 from cardiovascular causes) and 523 patients suffered at least one HF hospitalization. The primary end-point occurred in 941 patients (in 111 of the 144 patients with LVEF >57%). Table 1 shows sNEP age- and sex-adjusted hazard ratios for the primary and secondary end-points.

Conclusions

sNEP prognostic value in patients with HFpEF and LVEF >57% outperforms that observed in patients with lower LVEF. These data support the personalized use of sNEP in identifying HFpEF patients that may benefit from treatment with sacubitril/valsartan.

Funding Acknowledgement

Type of funding source: None
Lung ultrasound in patients with suspected HFpEF
Authors: Malek J , Vecera J , Kubrycht M , Matejka J , Vojtisek P
Published: November 2020

Purpose

The aim of the present study was to test correlation of laboratory, echocardiographic and clinical parameters with recently developed scores for HFpEF diagnostics in patients with exertional dyspnea and preserved ejection fraction.

Methods

We performed rest and stress echocardiography, rest and peak exercise B-lines count assessed by 8 zone LUS, cardiopulmonary exercise test and laboratory testing in 47 patients (age 62,6±92 years; 57,4% females) refferred for exertional dyspnea. H2FPEF and HFA-PEFF score was calculated for each patient.

Results

H2FPEF score correlated significantly with rest B-lines count (r=0,350, p=0,016). We observed negative correlation of H2FPEF with peak workload (r=−0,558, p<0,001) and peakVO2 (r=−0,519, p<0,001). HFA-PEFF score correlated with peak workload (r=−0,468, p<0,001) and peakVO2 (r=−0,403, p=0,009). No correlation of B-lines count with HFA-PEFF score was observed. We also observed significant correlation of HFA-PEFF and H2FPEF (r=0,545, p<0,001).

HFpEF was diagnosed in 17 patients according to ESC guidelines. Patients with HFpEF had higher HFA-PEFF score (4,0±1,1 vs 1,9±1,4; p<0,001) and H2FPEF score (4,2±1,8 vs 2,2±1,8; p<0,001) and lower peakVO2 (17,0±4,8 ml/kg/min vs 22,9±5,6 ml/kg/min; p=0,001) and workload (1,3±0,4 W/kg vs 1,8±0,6 W/kg; p=0,002). B-lines count was similar in HFpEF patients and rest of population.

Conclusion

According to our data it seems that recently developed scores HFA-PEFF and H2FPEF would be more useful for HFpEF diagnostics than B-lines scoring.

Funding Acknowledgement

Type of funding source: None
Long-term outcome of minimally invasive mitral valve annuloplasty in disproportionate mitral regurgitation
Authors: Albano M , Nagumo S , Vanderheyden M , Bartunek J , Collet C , Balogh Z , Katbeh A , Kodeboina M , Van Camp G , Penicka M
Published: November 2020

Background

Hypothetical concept of disproportionate secondary mitral regurgitation (SMR) has been recently introduced to facilitate patient's selection for mitral valve intervention. However, real world data validating this concept are unavailable.

Purpose

To investigate long-term effects of minimally invasive mitral valve annuloplasty (MVA) in patients with disproportionate (dSMR) versus proportionate SMR.

Methods

The study population consisted of 44 consecutive patients (age 67±9,5 years; 64% males) on guidelines-directed therapy with advanced heart failure (HF), reduced LV ejection fraction (EF) (32±9,7%) and SMR undergoing isolated mini-invasive MVA. Patients with organic mitral regurgitation or concomitant myocardial revascularization were excluded. To assess SMR disproportionality, the PISA-derived effective regurgitant orifice area (EROA) and regurgitant volume (RV) were compared to the estimated EROA and RV by using Gorlin formula and pooled real world data.

Results

According to EROA, a total of 20 (46%) and 24 (54%) patients, respectively, had dSMR and proportionate SMR (pSMR). According to RV, a total of 17 (39%) had dSMR and 27 (61%) had pSMR. Patients with dSMR showed significantly lower prevalence of male gender and higher prevalence of diabetes mellitus than patients with pSMR (p<0,001). Moreover, we observed smaller LV end-diastolic volume, larger EROA and RV (both p<0,01) and higher LV EF (p=0,02) in the dSMR versus the pSMR group. Other baseline characteristics were similar. During median follow up of 4.39 y (IQR 2,2–9,96y), a total of 25 (56%) patients died from any cause while 21 (47%) individuals were readmitted for worsening HF. Patients with dSMR versus pSMR according to both EROA and RV showed significantly lower rate of HF readmissions (both p<0.05) (Figure 1, 2). In Cox regression analysis combining clinical and imaging parameters, dSMR was the only independent predictor of HF readmissions (HR 0.20, 95% CI 0.07–0.60, p=0.004). In contrast, mortality was similar between dSMR and pSMR (NS) with age as the only independent predictor (HR 1,10; 95% CI 1,03–1,18, p=0,003).

Conclusions

Minimally invasive MVA is associated with significant reduction of HF readmissions in patients with dSMR versus pSMR while the mortality is similar. This suggests the importance of other parameters, i.e. age and degree of LV remodeling, to guide clinical management in SMR.

Funding Acknowledgement

Type of funding source: None
Reverse remodelling, changes in diastolic function and their prognostic value compared to natriuretic peptides
Authors: Aimo A , Vergaro G , Fabiani I , Chubuchny V , Taddei C , Giannoni A , Arzilli C , Passino C , Emdin M
Published: November 2020

Background

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilation and dysfunction in response to treatment for heart failure (HF). RR is usually associated with improved prognosis. The impact of RR on indices of diastolic function, and the relative prognostic value of RR, changes in diastolic function and natriuretic peptide levels are currently unknown.

Methods

We analysed data from patients with stable systolic HF (LV ejection fraction [LVEF] <50%) undergoing 2 transthoracic echocardiograms (TTE) within 12±2 months. RR was defined as a ≥15% reduction in LV end-systolic volume index (LVESVi). The follow-up started after the second TTE.

Results

927 patients were evaluated (68±12 years; median LVEF 35% [interquartile interval 30–43%]; 27% women; 52% ischaemic aetiology). Patients experiencing RR (n=286, 31%) displayed more prominent positive changes in several parameters reflecting diastolic dysfunction, namely E/e' ratio, left atrial volume index (LAVi), and systolic pulmonary artery pressure (sPAP), as well as N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP; Figure). In the whole population, percent changes (Δ%) LVESVi displayed weak but significant correlations with Δ% E/e' (r=0.237, p<0.001), LAVi (r=0.316, p<0.001), and sPAP (r=0.158, p<0.001), and also with Δ% NT-proBNP (r=0.279, p<0.001). There were 123 cardiovascular deaths and 4 heart transplantations over 2.8 years (1.3–4.9). Δ% LVESVi, RR, Δ% sPAP and Δ% NT-proBNP were univariate predictors of this endpoint. In 2 multivariable models including Δ% sPAP and Δ% NT-proBNP and either RR or Δ% LVESVi, only Δ% NT-proBNP emerged as independent predictor of outcome (hazard ratio 1.01, 95% confidence interval 1.01–1.02; p<0.001).

Conclusions

A recovery of LV geometry is accompanied by positive modifications in several indices related to diastolic function, as well as a decrease in NT-proBNP levels. Percent changes in NT-proBNP over 12 months are stronger predictors of outcome than variations in LV geometry or sPAP.

Funding Acknowledgement

Type of funding source: None