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P966
Relationship between reduction of systolic blood pressure and atrial fibrillation burden after renal denervation and pulmonary vein isolation
Abstract
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Background: Renal artery denervation (RDN) has provided incremental atrial fibrillation (AF) suppression after pulmonary vein isolation (PVI) in patients with AF in the setting of drug-resistant hypertension, but the antiarrhythmic mechanism by which RND functions is unknown. Objectives. The aim of this study was to assess the relationship between blood pressure changes after RDN when added to PVI and AF recurrences/AF burden detected by implantable loop recorder (ILR) during one-year follow-up.
Methods: All patients from two randomized studies (NCT01117025 and NCT01897545) with a history of symptomatic paroxysmal (P) AF and/or persistent (Pers) AF and resistant hypertension (≥3 antihypertensive drugs) who underwent PVI or PVI with RDN, and ILR implantation, were eligible for this study. Patients underwent PVI only (n=37) or PVI with RDN (n=39) and were followed-up for one year to assess maintenance of sinus rhythm by ILR. Results. At the 12-month follow-up examination, 25 of the 39 (64%) PVI with RDN group remained AF-free. In contrast, in the PVI-only group, only 15 of the 37 (41%) patients were AF-free on no antiarrhythmic drugs (p=0.014). RDN was associated with substantial and significant reduction of AF recurrences (HR = 0.44; 95% CI, 0.22 to 0.86; p=0.017). AF burden was also significantly lower in RDN group, 9.7±5.6% vs 20.2±8.5%, respectively (p<0.001). The likelihood of AF suppression was associated with change of BP after RDN, and was significantly correlated with reduction of SBP (p=0.03) and DBP (p=0.003). The RDN strategy was also an independent predictor of AF burden regression (HR = 0.38, 95% CI: 0.15–0.96, P = 0.04).
Conclusions: RDN when added to PVI significantly decreases AF recurrences and AF burden and is correlated to improvement in BP control.
P967
A prospective national study of the prevalence, incidence, management and outcome of a large contemporary cohort of patients with incident non-valvular atrial fibrillation
Abstract
Background: There are few studies of atrial fibrillation (AF)outside of North-America or Europe. The aim of the present study was to assess the prevalence, incidence, management and outcomes of patients with new atrial fibrillation, in a large contemporary cohort (2004-2012) of adult patients.
Methods and Results: The Clalit Health Services (CHS) computerized database of 2,420,000 adults, includes data of community clinic visits, hospital discharge records ,medical diagnoses, medications , medical interventions and laboratory test results.
The prevalence of AF on January 1, 2004 was 71,644 (3%). Prevalence and incidence of AF increased with age and was higher in men vs. women. During the study period (2004 - 2012) 98,811 patients developed new non-valvular AF (mean age -72, 50% women, 46% with cardiovascular disease, 6% with prior stroke). The rate of persistent warfarin use (dispensed for >3 months in a calendar year) was low (25.7%) and it increased with increasing stroke risk score. Individual Time in Therapeutic Range (TTR) among warfarin users was 40%. The incidence rate of ischemic stroke and death increased with age. The rate of stroke increased from 2 per 1000 person years in patients with CHA2DS2_VASC SCORE of 0, to 58 per 1000 person years in those with a score of 9.
Conclusions: In the present study the prevalence and incidence of AF, stroke, and death were comparable to those reported in Europe and North America. The low use of anticoagulation calls for measures to increase adherence to current treatment recommendations in order to improve outcomes
P968
The long-term outcome of carotid endarterectomy in real-world practice: implications of atrial fibrillation
Abstract
Background: Clinical trials have shown that carotid endarterectomy (CEA) is effective at reducing risk of stroke/transient ischemic attacks(TIA) in patients with carotid artery disease, but had short-term follow-up and did not assess risk of stroke/TIA associated with atrial fibrillation (AF).
Methods: All-cause mortality and a combined endpoint of fatal stroke and non-fatal stroke/TIA were assessed in patients who had CEA in England from 2002 to 2014, assessed using Hospital Episode Statistics and death certification.
Results: 45,216 patients [age 70.7 ±9.2 yrs; 67.7% male] underwent CEA. Over 231,138 patient-years of follow-up (median 4.71 yrs), there were 12,213(27.0%) deaths from any cause, 1,586(3.5%) fatal strokes and 14,601(32.3%) non-fatal stroke/TIA after CEA. A total of 4,451(9.8%) patients were hospitalized for AF prior to CEA. By year 5 after CEA, 2,581 (65.4) % of patients who had AF prior to CEA were hospitalized for AF and 3,434 (8.4%) who did not have AF prior to CEA were hospitalized for AF. Hospitalization for AF before (HR:1.28, 95% C.I. 1.21 to 1.35), only after CEA (HR 1.41, 95%CI 1.35-1.47) (all p<0.0001) or at any time (HR 1.44, 1.39-1.50) was associated with the combined endpoint of fatal stroke and non-fatal stroke/TIA, independent of risk factors proven to predict outcome in patients with AF.
Conclusions: AF is associated with a poor outcome after CEA, whether before or after the operation. A systematic strategy for the detection of AF in patients before and long after CEA is warranted.
Figure 1
P969
The role of the parameters of heart rate variability in the patients with different clinical types of nonvalvular atrial fibrillation
Abstract
Background: Atrial fibrillation (AF) is the most frequent arrhythmia found in clinical practice. Based on the results of recent studies it can be concluded that the deviation of dynamic balance between the sympathetic and parasympathetic influences affect the parameters of heart rate variability (HRV), which is important for the diagnosis and prognosis of heart disease, including the formation and maintenance of the various clinical types of AF.
The aim of this study to evaluate the prognostic role of the parameters of HRV in occuring and maintaining different clinical types of nonvalvular AF.
Methods: In our study we have included 116 patients who were divided into 4 groups (mean age was 61.84±10.68):
1)patients with paroxysmal AF(n=31);2)patients with persistent AF(n=27);3)patients with permanent AF(n=28); 4)control group-patients with ischemic heart disease, arterial hypertension, heart failure, who had never had documentated AF(n=30).
The activity of the autonomic nervous system was estimated by using spectral and statistical analyses of HRV (Kubios HRV, HRV tracker programs). Estimated time-domain parameters of HRV were SDNN, RMSSD, frequency-domain parameters were LF, HF and their ratio LF/HF. The 24h Holter-monitoring was used to evaluate HRV parameters.
Results: The analyses of the HRV parameters showed, that in the groups of all clinical types of AF the values of HRV parameters were greater compared with control group. In the 4 groups of patients the values of time-domain parameters were: SDNN–132.8±32.9(paroxysmal AF), 98.3±42.8(persistent AF), 125.8±30.1(permanent AF), 49.6±16.7(control) (p=0.001). RMSSD – 67.8±35.1(paroxysmal AF), 91.2±44.4(persistent AF), 125.9±33.5(permanent AF), 52.5±40.4(control) (p=0.003).
In the studied groups the values of frequency-domain parameters were: LF – 1395.0±2177.2(paroxysmal AF), 4408.9±4858.5(persistent AF), 5898.6±3990.7(permanent AF), 524.1±393.3(control) (p=0.005). HF – 918.0±1351.9(paroxysmal AF), 3157.6±2480.5(persistent AF), 3972.1±1945.3(permanent AF), 241.4±183.8(control) (p=0.007). LF/HF – 1.6±1.2(paroxysmal AF), 1.4±0.8(persistent AF), 1.4±0.5(permanent AF), 2.7±0.5(control) (p=0.002).
Conclusion: In the result of comparative analysis of HRV parameters we can conclude, that in patients with AF the increase of HRV parameters, which demonstrated sympathetic and parasympathetic influences on the heart and the deviation of that parameters ratio to the sympathetic activation can have prognostic value in maintaining of AF and also in transforming of paroxysmal AF into permanent clinical type.
P970
Advantage of preprocedural thrombus evaluation of the left atrial appendages by intracardiac echocardiography in catheter ablation patients with persistent atrial fibrillation
Abstract
Background: Although transesophageal echocardiography (TEE) is the clinical standard of diagnosis of thrombi in the left atrial appendage (LAA) before ablation for atrial fibrillation (AF), its thrombus detection ability is not 100% accurate. Intracardiac echocardiography (ICE) has been used in ablation procedures, and previous studies showed that ICE of the LAA from the pulmonary artery was comparable to or better than TEE. However, the clinical advantage of ICE in persistent or long-standing persistent AF is not clear. The aim of our study was to demonstrate the safety advantage of additional preprocedural LAA thrombus evaluation by using ICE.
Methods and Results: We analyzed data from 67 consecutive patients with persistent or long-standing persistent AF who were scheduled for a first session of AF ablation at our institute between September 2013 and December 2014. TEE was performed within 24 hours before ablation. Thrombus or sludge was diagnosed by performing TEE in 11 patients (16.4%) in whom ablation treatment had been canceled. The remaining 56 patients were planned to undergo thrombus evaluation by ICE before the ablation procedure. Two patients (3.6%) were diagnosed with thrombus in the LAA and then ablation was canceled. One patient did not undergo ICE evaluation because of difficulty of advancing the ICE probe in the right ventricular outflow tract. No complication occurred with the ICE imaging.
Conclusion: ICE imaging in addition to the standard TEE procedure increases the detection rate of LAA thrombus in catheter ablation patients with persistent or long-standing persistent AF, allowing for unexpected thromboembolic complications.
P971
Arrhythmia pattern during follow-up after electrical cardioversion does not correlate with the extent of left atrial anatomical remodeling at computed tomography
Abstract
Introduction: It is not clear whether higher degrees of left atrial (LA) dilatation (as a sign of structural remodeling) are associated with type of and/or atrial fibrillation (AF) recurrence following electrical cardioversion (CV) and antiarrhythmic drug therapy.
Methods: Patients (pts) with persistent atrial fibrillation (persAF) undergoing CV and antiarrhythmic drug therapy were included. A 64-slice dual source computed tomography (CT) of the heart (Siemens) was done in sinus rhythm (acquisition during ventricular diastole), and LA volume was calculated (in ml, excluding the veins).
Results: 118 pts [median age 62 (57, 69) years, 38 (32%) females, 37 (14, 79) months of AF duration, 2 (1, 3) previous CV, CHA2DS2Vasc score 2 (1, 3)] were enrolled. At a median follow up of 72 (55, 112) days, 53 (45%), 27 (23%) and 38 (32%) pts presented with PAF, persAF and without AF, respectively. No difference in LA volume was found [No AF: 148 (122, 162) ml; PAF: 132 (117, 145) ml; persAF 138 (110, 160) ml; P>.05). Except for a slightly different follow-up duration [74 (52, 101) vs. 64 (52, 101) vs. 84 (69, 208) days for no AF, PAF and persAF, respectively], clinical characteristics (age, sex, AF duration, number of ECV and of antiarrhythmic drugs, hypertension, CHA2DS2-Vasc score, EF and LA diameters at echocardiography) were similar between groups. The results did not change when LA volume was corrected for body surface area or patients were dichotomized in recurrence of persistent vs. not-persistent AF and presence vs. absence of AF.
Conclusion: Irrespective of arrhythmia recurrence after CV, patients with persistent AF have similar LA volumes at CT (i.e comparable degrees of structural remodeling). Because presence of structural remodeling has been shown to be a powerful predictor of AF recurrence after ablation, these results suggest that arrhythmia presentation may not be ideal to guide further clinical decision, and if catheter ablation is planned, the treatment strategy should not be influenced by recurrence or remission of AF.
P972
Semi automated segmentation of the left atrial blood pool for the assessment and display of left atrial wall thickness
Abstract
Introduction: Left atrial wall thickness (LAWT) has implications for safety and effectiveness of treatment of AF. Areas of change in LAWT may anchor drivers of AF. CT is the optimal imaging modality to assess LAWT because of high spatial resolution. An assessment of global LAWT depends on accurate, reproducible identification of the LA blood pool. We test inter and intra observer variability of a semi-automated algorithm to segment the LA blood pool.
Methods: We analysed 15 CT Coronary Angiograms (CTCA). Hounsfield Unit intensity thresholding is carried out. Connections between nearby contrast enhanced structures require manual removal. We compared segmented volume and surface area when analysed by two different observers and by same observer on different days.
Results: Inter observer variability: Type A intra-class correlation coefficient (ICC) between two observers for the LA volume, using an absolute agreement definition for average measures, was 0.992 (95%CI 96.8 – 99.8, p<0.001) and for the LA surface area 0.993 (95%CI 98.0 – 99.8, p<0.001). The Kappa statistic for agreement as to voxels forming part of the LA endocardial wall (defined as being of 1 voxel thickness) was 0.974. Intra-observer variability: Type A ICC between two observers for the LA volume, using definition above, was 0.996 (95%CI 98.8 – 99.9, p<0.001) and for the LA surface area 0.979 (95%CI 93.7 – 99.3, p<0.001). Kappa statistic for agreement as to voxels forming part of the LA endocardial wall was 0.985.
Conclusion: There is excellent inter and intra observer agreement using our method to segment the left atrial blood pool. Observer-independent displays of left atrial wall thickness in three dimensions may improve atrial structural assessment and inform ablation strategy.
P973
Impact of postprocedural antiarrhythmic drug therapy with bepridil on maintaining sinus rhythm after catheter ablation in patients with persistent atrial fibrillation
Abstract
Background: Several studies have although assessed the predictors of recurrent atrial fibrillation(AF) after catheter ablation for persistent AF, the impact of postprocedural antiarrhythmic drug(AAD) therapy with bepridil on maintaining sinus rhythm after catheter ablation for persistent AF has not been fully evaluated. This case control study was aimed to evaluate the effect of bepridil on maintaining sinus rhythm after catheter ablation for persistent AF.
Methods: We enrolled a total of 122 consecutive patients(87 men, mean age of 62.3years) with persistent AF who underwent catheter ablation and received postprocedural AAD therapy after the initial procedure. We conducted univariate and multivariate analyses to evaluate correlated factors with freedom from recurrent AF after catheter ablation for persistent AF.
Results: 51 of 122(41.8%) patients had recurrent AF during median follow-up of 12 months. There were no significant differences between patients with and without AF recurrence in variables, such as age, gender, hypertension, DM, stroke, CHADS2 score, LVEF, and BNP level. AF lasting duration tend to be longer in patients with AF recurrence than in those without AF recurrence(P=0.056). Compared with the patients without recurrence of AF, left atrial diameter was significantly larger in those with recurrence of AF(P=0.025). With regard to AAD, we compared the use of bepridil to that of other AADs. The number of patients received postprocedural AAD therapy with bepridil was significantly larger in the patients without recurrence of AF than in those with recurrence of AF(33 of 71(46.5%) vs 13 of 51(25.5%);P=0.023). In Cox proportional hazards regression analysis adjusted for age, gender, lasting duration of AF, left atrial diameter, and postprocedural AAD, postprocedural AAD therapy with bepridil was the only correlated factor with freedom from recurrent AF(HR 0.446; 95% CI 0.236-0.842;P=0.012), and bepridil reduced the recurrence of AF by 55.4% compared with other AADs in patients who underwent catheter ablation for persistent AF. Kaplan-Meier analysis of the incidence of recurrent AF after the initial procedure showed that freedom from recurrent AF was significantly greater in patients who received postprocedural AAD therapy with bepridil than in those who received AAD therapy with other AADs (log-rank test: P=0.009).
Conclusions: Postprocedural AAD therapy with bepridil was the only correlated factor with good outcome of catheter ablation for persistent AF, and bepridil reduces the recurrence of AF compared with other AADs by 55.4% in patients who undergo catheter ablation for persistent AF.
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P974
A severity of sleep-disordered breathing with atrial fibrillation ablation candidates is associated with the long-term outcome after pulmonary vein antrum isolation
Abstract
Purpose: Sleep-disordered breathing (SDB) may be associated with pulmonary vein antrum isolation (PVAI) failure. The aim of the present study was to investigate the impact of the severity of SDB for long-term outcome after PVAI.
Methods: From December 2011 to March 2014, 269 consecutive patients underwent PVAI. Known SDB cases with continuous positive airway pressure (CPAP) therapy, cases without appropriate oxygen desaturation data, and ablation failure cases due to the complications were excluded. A total of 244 patients were analyzed. Before the procedure, we measured the oxygen desaturation index (ODI) by pulse oximetry overnight as an indicator of SDB, and classified SDB severity by 3% ODI as normal (ODI <5 events/h), mild (ODI ≤5 to <15 events/h) or moderate-severe (ODI ≥15 events/h).
Results: At the mean follow-up period (18±11 months), 82.2% of normal, 74.9% of mild, and 59.2% of moderate-severe SDB group were free of atrial fibrillation (log-rank P=0.0047). The severity (severe-moderate) of SDB was only predictor of procedural recurrence after single PVAI (hazard ratio, 1.87; 95% CI, 1.01-3.39 P=0.046) including with other known risk factors such as LAVI (< or ≥34ml/m2), AF type (paroxysmal or non-paroxysmal), and concomitance of left ventricular diastolic dysfunction.
Conclusions: The moderate-severe SDB was an independent predictor for single PVAI failure. We recommend that pulse oximeter testing become a routine part of the procedural work-up before AF ablation.
P975
Hybrid approach for persistent atrial fibrillation: a single centre experience
Abstract
Introduction: Atrial fibrillation (AF) is an arrhythmia associated with a high morbidity, mortality and a significant reduction in quality of life. Rhythm control in patients with AF may improve symptoms and hemodynamics, reverse atrial remodeling and reduce the risk of thromboembolism. Indeed, the isolation of pulmonary veins (PVs) with different techniques has become an increasingly common procedure. Different ablation approaches are improved thanks to the new 3D mapping system and the introduction of minimally invasive epicardial surgical techniques: during last years has been developed a new hybrid approach.
Aim: evaluate efficacy and safety of hybrid approach for persistent or long standing persistent atrial fibrillation.
Methods: We enrolled 48 patients refractory to treatment. Mean age was 62.3±9.7 yrs, mean left atrial diameter 48.5±7.5 mm, mean duration time of AF 70±59.5 months, mean EF 57±7.9%. Minithoracotomy or ministernotomy was performed in 55% as surgical approach, for 45% pts the approach was fully endoscopic. For the hybrid approach, first step was done by the surgeon (Box lesion), after four weeks was done the electrophysiological (EP) study with or without PVs ablation. During the surgical step validation of outgoing and incoming blocks were performed and an implantable loop recorder was positioned. During the EP study was performed a validation of surgical lesion and eventually a completion of the PVs isolation.
Results: In our series surgical ablation was completed successfully in all patients with a mean ablation time of 25±7 min and mean procedural time of 78±18 min. In all cases has been documented the block outgoing while the block incoming was documented in 85% of the cases. 32±2 days after surgery was performed an EP study in which were documented blocks incoming and outgoing in 70.8% cases, instead in 29% of cases were documented gap at the ‘Box Lesion’ level. In 62% of cases we perform a completion of PVs isolation. At the follow-up (32 months), 83.3 % of pts were in sinus rhythm, 4.2% have persistent AF and 12.5% paroxysmal AF without any cases of left atrial flutter.
Conclusions: The hybrid approach is a feasible and effective strategy, especially in persistent and long-term persistent AF. EP study is necessary for a clear assessment of the ablation and to refine the endoscopic surgical procedure. Continuous monitoring device is also mandatory to evaluate results and to discontinue anticoagulation and antiarrhythmic drugs. This approach also combines advantages and reduces risks and limitations of both the surgical and EP procedures.
P976
Catheter ablation vs. rate control for atrial fibrillation in patients with heart failure: a meta-analysis
Abstract
Purpose: Rhythm control using antiarrhythmic drugs has not been shown to confer benefit compared to rate control in patients with atrial fibrillation (AF) and heart failure (HF). Rhythm control using catheter ablation (CA) may improve outcomes in these patients. We performed a meta-analysis of randomized controlled trials to examine whether CA-based rhythm control improves outcomes compared to rate control in this patient population.
Methods: We searched electronic databases for studies evaluating the effect of CA in patients with AF and HF. The outcomes of interest included left ventricular ejection fraction (LVEF), quality of life using the Minnesota Living with Heart Failure questionnaire (MLWHF) and peak oxygen consumption (VO2max). Pooled mean differences with 95% confidence intervals (CI) were calculated using a random effects model.
Results: Four trials involving 219 patients (112 undergoing CA and 107 rate control) were included in the analysis. The rate control group strategy included medical therapy in 3 studies and atrioventricular junction ablation and pacemaker implantation in 1 study. Median follow up was 6 months. The median AF-free survival in the CA group was 83%. Based on the pooled estimate across the studies, CA resulted in a significant improvement in LVEF (mean difference=7.38%, 95% CI 3.33% to 11.44%; p=0.0004), quality of life (reduction in MLWHF; mean difference=-16.31, 95% CI=-20.91 to -11.71; p<0.00001) and VO2max (mean difference 2.97ml/kg/min, 95% CI 2.65ml/kg/min to 3.28ml/kg/min; p<0.00001) compared to rate control (Figure).
Conclusion: CA improves left ventricular function, quality of life and functional capacity in patients with AF and HF compared with rate control. Further studies, adequately powered to detect clinical outcomes, are required.
P977
Ipsilateral (superior to inferior and inferior to superior) pulmonary vein capture to demonstrate antral circumferential ablation
Abstract
Introduction: Wide antral circumferential ablation (WACA) of the ipsilateral pulmonary veins (PV) eliminates the trigger and modifies (part of) the substrate for atrial fibrillation (AF). If successful electrical antral isolation is achieved, ipsilateral (superior↔inferior) PV capture dissociated from the left atrial activity would be expected.
Methods: Consecutive patients (pts) undergoing their first AF ablation procedure by a single operator (MB) between April 2012 and October 2014 were included. After double transseptal puncture, WACA of the ipsilateral PVs was attempted with an irrigated ablation catheter and 3D-mapping (NAVX, SJM or CARTO 3, Biosense Webster). After isolation, all veins were mapped with a circular mapping catheter and the ablation catheter placed in the ipsilateral superior or inferior PV. In each position, pacing at maximal output (20V/2ms) was performed via the circular mapping and the ablation catheter to demonstrate exit-block and asses ipsilateral PV capture, both baseline and after a bolus of 30mg adenosine.
Results: 90 pts [62 (54, 69) years old, 36 (40%) female, 36 (40%) paroxysmal AF, 37 (17, 75) months since first AF diagnosis] underwent successful WACA after 108 (84, 128) and 82 (68, 99) min of mapping and radiofrequency time. After left sided WACA, 67 (74%) pts showed ipsilateral PV capture baseline and during adenosine, 2 (2%) pts only after adenosine. Only 7 (8%) and 12 (13%) of the superior and inferior left PVs did not show PV capture. After right sided WACA, 64 (71%) pts showed ipsilateral PV capture baseline and during adenosine, 2 (2%) pts only after adenosine. Only 6 (7%) and 17 (19%) of the superior and inferior right PVs did not show PV capture.
Conclusion: Ipsilateral superior↔inferior PV capture, proving successful electrical isolation of a significant amount of antral tissue, is achieved in most septal and lateral PV pairs. When ipsilateral PV capture is not achieved, dissociated capture of the individual veins is observed in the majority. Introduction to computer law fifth edition. Catheter displacement and/or shorter muscular sleeves (especially for the right inferior PV) might explain why some veins are no longer excitable after isolation.
P978
Management of tamponade complicating catheter ablation for atrial fibrillation: early removal of pericardial drains is safe, effective and may reduce pain and hospital stay compared to delayed removal
Abstract
Tamponade complicating atrial fibrillation catheter ablation (AFCA) procedures is traditionally managed by pericardiocentesis with delayed removal of the drain (typically 12-24 hrs later) in case of re-bleeding. Because this often causes severe pain but ongoing blood loss is rare, our institution has adopted the practice of early removal of drains before leaving the lab if bleeding has stopped.
We did a retrospective analysis of 42 cases of tamponade complicating AFCA during 2006-14 comparing patients in whom the drain was removed immediately (group IR, n=22) vs traditional delayed removal (group DR, n=20). The groups were similar with respect to clinical/demographic characteristics, proportions of first-time vs. re-do and PVI (pulmonary vein isolation) vs. PVI plus procedures. More IR patients underwent AFCA on uninterrupted warfarin. Protamine was administered routinely, but prothrombin complex concentrate (PCC) only if bleeding continued. Primary end-points were need for repeat pericardiocentesis and major adverse outcomes (death, stroke, multi-organ failure). Secondary endpoints were length of stay (LOS) and need for morphine or equivalent opiate analgesia.
The table describes baseline characteristics and outcomes.
Early removal of pericardial drains after tamponade complicating AFCA procedures appears to be safe and effective, with re-insertion rarely required. The traditional practice of leaving drains in-situ for 12-24 hrs may result in more patient discomfort and longer hospitalisation.
P979
Electrocardiographic characteristics of atrial fibrillation onset as a predictor of long-term therapy outcome in patients with paroxysmal atrial fibrillation: A substudy of the MANTRA-PAF trialAbstract
Aims: The impact of electrocardiographic changes triggering paroxysmal atrial fibrillation (AF) episodes on the efficacy of long-term rhythm control therapy is largely unknown. In this post-hoc analysis of the Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) study we evaluated whether spontaneous AF episode onset mechanism can predict antiarrhythmic drug (AAD) and radiofrequency catheter ablation (RFA) therapy outcome.
Methods and Results: A total of 124 AAD naíve patients (age 55±9 years, 77% males) were included in the analysis. At baseline (before the assigned therapy) 2317 AF episodes lasting for at least 60 s were detected in the 7 day Holter recordings. The majority of the episodes (2177 episodes, 94%) were initiated by atrial premature beats (APB) with mean coupling interval of 382±61 ms. In 703 (30%) episodes APB was followed by rapid, repetitive atrial activity (RRAA) with mean measured cycle length of 184±65 ms. During the two year follow up, 46 patients were completely free of AF and 74 patients had at least one AF relapse. RRAA was associated with worse treatment outcome (P=0.025). In patients treated with AADs but not with RFA, longer APB coupling interval at initiation (425 vs. 370 ms) was associated with better outcome (P=0.011).
Conclusions: The results of this analysis reinforced that APBs play important role in initiation of spontaneous AF. The presence of RRAA at AF onset was associated with worse outcome. Whether RRAA is a surrogate to stable rotors or focal drivers of AF requiring additional ablation beyond pulmonary vein isolation remains to be established.
P980
Relationship between left atrial wall thickness by computed tomography and voltage amplitude in patients undergoing radiofrequency catheter ablation of paroxysmal atrial fibrillation
Abstract
Purpose: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), the creation of transmural radiofrequency (RF) lesions along the PVI lines is important to achieve complete bidirectional conduction block between the left atrium (LA) and PVs. Thicker LA wall may require more RF applications to create tramsmural lesions. We investigated the relationship between the left atrial wall thickness (LAWT) determined by computed tomography (CT) and electrophysiological parameters in patients with paroxysmal AF (PAF).
Methods: Forty-two consecutive patients (27 males, 66±9.6 years) underwent initial RF catheter ablation of PAF guided by a three-dimensional geometry merged with CT. The unipolar and bipolar voltage amplitudes (Uni-vol and Bi-vol) were recorded using a contact force (CF) sensing catheter at a total of 635 sites in the anterior, posterior, superior, and inferior LA, and the LAWT was measured at the corresponding sites on the CT.
Results: The mean Uni-vol, Bi-vol, and LAWT were 3.2±1.5 mV, 2.1±1.2 mV, and 2.8±0.6 mm, respectively. A significantly positive correlation was observed between LAWT and Uni-vol, and LAWT and Bi-vol (both P<0.0001), and the LAWT was more strongly correlated with Uni-vol than Bi-vol (Correlation coefficient: 0.52 vs. 0.32). The median LAWT at the sites with Uni-vol <2 mV, 2-3 mV, 3-4 mV, 4-5mV, and >5 mV was 2.3 mm, 2.6 mm, 2.9 mm, 3.1 mm, and 3.4 mm respectively, and the sites with Uni-vol >5 mV had a significantly thicker LAWT than those with Uni-vol <5 mV (P<0.001). The gender differences were observed in Uni-vol and LAWT. Males had a significantly higher Uni-vol and thicker LAWT than females (P=0.01 and <0.01), and the mean Uni-vol and LAWT were 3.5±0.2mV vs. 2.5±0.2mV and 2.9±0.1mm vs. 2.6±0.1mm, respectively.
Conclusions: The higher Uni-vol was associated with the thicker LA wall, and these parameters were significantly greater in males than in females. More RF applications may be needed to create transmural lesions at the higher Uni-vol sites.
P981
Analysis of redo-procedures out of the FIRM ONLY study cohort
Abstract
Introduction: Ablation of focal activity during atrial fibrillation (AF) becomes more and more popular in patients with persistent AF. We performed redo-procedure in 8 patients out of our FIRM ONLY study cohort having been treated with ablation of focal activity without pulmonary vein isolation.
Methods: 8 Pts underwent redo-procedures at a medium of 5.5 months after FIRM only ablation as first AF ablation strategy. All patients had recurrent atrial arrhythmia during a 3-month blanking period and were ablated after one additional arrhythmia recurrence afterwards.
Results: 4 patients had AF (50%), 4 had atypical atrial flutter (50%). In all patients with atrial fibrillation pulmonary vein isolation was performed. In one patient developing right atrial flutter during the redoprocedure ablation of the CTI was additionally performed. This patient had right septal ablation of focal acitivity in the first procedure. In another patient a additional microreentry tachycardia with its focus between LAA and roof could be successfully ablated after had been ablated a focal acitivity around the left superior vein.
In the 4 patients with atypical atrial flutter all reentries mapped were clearly related to former ablation sites where focal activity had been located. (pt. 1 rotor near LAA, reentry ablated near LAA, pt 2 rotor around the left veins, reentry ablated roof of LSPV, pt. 3 rotor left septum, reentry ablated left septal , pt. 4 rotor in front of RSPV, reentry ablated anteroseptal close to RSPV). Finally also these 4 patient were checked for complete pulmonary isolation.
Conclusion: FIRM only ablation in patients with persistent AF appear to have a high incidence of ablation-caused arrhythmia recurrences. Potential indicators at first FIRM ablation approach and larger studies are needed to confirm this oberservation.
P982
Increase of power could enhance effectiveness of radio frequency ablation at the same force-time integral level
Abstract
Purpose: The critical role of force-time integral (FTI) for effective lesion creation in radiofrequency (RF) ablation has been proved in several studies. However, the interaction between power and FTI has not been clearly elucidated.
Methods: 418 ablation points were acquired from 22 patients with paroxysmal atrial fibrillation who underwent pulmonary vein isolation for the first time. The points were collected at the beginning of the procedure at separate sites to avoid the mutual effect. A Thermocool SmartTouch catheter was used for RF ablation and all data were recorded on a Carto 3 system. RF energy was delivered for 60s at each site. Points were grouped by power (25W n=124, 30W, n=161 and 35W, n= 132). Impedance drop (ID) was used as a surrogate measurement of ablation effect. ID≥10 Ω was regarded as an adequate lesion formation. The real-time ID under various FTI (200-1000g·s) were recorded for analysis.
Results: ID increased with either FTI increase under a constant power or higher power under a certain FTI until FTI crossed 600g·s (Table). FTI required to reach the ID of 10Ω under 25W, 30W and 35W were 140 (76-276, q1-q3), 112(73-207, q1-q3) and 68g·s (46-118, q1-q3), respectively. The corresponding ablation times were 12 (8-28, q1-q3), 11(7-18, q1-q3) and 9s (6-12, q1-q3). Under power of 35W, less FTI (P<0.01) and shorter ablation time (P<0.01) were needed to reach the ID of 10 Ω compared with both 25W and 30W. There was no statistical difference between groups of 25W and 30W.
Conclusions: Increase of power could enhance the effect of ablation at the same FTI level. This effect might not be strengthened further after FTI passed 600g·s. Reinforcing power to 35W could decrease the minimal requirement of FTI to obtain an adequate ablation lesion.
P983
Esophagus temperature monitoring during cryoballoon ablation on left atrium using deflectable probe and fixed sensor probeAbstract
Purpose: Periesophageal injury is one of serious complications on atrial fibrillation (AF) ablation also with cryoballoon technique. Temperature monitoring of the esophagus during ablation has been recognized as promising tools to avoid these collateral damages. However, the characteristics of esophagus temperature during cryoablation using a deflectable probe or a fixed sensor probe have not been fully estimated. We assessed the distinctive features and effectiveness of the monitoring systems of esophagus temperature.
Methods: Consecutive 40 patients with drug refractory AF undergone cryoballoon pulmonary vein (PV) isolation were enrolled. PVI was performed with second generation 28mm cryoballon system. Applications were delivered up to 180sec or until falling below 15°C of esophagus temperature during atrial pacing of AF. We monitored temperatures at the anterior aspect of the esophagus simultaneously using a deflectable thermometer (DEF) and a fixed multisensor probe (FIX) during cryoablation on the posterior left atrium (LA).
Results: Application sites fell below 15oC of esophagus temperature were 1.9% (3/160 sites) in FIX and 11.9% (19/160 sites) in DEF (p<0.01). The temperature at beginning of applications is the similar (35.6±0.9oC in DEF vs 36.0±0.9oC in FIX; ns). The minimum temperature was significantly lower in DEF; 25.5±8.2oC [9.1-36.5] than in FIX; 31.0±5.9oC [11.1-37.7] (p<0.001). Thermal luminal lesion (reddening) was observed by esophagus endoscopy on the day after the ablation in a case with minimum temperature of 9.1 oC in DF and 20.7 oC in FIX.
Conclusions: DEF probe could assess more precise esophagus temperature during cryoballoon ablation. FIX probe might underestimate the risk of periesophageal damage.
P984
Robotic navigation system nullifies the benefit of general anesthesia during pulmonary vein isolation: results from a randomized single-center study
Abstract
Purpose: Radiofrequency catheter ablation of atrial fibrillation (AF) can be performed under general anesthesia or conscious sedation according to the physician's preference. The use of general anesthesia has been reported to be associated with a higher procedural success rate because of greater catheter stability during ablation. The Sensei X™ Robotic Navigation System (RNS) (Hansen Medical, Mountain View, CA, USA) has been validated to achieve a higher contact force compared to manual approach. Aim of this study was to assess the long-term success rate in patients undergoing radiofrequency catheter ablation using the RNS evaluating the anesthesiologic approach used.
Methods: A total of 50 consecutive patients with paroxysmal AF undergoing AF ablation were prospectively enrolled and randomized to either conscious sedation with fentanyl or midazolam (25 patients, group 1) and general anesthesia (25 patients, group 2). In all patients a regular follow-up with 7-day-Holter-ECG recording and outpatient clinic evaluation every 3 months was performed.
Results: Baseline clinical characteristics were not significantly different between the 2 groups. There was no significant difference in procedural time (141.1 min vs 152.4 min, p=0.35) as well as fluoroscopy time (18.7 min vs 18.1 min, p=0.80). At 1 year of follow-up after ablation, 21 (84%) patients in group 1 were free of atrial fibrillation, as compared with 22 (88%) in group 2 (log-rank p=0.69).
Conclusions: This is the first randomized single-center study showing no difference in 1-year freedom-from-AF recurrence between conscious sedation and general anesthesia using the RNS. Interestingly, in our experience the use of general anesthesia is not associated with a statistically significant prolonged duration of the procedure.
P985
Early ablation in paroxysmal atrial fibrillation demonstrates significant benefit in atrial function and reverse remodelling: a study with 3D strain
Abstract
Purpose: The aim of the study was to assess the atrio-ventricular remodelling and compliance with 3D strain in patients undergoing early ablation for paroxysmal atrial fibrillation (on the first diagnosis of PAF).
Methods: 40 PAF patients with no previous medical history and no risk factors for coronary artery disease, who agreed to have catheter ablation, were recruited to the study. All patients were followed up 6 months post successful ablation, with Holter monitor tape and outpatient clinic visits. All patients had a 2D and 3D strain assessment of left ventricular (LV) and atrial (LA) longitudinal strain. LA global and free wall longitudinal strain were measured separately as well as the peak global systolic, early and late diastolic LV and LA strain rate. The parameters were associated also with the degree of recurrent AF post ablation.
Results: Mean age was 52.3 ± 9.5 years while mean body surface area was 1.92 ± 0.6 m2. Mean heart rate was 82 ± 12 bpm and mean systolic blood pressure 142 ± 67 mmHg.
Eight patients (20%) had AF recurrence. Post PAF ablation, there was a significant increase of LA global strain (pre-ablation: -22.8 ± (-4.9) % vs. post-ablation: -32.5 (-3.1) %, p<0.001) as well as in LV global strain (pre-ablation: -16.7 (-1.8) % vs. post-ablation: -25.8 (-2.7), p=0.0002). LA volume index was significantly reduced (pre-ablation: 42.3 (2.1) ml/m2 vs. post-ablation: 32.9 (2.8) ml/m2, p=0.007). LV remodelling as measured with 3D volumes, EF and mass was similar in both groups. The rate of AF recurrence was strongly associated with increased LA volume index (r=0.82, p<0.05) Interestingly, only LA early and late diastolic peak strain rate were increased post PAF ablation (p=0.0002 and < 0.01 respectively
Conclusion: Early PAF ablation benefits atrial and ventricular function by increasing regional strain and strain rate and leading to reverse atrial remodelling.
P986
Apixaban is a safe alternative to uninterrupted warfarin during catheter ablation of atrial fibrillation
Abstract
Introduction: With the increased use of the novel oral anticoagulants (NOACs), perioperative management of anticoagulation of patients undergoing atrial fibrillation ablation has yet to fully be defined. Observational data exist concerning dabigatran and rivaroxaban, but data investigating the efficacy and safety of apixaban is currently lacking.
Hypothesis: We hypothesized that apixaban, discontinued the evening prior to the procedure, is as safe and efficacious as uninterrupted warfarin.
Methods: From February 2013 to September 2014, 105 eligible patients (age 63.9 ± 1.0; 66.7% men) from a single center were enrolled into a standardized 30-day follow-up. 20 patients were given apixaban (age 65.4 ± 1.8; 70.0% male), 4 patients were given dabigatran (age 62.5 ± 5.3; 25% male), 55 patients were given rivaroxaban (age 61.3 ± 1.5; 80.0% male), and 26 patients were given uninterrupted warfarin (age 68.5 ± 1.8; 42.3% male). Install linux package from source. We evaluated intraprocedural anticoagulation requirements, peri-procedural major events (mortality and systemic or pulmonary thromboembolism) and safety (major and minor bleeding events) based upon the anticoagulation regimen.
Results: Patients on apixaban required significantly more intraprocedural heparin than patients on coumadin (apixaban: 89.6+25.6 vs. Coumadin: 48.8+12.6 U/kg/hr, p<0.001). Intraprocedural Activated Clotting Times (ACTs) were less likely to be outside the therapeutic range (< 300 or > 400 seconds) with apixaban as compared with heparin (20.7% vs 34.4%, p=0.015). No fatalities or thromboembolic events were observed with either apixaban or coumadin. The overall rate of complications was low with no significant differences observed in either major bleeding events (0% vs. 11.5%; P = 0.122) or minor bleeding (5.0% vs. 11.5%; P = 0.274).
Conclusion: In conclusion, these data corroborate previous studies demonstrating the safety and efficacy of NOACs in the setting of AF catheter ablation and suggest that apixaban is both as safe and effective as uninterrupted warfarin in the peri-procedural setting.
P987
Redo-ablations of atrial fibrillation: procedural characteristics depending on the choice of cryoenergy or radiofrequency ablation as the first line therapy
Abstract
Purpose: Pulmonary vein (PV) isolation, mostly using cryoenergy and radiofrequency (RF) ablation, is the cornerstone therapy for symptomatic paroxysmal AF. One third of the patients have recurrences, mainly due to PV reconnections. Little is known about the characteristics of the redo procedure, depending on the choice of the initial energy.
Methods: Patients referred for a RF redo ablation procedure of symptomatic paroxysmal AF between 2010 and 2014 were enrolled. Demographic data and characteristics of the initial ablation, i.e. cryoenergy or RF ablations, were collected. Number and location of PV gaps, and redo characteristics were reviewed.
Results: 74 pts scheduled for a redo ablation of AF were included, 38 and 36 using RF or cryoablation for the first procedure, respectively. For the initial ablation, procedural (147.8±52.6 vs. 226.6±64.3 min, p<0.001) and fluoroscopy times (37.0±17.7 vs. 50.8±22.7 min, p=0.005) were shorter when using cryoenergy. Overall, an identical number of gaps were found during redo procedures of cryo and RF ablations. However, a significant higher number of gaps were found in the right superior PV (RSPV) for patients first ablated with RF (median 1.0 [0.0, 1.0] vs. 0.0 [0.0, 1.0], p=0.009). Location of gaps followed different patterns between RF and cryoablation (Figure). Redo procedures of cryoablations were slightly shorter (160.0±55.7 vs. 175.7±59.1 min, p=NS) and needed significantly less RF duration times to achieve PV isolation (954±796 vs. 1476±1269 sec of RF p=0.039).
Conclusions: During redo procedures, gaps location pattern is different for patients first ablated with cryo or RF energy. RSPV reconnections occur more frequently after RF ablation and redo procedures of cryoablation need less RF ablation time to achieve PV isolation.
Gaps location for the redo procedure
P988
Head-to-head comparison of contact-force sensing catheters: the same benefit on catheter ablation of paroxysmal and persistent atrial fibrillation?
Abstract
Introduction: Contact-force (CF) sensing catheters have been recently shown to improve procedural success in patients undergoing paroxysmal atrial fibrillation (AF) ablation. The SmartTouch (ST) and TactiCath (TC) are the two leading CF monitoring catheters. To best of our knowledge, there are no head-to-head comparisons between these two catheters in the setting of paroxysmal AF ablation. Furthermore, it is not yet known if using CF while doing persistent AF ablation is of any benefit.
Methods: Single-centre study including all patients undergoing a first procedure of radiofrequency ablation of paroxysmal or persistent AF during a 37-months time interval. Patients were divided in three groups according to the used type of catheter: ST(n=253), TC(n=110) and non-CF(n=358, all remaining point-by-point radiofrequency catheters). Comparisons were performed regarding freedom from AF after a blanking period of 3 months. Predictors of procedural success were assessed.
Results: In patients ablated with non-CF catheters, fluoroscopy time was 6 to 7 minutes longer, in average, for paroxysmal and persistent AF ablation (both P<0.001). At 12 months, 89.3%ST, 87.9%TC and 81.5%non-CF were free from relapse after paroxysmal AF ablation (CF vs non-CF P=0.042). Among the 45.5% of patients who had persistent AF ablation, relapse was more frequent in non-CF(41.3%) than in ST(26.6%) and TC(27.3%) patients(CF vs non-CF P=0.019). During an average follow-up of 11±7months, a significant benefit was found in favour of CF catheters (overall log rank P=0.007). No significant differences were found in head-to-head comparisons of ST vs. TC. On multivariate Cox regression, persistent AF (HR =2.05; 95%CI 1.48-2.83), left atrial volume ≥40ml/m2 (HR=1.42 CI95% 1.04-1.93), CF use (HR=0.58 CI95%0.42-0.79), body mass index(HR=1.04 CI95%1.01-1.08) and AF duration in years (HR=1.07 CI95%1.04-1.09) were predictors of AF relapse.
Conclusion: The ST and TC catheters displayed a similar effectiveness in the setting of catheter ablation of paroxysmal and persistent AF. Using CF catheters was an independent predictor of procedural success, adding incremental predictive value to other well-known and validated variables.
P989
The incidence and characteristics of right phrenic nerve stimulation from right pulmonary veins
Abstract
Background: Right phrenic nerve (RPN) injury is a very symptomatic but an uncommon complication of right pulmonary vein (RPVs) ablation. Pace-mapping has been proposed to infer the course of the RPN and avoid ablation at capture sites, in order to avoid RPN palsy. However, the incidence and characteristics of RPN stimulation from the RPVs is unknown.
Methods: A total 158 patients (116 male, age 67±9 years, 67 paroxysmal) with atrial fibrillation who underwent an initial catheter ablation were enrolled. We performed stimulation (10V/2ms) circumferentially around the RPVs. The points with RPN capture were noted on the 3D map and divided into three groups depending on the location (superior site, middle site, and inferior site).
Results: The RPN was captured in 14 patients (8.8%). Points with RPN capture were located at superior sites in 11, middle sites in 6, and an inferior site in 1. Patients with RPN capture had a large left atrial volume index (LAVI) compared those without (110±42 vs. 85±29, p<0.01). Phrenic nerve palsy occurred in 1.3% after ablation.
Conclusion: RPN capture was frequently observed at superior or middle RIPV sites. Attention needs to be paid to patients with large LAVIs.
P990
NMARQ survey: results of using a novel irrigated multielectrode mapping and ablation catheter for atrial fibrillation ablation
Abstract
Background: Pulmonary vein isolation (PVI) by catheter ablation has been well established as important and often resolved approach for atrial fibrillation (AF), but at the same time it remains a complex and time-consuming procedure. In this study we assesses acute and middle-term follow up efficacy of a novel irrigated multi-electrode ablation catheter (NMARQ) for PVI in patients with paroxysmal and persistent AF.
Methods: 70 consecutive patients (age 56±11 years, 52 male) were enrolled to perform PVI for symptomatic paroxysmal or persistent atrial fibrillation. All patients underwent PVI with the nMARQ catheter and all the procedures were performed using the CARTO3 system. All patients performed a clinical follow-up.
Results: No patients had procedural complications. All PVs were acutely isolated using solely the nMARQ catheter. The mean total fluoroscopy time and procedure time were respectively 14.6 ± 4 min and 78 ± 20 min. Transient reconnection provoked by isoprenaline was observed in 10 of 70 patients. After a follow-up of 12 months, 15 patients (10 with persistent AF and 5 with paroxysmal AF) had AF recurrence
Conclusions: The use of nMARQ catheter for PVI is feasible and safe. In this study we showed a low percentage of AF recurrence after 1 year follow-up.
P991
Non-fluoroscopic navigation system in atrial fibrillation ablation: reducing reference displacement using active fixation lead
Abstract
Introduction: Velocity non-fluoroscopic navigation system (St Jude Medical) uses impedance changes to build a virtual anatomy over a reference that must be stable throughout the procedure (usually a coronary sinus catheter (CSc) or a system reference (SR)). Changes in body impedance or catheter displacement may cause discordance between virtual and real anatomy. This is more frequent in those procedures without general anesthesia (GA) or if electrical cardioversion (EC) is performed. An active fixation lead (AFL) as reference of the system, with less rate of displacement, may be the solution for this problem.
Methods: Compare the global displacement of the virtual anatomy during AF ablation procedures between AFL reference and the regular ones (CSc and SR). The 3 references were used simultaneously in all patients. Displacement was the mean distance between initial and final position in the Velocity system of 6 structures easily recognized in X-ray (pulmonary veins ostia, distal CS and left atrial appendage)
Results: A total of 49 patients were included. Results shown in Table. AFL presented smaller displacement, showing a of 4,49 mm and 3,72 mm compared with SR and CSc respectively (p<0,05). These differences were higher in those procedures without GA and if EC was performed but, due to the small sample, statistically significant difference was not found in these situations.
Conclusion: In our study AFL reference showed smaller displacement that SR and CSc, even more in those procedures without GA and if EC was performed.
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Population| Procedure | | Age (years) | 54±10 | Anesthesia/Sedation | 73,5/26,5% | EC | 30,6% |
| Gender (M/F) | 87,8/12,2 % | Transeptal Puncture/PFO | 83,7/16,3% | CTI ablation | 18,4% |
| Paroxysmal/ persistent AF | 63,3/36,7% | Re-do | 24,5% | Time of procedure (min) | 179,92±46,74 |
| Antiarrhythmic drugs | Amiodarone 34,7% Flecainide 38,8% Dronedarone 10,2% Sotapor 2% None 8,2% | Complete vein isolation | 100% | Time of ablation (min) | 39,48±17,46 |
| CFAEs ablation | 28,6% | Time of X-ray (min) | 49,01±17,47 |
| Displacement (mm) |
| Global | EC (15 p) | Sedation (13 p) |
| Active fixation lead | 7,31±3,97* | 8,71±4,47 | 8,31±2,53 |
| CS catheter | 11,03±8,52* | 12,68±11,01 | 13,34±11,23 |
| System Reference | 12,25±8,52* | 15,43±9,10 | 16,07±9,02 |
Population| Procedure | | Age (years) | 54±10 | Anesthesia/Sedation | 73,5/26,5% | EC | 30,6% |
| Gender (M/F) | 87,8/12,2 % | Transeptal Puncture/PFO | 83,7/16,3% | CTI ablation | 18,4% |
| Paroxysmal/ persistent AF | 63,3/36,7% | Re-do | 24,5% | Time of procedure (min) | 179,92±46,74 |
| Antiarrhythmic drugs | Amiodarone 34,7% Flecainide 38,8% Dronedarone 10,2% Sotapor 2% None 8,2% | Complete vein isolation | 100% | Time of ablation (min) | 39,48±17,46 |
| CFAEs ablation | 28,6% | Time of X-ray (min) | 49,01±17,47 |
| Displacement (mm) |
| Global | EC (15 p) | Sedation (13 p) |
| Active fixation lead | 7,31±3,97* | 8,71±4,47 | 8,31±2,53 |
| CS catheter | 11,03±8,52* | 12,68±11,01 | 13,34±11,23 |
| System Reference | 12,25±8,52* | 15,43±9,10 | 16,07±9,02 |
Population| Procedure | | Age (years) | 54±10 | Anesthesia/Sedation | 73,5/26,5% | EC | 30,6% |
| Gender (M/F) | 87,8/12,2 % | Transeptal Puncture/PFO | 83,7/16,3% | CTI ablation | 18,4% |
| Paroxysmal/ persistent AF | 63,3/36,7% | Re-do | 24,5% | Time of procedure (min) | 179,92±46,74 |
| Antiarrhythmic drugs | Amiodarone 34,7% Flecainide 38,8% Dronedarone 10,2% Sotapor 2% None 8,2% | Complete vein isolation | 100% | Time of ablation (min) | 39,48±17,46 |
| CFAEs ablation | 28,6% | Time of X-ray (min) | 49,01±17,47 |
| Displacement (mm) |
| Global | EC (15 p) | Sedation (13 p) |
| Active fixation lead | 7,31±3,97* | 8,71±4,47 | 8,31±2,53 |
| CS catheter | 11,03±8,52* | 12,68±11,01 | 13,34±11,23 |
| System Reference | 12,25±8,52* | 15,43±9,10 | 16,07±9,02 |
Population| Procedure | | Age (years) | 54±10 | Anesthesia/Sedation | 73,5/26,5% | EC | 30,6% |
| Gender (M/F) | 87,8/12,2 % | Transeptal Puncture/PFO | 83,7/16,3% | CTI ablation | 18,4% |
| Paroxysmal/ persistent AF | 63,3/36,7% | Re-do | 24,5% | Time of procedure (min) | 179,92±46,74 |
| Antiarrhythmic drugs | Amiodarone 34,7% Flecainide 38,8% Dronedarone 10,2% Sotapor 2% None 8,2% | Complete vein isolation | 100% | Time of ablation (min) | 39,48±17,46 |
| CFAEs ablation | 28,6% | Time of X-ray (min) | 49,01±17,47 |
| Displacement (mm) |
| Global | EC (15 p) | Sedation (13 p) |
| Active fixation lead | 7,31±3,97* | 8,71±4,47 | 8,31±2,53 |
| CS catheter | 11,03±8,52* | 12,68±11,01 | 13,34±11,23 |
| System Reference | 12,25±8,52* | 15,43±9,10 | 16,07±9,02 |
P992
Figure-of-eight suture for vascular hemostasis in fully anticoagulated patients after atrial fibrillation catheter ablation
Abstract
Purpose: Limited data exists for types of vascular closure and its associated complications in patients (pts) after atrial fibrillation (AF) catheter ablation. We evaluated the figure-of-eight suturing for achieving vascular hemostasis after AF catheter ablation compared to that with manual pressure.
Methods: Two hundred nine consecutive pts that underwent AF catheter ablation by two operators were included. All pts received continuous therapeutic warfarin through the procedure or interrupted novel oral anticoagulants (NOAC) and heparin (activated clotting time [ACT] 300-400) without reversal. Venous sheaths were placed in both groins. Pts were divided into two groups: 1) sheaths were left in place and pulled once the ACT <180, and hemostasis was achieved with manual pressure (MP); and 2) subcutaneous figure-of-eight sutures closed the venous access site immediately after the ablation on each groin site (Fo8). 1-silk suture was placed in a figure-of-eight configuration with a deep bite superior and inferior to the venous insertion sites. Traction on the suture with a locking knot gathered the tissue to tamponade the venipunctures sites, and sheaths were removed immediately after the ablation despite a therapeutic range ACT and PT. Sutures were removed after four hours, and the patients laid flat for another two hours.
Results: The MP group (n=105) was similar to the Fo8 group (n=104) regarding mean age (63 years each), male gender (60% vs. 62%), paroxysmal atrial fibrillation (60% vs. 61%), BMI (30 vs. 29.5), EF (57% vs. 58%), CAD (20% each), HTN (38% vs. 44%), DM (30.5% vs. 29.8%), PVD (19% vs. 15.4%), INR pre-procedure (2.5 vs. 2.5), NOAC use (21.9% vs. 30.7%), CHA2DS2VASc score (2.2+1.4 vs. 2.1+ 1.2), and post-ablation ACT (312 vs. 309 sec), respectively. Time in bed was 573 ± 80 min for MP vs. 366± 35 min for Fo8 pts (p<0.0001). Eleven hematomas were seen in the MP group compared to 4 in the Fo8 pts. One patient in the MP group had a pseudoaneurysm that was treated with surgery.
Conclusions: In fully anticoagulated pts undergoing AF catheter ablation, excellent hemostasis was achieved with figure-of-eight sutures, with no major vascular complications, a lower hematoma rate, and a significantly shorter flat-time-in-bed compared to manual pressure.
P993
Pulmonary vein anatomy and nadir temperature during cryoballoon ablation for atrial fibrillation
Abstract
Introduction: Cryoballoon-based technique has been successfully used for ablation of atrial fibrillation (AF). However, little is known about anatomical predictors of acute success of pulmonary vein isolation (PVI) and relationship between vein ostium shape and temperature achieved during cryoapplication.
Methods: 32 patients (21 males, mean age 56+/-12) undergoing cryo-ablation (28 mm size) for AF were included. Using computed tomography, PV ostia area were measured and ovality index (OI) was calculated. Also, the nadir temperatures obtained during successful applications (240 seconds) were recorded. PVI was confirmed using the Achieve catheter.
Results: All 128 PV ostia were measured with RSPV being the largest and LIPV – the smallest. The most oval vein was LSPV, followed by LIPV and RSPV. The RIPV had significantly lowest OI. The most negative temperature was recorded in RSPV, and the least negative – in RIPV. Both these veins had significantly different OI (see table for detailed results).
Conclusion: The ovality and ostium area of PV may be associated with achieved nadir temperature which may have important implications for the effectiveness cryoballoon-based PVI.
| Area of the ostium | 197,7 ± 49,1 | 227,1 ± 74,3 | 272,6 ± 114,2 | 294,0 ± 139 | 0,0014 LIPV vs RIPV; p= 0,0260 LIPV vs RSPV; p=0,0021 LSPV vs RSPV; p=0,0543 |
| Ovality | 0,37 ±0,17 | 0,38 ± 0,21 | 0,19 ± 0,14 | 0,33 ± 0,17 | p=0,0001 RIPV vs LIPV; p=0,0009 RIPV vs LSPV; p=0,0002 RIPV vs RSPV; p= 0,0152 |
| Minimal temperature | -46,0 ± 8,8 | -48,7 ± 7,0 | -45,6 ± 6,6 | -50,7 ± 6,1 | p=0,0225 LIPV vs RSPV; p=0,0558 RIPV vs RSPV; p=0,0397 |
| Area of the ostium | 197,7 ± 49,1 | 227,1 ± 74,3 | 272,6 ± 114,2 | 294,0 ± 139 | 0,0014 LIPV vs RIPV; p= 0,0260 LIPV vs RSPV; p=0,0021 LSPV vs RSPV; p=0,0543 |
| Ovality | 0,37 ±0,17 | 0,38 ± 0,21 | 0,19 ± 0,14 | 0,33 ± 0,17 | p=0,0001 RIPV vs LIPV; p=0,0009 RIPV vs LSPV; p=0,0002 RIPV vs RSPV; p= 0,0152 |
| Minimal temperature | -46,0 ± 8,8 | -48,7 ± 7,0 | -45,6 ± 6,6 | -50,7 ± 6,1 | p=0,0225 LIPV vs RSPV; p=0,0558 RIPV vs RSPV; p=0,0397 |
| Area of the ostium | 197,7 ± 49,1 | 227,1 ± 74,3 | 272,6 ± 114,2 | 294,0 ± 139 | 0,0014 LIPV vs RIPV; p= 0,0260 LIPV vs RSPV; p=0,0021 LSPV vs RSPV; p=0,0543 |
| Ovality | 0,37 ±0,17 | 0,38 ± 0,21 | 0,19 ± 0,14 | 0,33 ± 0,17 | p=0,0001 RIPV vs LIPV; p=0,0009 RIPV vs LSPV; p=0,0002 RIPV vs RSPV; p= 0,0152 |
| Minimal temperature | -46,0 ± 8,8 | -48,7 ± 7,0 | -45,6 ± 6,6 | -50,7 ± 6,1 | p=0,0225 LIPV vs RSPV; p=0,0558 RIPV vs RSPV; p=0,0397 |
| Area of the ostium | 197,7 ± 49,1 | 227,1 ± 74,3 | 272,6 ± 114,2 | 294,0 ± 139 | 0,0014 LIPV vs RIPV; p= 0,0260 LIPV vs RSPV; p=0,0021 LSPV vs RSPV; p=0,0543 |
| Ovality | 0,37 ±0,17 | 0,38 ± 0,21 | 0,19 ± 0,14 | 0,33 ± 0,17 | p=0,0001 RIPV vs LIPV; p=0,0009 RIPV vs LSPV; p=0,0002 RIPV vs RSPV; p= 0,0152 |
| Minimal temperature | -46,0 ± 8,8 | -48,7 ± 7,0 | -45,6 ± 6,6 | -50,7 ± 6,1 | p=0,0225 LIPV vs RSPV; p=0,0558 RIPV vs RSPV; p=0,0397 |
P996
Predictors of pocket hematoma occurrence in patients on uninterrupted oral anticoagulation undergoing cardiac implantable electronic device procedures
Abstract
Purpose: Patients on oral anticoagulation (OAC) are a growing group undergoing CIED procedures. A strategy based on uninterrupted OAC is associated with reduced hematoma formation as compared with bridging approach. But patients on OAC remain at increased risk for developing pocket hematoma. In this setting HASBLED score failed to show a correlation with the bleeding risk related to the procedures in the main randomized trials performed. Our pilot study was designed to investigate whether the others common used bleeding scores are able to predict hematoma occurrence in this population.
Methods: We consecutively enrolled 64 patients (mean age 77,3±11,1, F:M=26:38) on uninterrupted OAC undergoing CIEDs procedures (29 ex novo implants, 28 replacements, 7 revisions). All patients signed an informed content. They were followed during the next 15 days monitoring bleeding complications. Bedside calculations of the main bleeding risk scores (HASLBED, ATRIA, HEMORR2HAGES) and GFR (ml/min) were performed. Hematoma occurrence was described as any suffusion or swelling in the pocket area determining a clinical intervention: from watchful waiting to re-intervention for evacuation.
Results: Eight out of 64 patients (12,5%) developed pocket hematoma during the next 30 days after the procedure. No major bleedings were observed during procedures. There was no need for re-intervention for pocket hematoma evacuation. All patients were at moderate-high thromboembolic risk (mean CHA2DS2VASc 3,6±1,3). Most of them showed a mild-moderate CKD (mean GFR 58,4±28,6 ml/min). Main indication to anticoagulation was Atrial Fibrillation/Flutter (78%). Comparing the two groups (pocket hematoma present vs pocket hematoma absent) we analyzed all the anthropometric and clinical variables (age, sex, type of procedure performed, BMI, BSA, GFR, INR value, diabetes mellitus, CHA2DS2VASc, HASBLED, ATRIA, HEMORR2HAGES). Interestingly only INR the day of the procedure (2,54±0,2 VS 2,25±0,3 , p<0,05) and HEMORR2HAGES bleeding score (2,7±1 VS 1,8±1,1 p<0,05) resulted significantly associated with pocket hematoma occurrence.
Conclusions: While performing CIED procedures in patients on uninterrupted OAC implanters should pay attention to patients with high intrinsic bleeding risk calculated with HEMORR2HAGES score. In this population lower INR values are warranted to minimize bleeding risk and pocket hematoma occurrence.
P997
Comparison of pulmonary vein isolation guided by remote magnetic navigation in patients with paroxysmal atrial fibrillation using an irrigated gold-tip and a classical irrigated catheter
Abstract
Aims: The present case–control study seeks the efficacy and the safety of RMN guided ablation using the irrigated gold-tip and a classical irrigated in patients with PAF and normal structural heart.
Methods: Patients with PAF refractory to antiarhythmic drug, normal structural heart and no previous pulmonary vein isolation (PVI) were included. The procedures were performed using the Stereotaxis Niobe II (Stereotaxis, Inc., St Louis, MO, USA). 40 patients were ablated using theNaviStar RMT ThermoCool catheter guided by CARTO mapping (Biosense Webster, Diamond Bar, CA, USA) and 30 with the Trignum Flux Gold-tip catheter (Biotronik GMBH, Berlin, Germany) guided by the Ensite Velocity system (St. Jude Medical, St. Paul, MN,USA). Reconnection of veins was checked with Adenosine after all 4 veins were isolated.
Results: This study includes 70 patients (64% males) with a mean age 60 ± 9,8 years. The 2 groups were comparable regarding the left atrium diameter, left atrium appendage velocity, left ventricular ejection fraction, E velocity and A velocity. Complication rate did not differ significantly between groups. Reconnection of veins after Adenosine was 20 % vs. 26,6% (P=0,24). Success rate after a mean period of follow-up of 10,9 months was: 80 vs. 86,66%, (P= 0,30). Index procedure time (135,71±46,17 vs 182,89±68,46 min, P =0,006) and radiofrequency application time (42±4,5 vs. 54,32±14,9 min, P =0,08 ) were longer in the Trignum Flux CA group; however, the respective total fluoroscopy time were similar (18,74±10,26 vs 18,47±9,74 min, P =0,46 ).
Conclusions: RMN guided ablation of PAF with the Trignum Flux catheter is as efficient and safe as with the Thermocool Navistar catheter, although it requires longer total procedural time.
P998
Endoscopically detected esophageal thermal lesions are related to the use of esophageal intraluminal temperature probe: Results from atrial fibrillation ablation using a novel irrigated multipolar abl
Abstract
Atrio-esophageal fistula (AEF) is a rare but mostly lethal complication of atrial fibrillation ablation. So far, no methodology to reduce the incidence of AEF has been identified. Asymptomatic endoscopically detected thermal lesions of the esophagus (EDELs) may be a precursor and indicator of a potential risk for AEF. We evaluated a novel ablation device using irrigated multipolar radiofrequency ablation (nMARQ) and its safety in regard to EDELs.
Methods: Consecutive patients undergoing left atrial ablation to treat AF using the nMARQ catheter were prospectively included if willing and undergoing postablation endoscopical evaluation of the esophagus. The nMARQ is a 10-pole irrigated radiofrequency ablation catheter used with integration into the CARTO electro-anatomical mapping system. Ablations were directed towards effective pulmonary vein isolation using a maximum of 20Watts energy for electrodes positioned towards the posterior left atrial wall and maximum of 25Watts for all other regions. An automated software adoption tool limiting energy application if no temperature increase above 38°C was noted during ablation was used. Patients undergoing ablation with a thermal intraluminal esophageal probe with a temperature cut-off of 39°C were compared to patients ablated without.
Results: Group 1 (N=32) and group 2 (N=44) were comparable in regard to patient baseline and procedural characteristics including total radiofrequency ablation and overall energy delivered. In Group 1 26 patients (81%) had a esophageal temperature increase to ≥ 39°C (mean 40.7°C maximum temperature). 25% of patients (4/32) in group 1 and 0% (0/44) had EDELs documented.
Conclusions: EDELs may be relevantly reduces when performing left atrial AF ablations using the nMARQ catheter not using a thermal probe. The exact mechanism and if this data is transferrable to other ablation devices and thermal probes needs to be further evaluated. Whether reducing EDELs may also influence the incidence of AEF remains unclear.
P999
Irradiation of the operator and the patient during radiofrequency ablation of common atrial flutter using three different settings of angiography system
Abstract
Background: We aimed to compare irradiation dose during Radio Frequency (RF) ablation of common Atrial Flutter (AFl), using different settings of angiography system.
Method: Patients admitted for common AFl ablation were randomly assigned to three groups : 1- low dose setting (3.75 frames per second), 2- regular dose (7.5f/s) or 3-regular dose and collimation of X-ray field. Procedural time, fluoroscopy time, Dose Area Product (DAP) (cGy.cm2), operator's absorbed dose (with 3 active dosimeters at left wrist, temple, and hip) (μSv) and patient's skin dose (mGy) (Gafchromic film) were compared. Acute clinical success was defined as obtaining sinus rhythm and isthmus block.
Results: Thirty patients have been included (n=7, 11 and 12 in each group). Sinus rhythm was obtained in all but one patient of group 1. Procedural time was comparable between the three groups (26±6.6, 19.2±5.1, 21.4±8 min respectively p=NS).
Despite a longer fluoroscopy time of group 1 (16.6±5.2 min vs 8.8±5.1 vs 10.2±5.9, p=0.03 for group 1 vs 3), DAP was significantly lower (279±105 cGy.cm2 vs 1787±1311 and 823±678 respectively, p<0.05 for group 1 vs group 3).
Operator's absorbed dose was significantly lower at all site comparing group 1 and 2, but without reaching significance comparing group 1 and 3: Temple: 1.29±1.05 vs 9.65±8.47 vs 2.65±2.56 μSv, wrist: 2.86±2.85 vs 14.1±9.88 vs 10.27±11.84, hip: 0.15±0.06 vs 1.88±1.88 vs 1.32±1.33, (p<0.05 for each comparison of group 1 vs 2, p=NS for each comparison of group 1 vs 3).
Patient's skin dose was also significantly reduced between group 1 and 2 (107±8 vs 245±163 mGy, p=0.02), whereas non significant between group 1 and 3 (107±8 vs 234±134 mGy, p=NS)
Conclusion: Use of low dose setting (3.75 f/s) can dramatically reduce operator's absorbed dose by a mean of 85.7% and patient's absorbed dose by 56.3% compared to regular setting (7.5f/s), without impairing acute clinical success rate or procedural time. Low dose setting seems to be preferable than regular setting with collimation of X-ray field for RF ablation of common AFl.
P1000
Cavotricuspid isthmus ablation using a catheter equipped with mini electrodes on the 8mm tip: a prospective comparison with an 8mm dumbbell shape tip catheter and an 8mm tip cryothermal catheter
Abstract
Introduction: The mini electrodes placed on the tip of the ablation electrode provide more precise local signal. Our objective in this study was to evaluate the efficiency of the catheter equipped with mini electrodes on the 8mm tip (ME catheter) (Intella, Boston) for cavotricuspid isthmus (CTI) ablation by prospectively comparing with an 8mm dumbbell shape tip catheter (DS catheter) (Ablaze, Japan Life Line) and an 8mm tip cryothermal catheter (Cryo catheter) (Freezor Max, Medtronic).
Methods: Eighty-five consecutive patients (68men; 61±10 years) underwent CTI ablation following pulmonary vain isolation either using a ME catheter in 25 patients (group A, 55 °C, 50W, 60s), a DS catheter in 30 patients (group B, 55 °C, 50W, 60s) or a Cryo catheter in 30 patients (group C, -80 °C, 120s). Individual lesions were placed in point-by-point fashion. Endpoint was achievement of bidirectional conduction isthmus block across CTI line. In cases of failed isthmus block, the catheter was changed to the other catheter, but patients remained in the original group following intention-to-treat analysis.
Results: The selected endpoint could be achieved in all patients after 13±7 applications in group A, 9±4 applications in group B, and 5±2 applications in group C (p<0.001). Fluoroscopic time and procedure time were longest in group A (9±7 and 28±17 min, p=0.001, and p=0.002, respectively) as compared with group B (6±4 and 13±6 min) and group C (4±3 and 14±7 min). CTI block was achieved in all patients eventually, but cross-over was performed in 16 (64%) patients of group A after primary use of the ME catheter, and in 3 (10%) patients of group C after primary use of the Cryo catheter. Importantly, mean power delivered in group A was significantly lower than group B (28.9±8.6 W vs. 38.6±7.6 W, p=0.015).
Conclusion: ME catheter was found to be less effective than a Cryo catheter and a DS catheter for CTI ablation. Mean power delivered during ablation was significantly lower for ME catheter than for DS catheter presumably due to tip shape difference.
P1001
Characterization of very low voltage/scar areas in patients with left atrial flutter by high density voltage maps
Abstract
Background: Circuits of left atrial flutter (LAFl) are delimited by scar areas (SA). We studied the location and extension of SA in patients without previous LA ablation.
Methods: 33 P included (67% women, age 71±10 years). High-density point-by-point activation/voltage maps were developed with a 3D navigator during LAFl or SR if the arrhythmia was unstable. Bipolar peak-to-peak amplitude at each point was shown. SA were defined by congruent points with <0,1 mV and normal tissue by >0,5 mV. Total endocardial surface (TES) and total scar areas (SA) surface were quantified by merging with a 3D TC image of the LA.
Results: 49 EP studies in 33 patients, 9 (27%) had a prosthetic mitral valve implated. In the first EP study in each patient the tisular substrate was characterized (number of points: 955±332, range 379-1481). TES was 114±31 cm2. Median SA was 25±31 cm2 (range 0-134 cm2), constituting 20±21% of TES (range 0- 86%). 2 P presented massive scar areas (>85%) and 1 P had no scar. Location of the widest scar area: anterosuperior wall 61%, posterior 15%, septal 6%, right PV antrum 6%, massive 6%, inferior 3%. 28 P had a secondary SA: posterior 25%, septal 21%, anterior 18%, right PV antrum 18%, inferior 15%. 61 LAFl were studied, 23 (37%) could not be fully characterized. Detailed characterized circuits: 35% perimitral, 18% mural superior, 12% mural posterior, around right PV 10%, septal 10%, around left PVs 8%, LAA flutter 6%. 59/61 circuits laid adjacent or crossed through scar areas. No relationshipt was found between scar areas and number of LAFl per patient.
Conclussions: Prevalence of SA is high but their distribution heterogeneous. SA are located frequently on the anterosuperior and posterior walls of the LA. Characterizing these SA is relevant for LAFl mapping and ablation.
P1002
Impact of evaluation of epicardial impedance before ablation to determine effective epicardial ablation sites
Abstract
Background: During epicardial mapping, determination of appropriate ablation sites in low voltage areas is challenging because of wide epicardial areas covered by adipose tissue. It has been reported that epicardial fat can be distinguished from scar tissue based on duration of local bipolar electrogram (EGM) and the degree of fractionation.
Objective: To investigate whether radiofrequency (RF) delivered to areas of higher impedance is less effective due to the presence of epicardial fat or not.
Methods/Results: This study included data from 11 patients (mean age, 63.8±6.5 years) with ventricular tachycardia (VT) recurrence after endocardial VT ablation. Retrospective analysis of 2150 mapping and ablation points was conducted. Of 369 ablation sites, the mean impedance was 124±25.7Ω, and the mean amplitude of local bipolar EGM was 0.82±0.79mV. Initial impedance before RF delivery was inversely correlated with the EGM reduction between pre- and post-RF delivery (p=0.02, r=0.539). The points with EGM reduction ≥50% revealed lower impedance than those with <50% (114±19.6Ω vs. 141±26.9Ω; p=0.001). Moreover, longer EGM duration and greater number of multiple deflections were observed in the ablation points of EGM reduction ≥50% compared with those of EGM reduction <50%.
Conclusions: Evaluation of epicardial impedance is useful to determine effective epicardial ablation sites. Higher impedance may indicate epicardial myocardium covered with adipose tissue.
P1003
Electroanatomical voltage and morphology characteristics in post-infarction patients undergoing ventricular tachycardia ablation: A pragmatic approach favoring late potentials abolition
Abstract
Purpose: Catheter ablation is an important therapeutic option in post-myocardial infarction (MI) patients with ventricular tachycardia (VT). We analyzed the endo-epicardial electroanatomical mapping (EAM) voltage and morphology characteristics, their association with clinical data and their prognostic value in a large cohort of post-MI patients.
Methods: We performed analysis of voltage (bipolar dense scar-DS and low voltage-LV areas, unipolar LV and penumbra areas) and morphology characteristics (presence of abnormal late-LPs and early potentials-EPs) in 100 post-MI patients undergoing EAM-based VT ablation (26 endo-epicardial procedures) from 2010-12. Unipolar LV areas were areas with a unipolar voltage <8 mV. Endo- and epicardial bipolar scar density was defined as the ratio of bipolar DS to LV area, reflecting the fibrosis density within the infarct region. Matching dense scar identified on the endocardium and epicardium was presumed to be transmural scar. We defined as unipolar penumbra area the unipolar LV area beyond the bipolar LV area.
Results: The mean endocardial surface area was 236.1 cm2. Of that, 10.2% was bipolar DS, 21.8% was bipolar LV and 46.7% was unipolar LV. Endocardial penumbra was present in all but one patients and mean area was 51.6 cm2 (24.9%). While unipolar LV was present in all cases, 18% of the post-MI patients had no evidence of endocardial bipolar DS. Endocardial bipolar DS area >22.5 cm2 (sensitivity 61.1% and specificity 87.5%) best predicted scar transmurality.
Endocardial LPs were recorded in 66% of the patients and epicardially in 17/26 (65.4%). Endocardial bipolar DS area >7 cm2 (sensitivity 88.2% and specificity 66.7%) and endocardial bipolar scar density >0.35 (sensitivity 52.9% and specificity 100%) predicted epicardial LPs. Abolition of endocardial LPs was achieved in 51/66 (77.3%) and of epicardial LPs in 10/17 (58.8%) patients.
As a primary strategy, LPs and VT-mapping ablation occurred in 48%, only VT-mapping ablation in 27%, only LPs ablation in 17% and EPs ablation (in the absence of LPs) in 6%. After a median follow-up time of 628 days, endocardial LP abolition was associated (HR 0.274, p=0.010) with reduced VT recurrence (32%). Endocardial LP presence (HR 0.177, p=0.041) acted as a prophylactic predictor while increased endocardial penumbra area (HR=1.028, p=0.044) as an adverse predictor of cardiac death (7%).
Conclusions: Endocardial scar extension and density predicted scar transmurality and endo-epicardial presence of LPs, although DS is not always identified in post-MI patients. LPs were abolished in 51% resulting in improved outcome.
P1004
Safety of anteroseptal atrioventricular accessory pathway catheter ablation: very long-term follow-up results
Abstract
Purpose: Catheter ablation (CA) of anteroseptal accessory pathways (APs) is considered at high risk of heart block because of the proximity of the atrioventricular (AV) conduction system. Very-late occurrence of AV block after CA in the AV junction area has been described, mostly following AV nodal reentrant tachycardia CA. The aim of our study was to retrospectively assess the safety of anteroseptal AP CA in a very long-term follow-up (FU).
Methods: From 1997 to 2013, 45 consecutive pts (12 women, mean age 29±14 yrs, range 11–66) underwent CA for APs located in the anteroseptal area (overt preexcitation in 34 pts). The procedures were performed by radiofrequency (RF) or cryoenergy according to operator preference and ablation system availability. All CA procedures were reviewed and pts were submitted to 12-lead ECG and 24-hour Holter monitoring to assess the long-term occurrence of fixed or paroxysmal AV or intraventricular conduction abnormalities.
Results: Acute success was achieved in 41 out of 45 (91%) pts and AP conduction recurrence occurred in 8 (19%) pts at 1 month FU. A second CA was attempted in 10 pts and succeeded in 9 cases (total success rate 93%). Overall, RF was used in 38/55 (69%) and cryoenergy in 17/55 (31%) CA procedures. Acute success rate was similar with RF or cryoenergy (92% vs 88%, p=0.64), while 1 month FU recurrences were slightly less frequent in the cryoablation group (7% vs 20%, p=0.41). Intraprocedural complications included transient right bundle branch block (RBBB) occurrence in 3 (6.7%) pts (during RF in 1), permanent RBBB in 3 (6,7%) pts (during RF in 2), transient complete AV block occurrence in 1 (2.2%) pt (during cryoablation). At a mean FU of 11±5 (range 1-18) yrs, 8 (18%) pts were lost and excluded from the analysis. In the remaining 37 pts, no further AP conduction recurrences were observed. Long-term 12-lead ECG and 24-hour Holter recordings revealed a I degree AV block occurrence in 1 (2.7%) 55 yr old man under treatment with metoprolol for coronary artery disease, and either II degree type 1 or high degree AV block asymptomatic episodes in another (2.7%) 36 yr old man. No further AV or intraventricular conduction disturbances were observed, including those pts with CA-related transient or persistent RBBB.
Conclusion: Given the very low risk of AV or intraventricular conduction disturbance occurrence, anteroseptal AP CA is a safe procedure even in a very long-term period. Either RF or cryoenergy seem to be associated with similar outcomes. Further studies including multicentre data should confirm these preliminary results.
P1005
Prognosis of atrial flutter-related tachycardiomyopathy did not differ from patients without atrial flutter-related tachycardiomyopathy after ablation
Abstract
Purpose of the Study: To determine the prevalence and predisposing conditions of atrial flutter (AFl)-related cardiomyopathy (CM). AFl-related CM is a rare and treatable cause of heart failure. Little is known about the epidemiology of AFl-related CM.
Methods: 1269 patients, mean age 64.8±11.6 years were consecutively referred for radiofrequency ablation of AFL between January 1996 and September 2014; 180 patients admitted with heart failure or CM and low left ventricular ejection fraction (LVEF) (<40%) were collected; 101 patients (56%) years with normalisation or marked improvement (>30%) of LVEF 6 months after ablation considered as having AFl-CM were studied and followed for 2.4±2.7 years.
Results: Patients with AFl-related CM (8.6% of total population), 84 men (85%) with a mean age of 64.6±11.6 years were compared to 1168 patients, 888 men (76%, 0.03), with a mean age of 64.9±11.6 years (NS) without AFl-related CM. They differed from those without the event by less frequent valvular and congenital heart disease (p<0.036, 0.044) but the most frequent presence of mild idiopathic dilated CM (p<0.0004). They did not know the date of AFl beginning. No data at the time of ablation or during follow-up differed between patients with and without AFl-related CM. AF occurrence, implantation of pace-maker, ablation of His bundle, ablation of AF and cardiac death were as frequent. Ten patients with AFL-related CM and who later developed AF still developed CM that was controlled by drugs or ablation. Multivariate analysis of factors of AFl-related CM was previous idiopathic mild CM, main factor (0.003); male gender (0.044), history of amiodarone-related hyperthyroidism (0.041) were also independent factors. AFl-related CM was not a factor of death or increased AF occurrence. HD presence (0.002) and AF occurrence (0.46) were independent factors of cardiac death. Male gender (0.001) and AF history (0.001) were independent factors of AF occurrence. Age (0.013), amiodarone-related hyperthyroidism (0. 18), antiarrhythmics (0.011) were less important.
Conclusions: The prevalence of AFl-related CM was 8.6% in a population admitted for atrial flutter. They were more frequently males and/or with history of mild idiopathic CM. Unlike known data, prognosis after treatment did not differ from patients without AFl-related CM with a similar risk of death or AF occurrence.
P1006
Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia with congenital heart disease
Abstract
Background: Atrioventricular nodal reentrant tachycardia (AVNRT) is generally a benign arrhythmia and is rare in association with complex congenital heart disease (CHD). Radiofrequency catheter ablation (RFCA) is considered the definitive therapy of choice in most patients. However, in CHD patients with altered atrial anatomy and conduction system morphology, slow pathway modification may be challenging.
Methods: Eight cases with CHD underwent RFCA for AVNRT (complete atrio-ventricular septal defect (cAVSD) in 3 (with asplenia syndrome in 2), congenital corrected transposition of great arteries (ccTGA) in 5). Three children underwent Glenn procedure before total cavo-pulmonary connection, median age was 2 years old. Median age in five patients after intra cardiac repair was 17 years old.
Results: Coronary sinus (CS) did not exist in six patients (cAVSD with asplenia syndrome in 2, ccTGA in 4). A distinct His bundle electrogram (HBE) was recorded at the unusual site in all cases. Common AVNRT was induced in two cases without CS, HBE was recorded at the posterior side of AV valve. We could ablate antegrade slow pathway at the ventricular side of AVN. In 6 patients with uncommon (slow/slow) AVNRT, successful RFCA was achieved in 5 at the earliest atrial activation during AVNRT (CS ostium in 2, CS musculature in 1, posterior side of AV valve with AVN at anterior side of AV valve and without CS in 2). In one patient after Fontan procedure, AVNRT is well controlled using anti-arrhythmic drug. In all ablative 7 patients no recurrence of tachycardia nor AV block was observed during a mean follow-up of 26 months.
Conclusions: We performed RFCA and successfully eliminated the slow pathway conduction. In the presence of associated CHD, it is crucial to understand the conducting system anatomy prior to RFCA.
P1007
The impact of NavX in pediatric arrhythmia ablation on safety, procedure duration and number of RF lesions. Is it a time to change approach?
Abstract
Non-fluoroscopic approach to pediatric ablation gets broad acceptance as it reduces the x-ray exposition. The only limitation is that it in most reports increases the duration of procedure.
Our objective is to compare the standard x-ray ablation (X) with nearly-0 fluoroscopy ablation with NavX (NavX) in pediatric population undergoing ablation. From the cohort of 538 consecutive patients we excluded 16 patients with complex congenital heart disease after surgical correction.
In the NavX group the procedure was started from RA reconstruction, followed by CS, tricuspid valve and His bundle. Left sided WPW ablation was performed retrogradely or transseptally. Short fluoroscopy was used during transseptal puncture, when VT originated close to aortic valve or when CS diverticulum was suspected. We analyzed the procedural (duration of GA and procedure), x-ray (fluoroscopy, dose) and ablation parameters (time to 1st and the last application, the number of applications and the cumulative duration of energy delivered as well and procedural success rate).
We included 522 patients (age 13,4±6,2 years, 238F) with SVT (202), WPW+AVRT/PAF (183), asympotomatic WPW (41), AT (26) and VEs/VT (48) or nondocumented palpitations. Finally AVNRT ablation was performed in 131 patients, WPW in 287 patients , AT in 22 and VEs/VT in 44 cases. The NavX was used in 278 patients. In patients with AVNRT the '0' fluoroscopy was possible in 82%, in WPW: 47%, in AT: 50% and for VEs/VT: 41% . Generally, the majority of ablations were completed with '0' fluoroscopy (162, 58%). For the NavX in comparison to X, the procedural parameters were significantly shorter (procedural time 66±33 vs 76±39 min., GA time 89±36 min. , DAP 10±24 vs 59±95mGy, and fluoro time 2±5 vs 17±14 min.). Ablation parameters were also in favour of NavX (time to 1st application 23±15 vs 27±18min., time to last application 47±31 vs 52±33 min, as well as the number of applications 7,7±7,8 vs 8,7 ±9 and total RF time 253±274 vs 264±271 sec) however this not reached statistical significance. Procedural success rate was 90% for NavX and 91% for RTG ablation.
We conclude that nonfluoroscopic approach with NavX is safe and successful method for pediatric ablation. If the method is used systematically it leads not only to reduced radiation burden but also to shorter procedural and GA time and the application lesions.
P1008
Effectiveness of extracorporeal life support for patients with cardiogenic shock due to intractable arrhythmic storm
Abstract
Purpose: Extracorporeal life support (ECLS) provides mechanical cardiopulmonary support and has been used for intractable heart failure as a bridge to heart transplantation or to recovery. Intractable arrhythmic storm is associated with high mortality. Little is known about the effectiveness of ECLS to treat refractory ventricular arrhythmias responsible for cardiogenic shock in patients non eligible for an urgent ablation.
Methods: Patients with intractable refractory ventricular arrhythmias and cardiogenic shock despite optimal medical therapy, and treated by ECLS implantation were retrospectively included. Patients' characteristics and outcome were analyzed.
Results: 20 patients (53±10 yo) were included. The underlying etiology to the refractory ventricular storm was ischemic cardiomyopathy (75%), short coupled Torsades de Pointes (10%), dilated cardiomyopathy (5%), myocarditis (5%) or unknown (5%). Mean LVEF was 33±17%. An average of 2.3±1.2 anti-arrhythmic drugs was tried before implantation. Arrhythmic storm stopped after a median time of 15 min after ECLS implantation. 8 patients (40%) eventually died, none of them because of a complication of ECLS implantation. The remaining 12 patients (60%) had ECLS withdrawn after a median time of 5.3 days, and were discharged after a median time of 29 days after admission (survival curve in the figure).
Conclusions: This is the largest database of patients temporary implanted with ECLS for refractory ventricular arrhythmia responsible for cardiogenic shock and non eligible for ablation. It provides efficient hemodynamic support to these critically ill patients, and survival rate after the implantation is 60%.
Survival after ECLS implantation
P1009
Predictive model of the probability of sudden cardiac death of the patients with dilated cardiomyopathy
Abstract
Purpose: This study was designed to determinate a noninvasive prognostic risk predictors of sudden cardiac death (SCD) in patients with dilated cardiomyopathy (DCM).
Methods: The study enrolled 217 pts (NYHA 3,1 ± 0,4; 151/69,6% male; aged 48,5 ± 11,8; LVEF 28,3% ± 12,4%) with non-ischemic DCM. Regression analysis was performed prospectively during 34±7 months of follow-up including analysis of clinical, echocardiographic and electrocardiographic data: QTc dispersion, heart rate turbulence (HRT) and microvolt T-wave alternans (mTWA). As well age, gender, NYHA, 6-MWT, BNP level and 24h-Holter ECG were analyzed. Primary endpoints were defined as sustained VTVF, sudden death, resuscitation and ICD discharges.
Results: By multivariate analysis positive mTWA (p=0,000), LV EF (p=0,0015), HRTO (p=0,001) and QTc dispersion (p=0,027) were detected as independent risk predictors with multiplier determination R=0,79 (F=30,8) in pts with sinus rhythm only. By binary logistic regression analysis three independent SCD risk factors (Wald χ2 = 80,2; p = 0,0000) were revealed: LVEF (b = 0,15; 95% CI: 0,07-0,23; p = 0,0003), mTWA (b1 = -0,095; 95% CI: -0,136 - 0,053; p = 0,00001), dispersion QTc (b2 = -0,015; 95% CI: -0.031 – 0,0007; p = 0,046) and the classifying formula to calculate the probability of the forecast SCD was defined:
P=1/(1+e^(-z) ), e = 2,72; Z = 0,8 – 0,015×dispQTc – 0,1×mATV+0,15×LVEF.
Prognosis of SCD will be adopted as positive for P ≥ 0,5 and negative for P<0,5.
This predictive model with the estimated logit regression equation was tested on an array of 124 patients with DCM. Sensitivity (proportion of patients with this correctly classified event VF/SCD/Resusc) was 79%, specificity (proportion of patients with the correct classification of “no event”) - 89%. The ratio of disagreement (OR) was 34,1.
Conclusion: The use of classification formula for prediction SCD and screening stratification of patients with DCM allows to select a group of potential candidates for preventive ICD therapy.
P1010
Quality of life, biomarkers and ICD indications in patients with a wearable cardioverter/defibrillator - preliminary results of a prospective trial with 1 year of follow-up
Abstract
Purpose: The wearable cardioverter/defibrillator (WCD) allows protection from sudden cardiac death (SCD) in patients with first diagnosis of severely reduced LVEF who do not (yet) fulfil indications for primary prophylactic ICD implantation. However, predictors of LVEF course are scarcely investigated.
Methods: In this prospective single-centre study, 30 patients with new diagnosis of severely reduced LVEF (≤35%) were included. Patients were recommended to wear a WCD for at least 3 months. Follow-ups were performed after 3, 6 and 12 months. Data on functional status LVEF, WCD data, ICD implantation were recorded. Additionally, a six-minute walk test (6MWT), laboratory parameters (blood count, sodium, potassium, creatinine, urea, uric acid, cystatin C, NTproBNP, iron, ferritin, cholesterol, triglyceride, HbA1c, TSH) and questionnaires on quality of life (Minnesota Living with Heart Failure Questionnaire, MLHFQ, and Hospital Anxiety and Depression Scale, HADS) were performed at inclusion and after 3 months.
Results: No patient died during follow-up of 1 year, 1 patient was lost-to-follow-up but is known to be alive. From inclusion to 3-months follow-up, patients significantly improved in NYHA functional class (2,4 vs. 1,9), 6MWT (353 vs. 462 m) and LVEF (26 vs. 34%), p<0,001 for each. 19 patients (63%) did not improve in LVEF >35% within 3 months ('non-improvers'), 11 patients (37%) improved in LVEF >35% ('improvers'). Besides age (60±12 vs. 50±14 years, p=0,04) and TSH (1,5±0,6 vs. 4,1±3,9 mU/L, p=0,01), comparison of baseline parameters for non-improvers vs. improvers did not reveal any significant differences regarding underlying diagnosis, medication, ECG parameters or laboratory findings. MLHFQ improved significantly in all patients within 3 months (38±23 vs. 26±21, p=0,048). QoL parameters did not show significant differences between improvers and non-improvers. 1 patient with ischemic cardiomyopathy presented sustained ventricular tachycardia during WCD wearing. 1 patient showed paroxysmal atrial fibrillation with numerous WCD alarms due to rapid conduction. 17 patients (57%) received an implantable ICD/CRT-D after a median of 3 (range 1-10) months.
Conclusions: Patients with first diagnosis of severely reduced LVEF recover in a relevant proportion. However, risk stratification in these patients is challenging. In our cohort with thoroughly chosen and extensively worked-up parameters, we could not identify a parameter indicating the patients at risk for arrhythmias or for non-improvement of LVEF. Further studies are needed to improve and specify risk stratification in these patients.
P1011
Role of NT-proBNP in the assessment of clinical outcome and prediction of arrhythmic events
Abstract
Background: Recent studies have been shown that Brain natriuretic peptide (BNP) is an useful biomarker for cardiovascular risk stratification. However, the predictive value of BNP level to predict Sudden Cardiac Death (SCD) or major cardiac events remains controversial.
We hypothesized that BNP may predict multiple outcomes in ischemic patients with indication to Implantable Cardioverter Defibrillator (ICD).
Methods: A total of 300 patients with previous MI who undergo ICD implantation were prospectively enrolled in order to determine the potential predictive value of NT-proBNP and the optimal cut-off points for risk stratification. NT-proBNP level, baseline demographic data, New York Heart Association (NYHA) functional class, 12-lead electrocardiogram and echocardiographic parameters were evaluated. Patients were followed up for a 24 months.
Results: The overall mortality rate was 13.3 per 100 PY (10.3-17.1, n=61) during a 24 months follow-up. The combined SCD-VT/VF endpoint was reached by 46 patients with an event rate of 10.9 per 100 PY (8.2-14.6). An NT-proBNP value above the optimal cut-off was significantly associated with occurrence of death from any cause [HR=5.12 (95%CI 3.01-8.72); p<0.001], hospitalization for HF [HR=4.91 (2.72-8.85), p<0.001] and the combined SCD-VT/VF endpoint (HR=2.04 (3.01-8.72), p=0.020], but not with the occurrence of VT/VF [HR=1.91 (0.96-3.80), p=0.06].
Conclusions: Preoperative BNP level has been shown to be a significant and independent predictor of mortality, especially in patients with LVE<=30%, chronic HF, myocardial infarction and acute coronary syndromes. Our results confirms that NT-proBNP is a powerful indicator for stratifying death and hospitalizations for heart failure at 2 years follow-up.
P1012
Incidence of new externalized conductors and electrical dysfunction in Riata leads: results from a multicenter study
Abstract
Introduction: We previously reported the prevalence of externalized conductors (EC) in Riata and Riata ST silicone ICD leads at enrollment in the on-going Riata Lead Evaluation study. We here report the 1st and 2nd year prospective follow-up results from this study evaluating the incidence of new EC and electrical dysfunction (ED).
Methods: Patients previously implanted with a Riata or Riata ST silicone lead and a St. Jude Medical ICD/CRT-D pulse generator were enrolled. Fluoroscopy is performed at enrollment and annually thereafter in three views (AP, LAO, RAO). All fluoroscopic images are adjudicated for the presence of EC by a panel of experienced electrophysiologists. Leads are classified as having EC if either a conductor cable does not fit within the shock electrode shadow width or if the radius of curvature of the suspected region with EC is significantly different from the remainder of the lead body. Upon occurrence of a lead revision, electrical performance data are adjudicated by another physician panel to determine the presence of ED based upon predefined criteria. Patients will continue follow-up for a period of 3 years.
Results: Time from implant was 8.8 ± 1.5 years for 8F leads and 7.1 ± 0.9 years for 7F leads. The incidence of new EC during the first year post-enrollment was 3.9% in 8F leads and 1.9% in 7F leads (p=0.24, N = 505 adjudicated leads). The incidence of new EC during the second year post-enrollment was 6.0% in 8F leads and 2.2% in 7F leads (p=0.20, N = 258 adjudicated leads). Over a follow-up period of 22.3 ± 9.6 months from enrollment, a total of 23 of the 776 leads enrolled (8 with EC, 15 without EC) were identified as having ED. There was no significant difference in the proportion of ED in leads with and without EC (4.7% vs. 2.5%, respectively, p=0.19).
Conclusions: Through 2 years of follow-up, there has been development of new EC post enrollment in 8F Riata and 7F Riata ST silicone leads. However, the presence of externalized conductors is not associated with an increased risk for electrical dysfunction.
P1013
Transvenous ICD Lead failure: which leads are more likely to fail? a meta-analysis of case-control studies and randomized control trials
Abstract
Background: Despite the widespread use of implantable cardioverter defibrillators(ICDs) in clinical practice, concerns exist regarding ICD-lead durability. The performance of specific lead designs and factors determining this in large populations need clarification.
Methods: A search was performed on MEDLINE, EMBASE and COCHRANE. Studies including ≥2 of the most commonly implanted leads (Endotak Reliance®, Sprint Quattro®, Durata®, Sprint Fidelis® and Riata®) were pooled using random-effects, according to the Mantel-Haenszel model. Sensitivity analyses were performed on recalled vs. non-recalled leads and 7-French vs. ≥8-French leads.
Results: Seventeen studies were pooled, including a total of 47,219 patients: 5,540 implanted with Durata, 10,567 with Endotak Reliance, 15,823 with Sprint Quattro, 11,790 with Sprint Fidelis and 5,900 with Riata giving a follow-up of 132,816 lead-years. No relevant differences in the mean incidence of lead failure (0.31-0.50% per-year) were observed in comparisons between the three non-recalled leads. Moreover, all comparisons of recalled leads vs. non-recalled leads led to significant differences confirming a higher event rate: 1.0% per-year increase with the Riata lead and more than 2.0% per-year with Sprint Fidelis. The increased risk of failure in 7-French leads was driven by the unfavourable results of the recalled leads.
Conclusion: These pooled data do not support the hypothesis of a significant association between lead size and lead failure, thus suggesting that it occurs due to specific lead family-related design aspects. Endotak Reliance (8-French), Sprint Quattro (8-French) and Durata (7-French) leads displayed a similar and very low annual incidence of failure. However, long-term follow-up data are still scarce.
P1014
Wearable cardioverter defibrillator reduces implantation rate of ICD in patients with high risk for life-threatening cardiac arrhythmias
Abstract
Background: Patients (pts) with reduced left ventricular function often suffer from fatal cardiac arrhythmias. Implantable Cardioverter Defibrillator (ICD) implantation is recommended after risk stratification and/ or a period of optimized pharmacological and/ or coronary interventional treatment. Wearable cardioverter defibrillator (WCD) have been invented to bridge this period, providing both, cardiac rhythm monitoring and defibrillation therapy delivery. As there are only few data about indication and outcome of WCD pts in community based hospitals, we present a single center experience.
Methods: 84 pts (64 male, 64±14 years) with reduced left ventricular function (EF 33,5±12.9 %) received a WCD (LifeVest®, ZOLL, Pittsburgh, PA, USA). 46 pts suffered dilative cardiomyopathy or non-ischemic cardiomyopathy, 21 pts from ischemic heart disease post coronary intervention or from CABG operation (n=3), 6 pts from acute myocarditis, 4 pts from ICD explantation, and 4 from other reasons.
Results: Pts wore WCD 48.5 ± 32.6 days and 20.3 ± 3.8 hours per day. During that time, 1355 events were registered, ranging from 2 to 213 events per pt. 1099 events were automatically detected, 179 events were manually activated and 71 were due to initiating the system. Out of the automatically detected events, 1095 were tachycardia and 4 were bradycardia or asystole. In 2 pts., arrhythmia detection led to an adequate and successful shock delivery. All data were transferred telemedically.
After WCD therapy, 33 pts (39.3%) received an ICD due to persistence of left ventricular ejection fraction reduction and/or persistence of high degree of ventricular ectopy. In 33 pts (60.7%), an ICD implantation could be avoided.
Conclusion: Among patients with reduced LV function and high risk of ventricular arrhythmia, the use of WCD was feasible and showed a high acceptance rate. In these pts, WCD allowed a high detection rate and shock application, if necessary. Furthermore, WCD seemed to avoid ICD implantation in selected cases, and thus contributed to a health cost reduction.
P1015
The subcutaneous implantable defibrillator:global experience in an high volume ICD lead extraction centre
Abstract
The S-ICD is a new device developed to treat life-threatening arrhythmias that works leaving the heart and vascular system completely untouched.
Purpose of the Study: To analyse S-ICD global experience at our referral centre for ICD lead extraction.
Methods: from April 2011 to December 2014, 25 pts (23 M; 2 F), mean age 43.3 ± 15.3 years underwent S-ICD implantation. 10 pts (40%) received an S-ICD as their first device (Naïve) while the remaining 15 (60%) where implanted after extraction of a trans-venous ICD system due to infection (10), malfunction (4) or symptomatic superior vena cava obstruction (1) (Explanted).
Results: S-ICD implantation was successful in all the pts. Induced VF was successfully treated with a 65J shock in 100%. No complications occurred; 1 pt experienced a pocket hematoma before discharge treated conservatively. No arrhythmic or cardiovascular deaths occurred at a mean FU of 13.6 ± 11.3 months. 1 N pt died due to progressively worsening CKD. 1 N pt (10%) and 1 EX pt (6.6%) experienced, respectively, 1 fast VT and 4 VF episodes, all converted by S-ICD first 80 J shock. Inappropriate shocks due to T wave oversensing occurred in 1 N (10%) and 2 EX (13.3%) pts (p=ns) and were treated by reprogramming.
No infection occurred both in N and EX group.
Conclusions: S-ICD therapy is safe and effective both for naïve and previously explanted ICD pts.
For explanted pts, S-ICD is an attractive solution due to the higher risk of reinfection and/or the higher incidence of venous obstruction and should be considered whenever pacing is deemed not necessary.
P1016
Developing a new classification and grading system for pocket hematoma after CIED proceduresAbstract
Purpose: Pocket hematoma is a common complication after CIED (Cardiac Implantable Electronic Device) procedures and an important risk factor for cardiac rhythm device infections, especially in patients on oral anticoagulation (OAC) or antiplatelet treatment. There is a wide variability in the incidence of pocket hematoma and bleeding complications in the numerous studies published during the past years on this issue. The major cause for such this wide range seems to be the variability of the used definitions for hematomas.
Methods: We reviewed all the studies published during the last fifteen years relating pocket hematoma occurrence after CIED procedures in different antithrombotic settings. Each study used its own definition of pocket hematoma ranging from 'any ecchymosis or suffusion surrounding the wound or the generator' (reported incidence of 33% in uninterrupted OAC group in the FinPac trial) to only 'clinical significant pocket hematoma' when necessitating evacuation, anticoagulation's interruption, or prolonging hospitalization (reported incidence of 3.5% in uninterrupted OAC group in the BRUISE control trial).
Bontempi Pm 64
Results: Collecting all the definitions used in literature we propose a uniform description of pocket hematoma suggesting a grading of different kinds of hematoma encountered in the clinical practice. Such a new concept of hematoma grading is based on dimensions as well as on therapeutic interventions applied as summarized in the table.
Conclusions: Pocket hematoma after CIED procedures is a common complication especially in patients on antithrombotic treatments constituting an important risk factor to pacemaker infections. The lack of generally accepted definition for pocket hematoma renders the comparisons across the literature difficult. Uniform classification of this common complication is needed for the research of magnitude of the problem and its clinical consequences.
P1017
Tricuspid regurgitation associated with pacemaker lead an underestimated problemAbstract
Purpose: Aim of the study was to determine if the mode of implantation and lead position influences tricuspid valve function.
Methods: Subsequent patients after permanent stimulation system implantation (pacemaker, implantable cardioverter-defibrillator, resynchronization system) presenting for routine follow-up in the out patient clinic. Transthoracic echocardiography (TTE) and chest X-ray were performed in all patients. TTE evaluated heart chamber diameters, ejection fraction and tricuspid valve function in its relation to the leads. X-ray evaluated leads position.
The exclusion criteria were: tricuspid regurgitation before implantation, severe mitral regurgitation, artificial mitral valve.
Patient's age and gender, dwell time, number and type of endocardial leads, presence of heart failure symptoms, concomitant diseases were analyzed in 2 groups divided according to severe tricuspid regurgitation (TR) presence.
Results: 100 pts were analyzed from November 2013 to September 2014. Medium time from implantation was 9 years (1-30 years). TR was observed in 28pts (28%). In 20 pts with TR+ (71.4%) radiological signs of lead malposition (excessive or insufficient length with lead interference with tricuspid apparatus) were present and in 12pts (16.7%) in TR- (p<0.0001). Patients with TR+ were older (71 vs 65.6 years, p=0.019) and had larger diameters of right ventricle (33.6±6.0 vs 28.5±4.0mm; p<0,0001) and both atria (LA 52.5±8.1 vs 45.2±5.2mm; p<0,0001; RA 57.7±9.4 vs 44.5±6.9mm; p<0.0001). Multivariate analysis showed that the only factors influencing TR+ were: insufficient lead length (OR=4.654; P<0.001) and excessive lead length (OR=2.591; P=0.004).
Conclusions: TR+ is a clinical problem after permanent leads implantation and it seems to depend on lead position in the heart.
P1018
Stability of pacing indices in cardiac transplant patients
Abstract
Introduction: The stability of pacing indices has not been determined in cardiac transplant recipients that require permanent pacemaker (PPM) implant.
Methods: Pacing indices (sensing, threshold and impedance) were recorded from cardiac transplant PPM recipients (n=30) on the day of PPM implant (day 0), the following day (day 1), and at 3 month and 1-year follow-up. Multivariate ANOVA was used to compare pacing indices in each cardiac chamber and at different time points. Sensing, threshold and impedance were used as outcome variables while follow-up time and cardiac chambers were used as predictor variables. Bonferroni correction was used to adjust for multiple comparisons. Values are presented as mean ± SEM and a p < 0.05 was considered statistically significant.
Results: Mean sensing (millivolts) in the right atrium (RA) was 2.9 ± 0.4, 2.8 ± 0.4, 3.4 ± 0.4, 3.2 ± 0.5 and in the right ventricle (RV) was 12 ± 2.7, 8.9 ± 2.3, 13 ± 1.8 and 11 ± 2.3 at day 0, day 1, 3 months and 12 months after PPM implant respectively. Sensing in the RV was significantly higher than the RA (p < 0.001) but there was no difference among the follow-up time points (p=0.2). Mean RA threshold (volts) was 0.8 ± 0.1, 0.9 ± 0.1, 1.2 ± 0.2 and 1.2 ± 0.3; and RV was 0.7 ± 0.07, 1.2 ± 0.3, 2.1 ± 0.3 and 1.4 ± 0.4 at a mean pulse width of 0.5 milliseconds, at day 0, day 1, 3 months and 12 months after implant respectively. The threshold at 3 months was significantly higher compared to day 0 (p=0.005) and day 1 after implant (p=0.04). There was no difference between RA and RV thresholds at any of the follow-up time points (p=0.07). Mean RA impedance (Ohms) was 555 ± 24, 450 ± 12, 428 ± 12 and 427 ± 14; and RV was 695 ± 95, 568 ± 51, 507 ± 50 and 446 ± 30 at day 0, day 1, 3 months and 12 months. RV impedance was significantly higher compared to RA (p=0.003). Impedance at day 0 was significantly higher compared to day 1 (p< 0.001), 3 months (p < 0.001) and 12 months (p <0.001).
Conclusion: In OHT, PPM acute impedances decrease and thresholds trend up in short term follow-up, but subsequent sensing, threshold and impedance remain stable at 1 year. This is comparable to the pattern observed among non-OHT PPM recipients.
P1019
Two years experience after decentralization of pacemaker follow-up visit to local especialty care centres using remote transmission
Abstract
Purpose: the progressive increase in the number of device implants has dramatically increased the device follow-up visit (DFV) in hospitals. We analyze our initial experience with the decentralization of DFV from the hospital to local Specialized Care Centers (SCCs) by remote monitoring transmission.
Methods: a sample of 90 patients with pacemakers and internal loop recorder (ILR) with automatic parameter checking functions and remote transmission capacity. Clinical characteristics, type of pacemaker and indication of implant were collected. An initial DFV at hospital was performed to adjust programming and inclusion in the specific remote monitoring web site. Later we performed the first remote consultation in the corresponding SCCs by the nurse with device interrogation remote transmission and real time evaluation by an electrophysiologist, with the corresponding validation report . All patients passed two evaluation questionnaires.
Results: the mean age was 72±13 years, 57% males (51). Of the 90 patients enrolled in the program, 89 have already completed a total of 151 transmissions, with an average of 2 ± 1 per patient. 89% of patients (80) were pacemakers (21 one chamber and 59 dual chamber pacemaker) and 11% (10) ILR. 28% (26) of the patients was completely dependent on ventricular stimulation. In relation to the DFV in the local SCCs, 77 patients (87%) considered it better,11 (12%) equal and 1 (1%) worse. However, most of patients (97%) preferred it. 7 patients (8%) had to be reevaluated in the hospital (4 for our incorrect programming 2 for device problems and 1 for patient preference). The other variables compared are shown in table.
Conclusions: DFV decentralization to the local SCCs by remote transmission is technically feasible, reliable and quick to make with clear benefits for patients and their complete cardiologic assessment in their SCCs.
P1020
Do quadripolar transvenous LV leads have advantages at the time of de novo CRT-D implantation?Abstract
Background: The purpose of our retrospective study was to analyze potential advantages (e.g. no need for re-positioning due phrenic nerve stimulation [PNS]) of quadripolar leads compared to bipolar leads on the course of CRT-D implantation.
Methods: All patients implanted with CRT-D by the first author from 29-Dec-2009 on (first implantation of a quadripolar LV lead) were included in this retrospective analysis. CRT-D implantations had to be de novo implantations (no upgrades from any kind of transvenous device) on the left pectoral side with 3 transvenous leads (atrial, right ventricular, left ventricular). Leads used in the CS had to be dedicated transvenous LV leads. In case the initially chosen lead was bipolar, but the finally implanted lead was quadripolar, fluoro time and procedure duration were attributed to the bipolar group. We compared intra-operative assessed data (sensing amplitude [mV], pacing capture threshold [PCT; V/0.5 ms], pacing impedance [Ω@ 5V], slew rate [V/s] fluoroscopy time [min], duration of implantation [min]) and lead revision rates. Continuous variables are expressed as mean±SD [median], and were compared using the Mann-Whitney U test. Categorial variables were compared using chi square test, and Fisher`s exact test where appropriate. A p<0.05 was considered significant.
Results: Out of 339 CRT-D related surgeries from 29-Dec-2009 on, 127 met the inclusion criteria for further analysis. Implantation characteristics of 82 bipolar and 45 quadripolar leads (SJM Quartet: 17; MDT Attain Performa: 23; BSCI Acuity X4: 4; Bio Sentus: 1) were compared. Sensing amplitudes (bi: 8.2±9.7 [3.3], quad: 8.3±9.4 [3.8]), PCT (bi: 1.3±0.87 [1.0], quad: 1.2±0.86 [0.91]) pacing impedances (bi: 1013±304 [1015], quad: 924±310 [901], and slew rate (bi: 1.6±1.5 [1.3], quad: 2.1±1.6 [2.3]) did not differ significantly between the two types of leads as well fluoro time did not (bi: 21.5±14.9 [17.2]; quad: 22.3±25.5 [13.1]), whereas procedure duration was significantly shorter with quadripolar leads (bi: 84.3±31.2 [77.5], quad: 77.1±44.0 [66.0]; p=0.018). A total of 7 (5.4%) leads had to be revised (bi: 5 [6.0%; high PCT: 3, dislocation: 1, PNS: 1], quad: 2 [4.4%; pocket infection: 1, dislocation: 1]; p=n.s.).
Conclusion: In our analysis on differences of bipolar and quadripolar LV leads during well defined de novo CRT-D implantations, procedure time was significantly shorter with quadripolar leads. Electrical parameters showed no differences. There were less lead revisions with quadripolar leads.
P1021
Utility and safety of temporary pacing using active-fixation leads and externalized re-usable pacemakers in transcatheter aortic valve implantation and other conditions requiring short-term pacing
Abstract
Purpose: With the beginning of transcatheter aortic valve implantation (TAVI), the use of active-fixation leads combined with externalized re-usable permanent pacemakers was initiated to improve lead stability, increase patient mobility and facilitate handling for nursing staff. Experience and benefits of temporary permanent pacemaker (TPPM) systems have thus far mainly been reported in patients suffering from cardiovascular implantable electronic device (CIED) infection. The aim was to investigate the safety and efficacy of TPPMs in a mixed group of patients usually requiring short-term pacing.
Methods: Between November 2008 and July 2014, 148 patients received a TPPM. An active-fixation lead was implanted in either an apical or septal position via the right internal jugular vein using a 7 French peel-away introducer sheet. A maximum pacing treshold of 1,0 V was accepted. The lead was then connected to a re-usable permanent pacemaker which was externally fixed on the thoracic wall.
Results: After successful primary implantation in all patients without any procedure-related complications defined as perforation or pneumothorax, lead dislocation occured in 2 patients (1,35%).
Conclusions: TPPMs are safe and effective in TAVI procedure and other conditions requiring short-term pacing.
P1022
Long-term follow up of pacemaker implantation through a persistent left superior vena cava, a safe approach?Abstract
Introduction: In the literature, there is several case reports related to implantation of cardiac devices through a persistent left superior vena cava (PLSVC). They all agree that attempting to implant pacing leads can be technical challenging. By contrast, there are few data on the monitoring of these devices.
Purpose: To analyse the incidence of complications during long-term follow-up, as some authors consider that the incidence of lead dislodgement and dysfunction is higher than in normal patients.
Methods: We describe a case series of five patients with PLSVC who had pacemakers implanted for bradycardia indications from January 2008 to January 2014. Atrial and ventricular leads were advanced separately with the assistance of hand shaped stylets. We used active fixation leads in all patients. Patients were followed from the end of the enrolment period or until death. The parameters examined were: P and/or R wave amplitude (mV), pacing threshold (V) and the impedance (Ω) at the implantation and during the follow up. Lead dislodgement and other complications were also studied.
Results: Five patients (4 male, 1 female) with a mean age of 83 year-old were included in the study. Following our algorithm, an echocardiography was performed prior to pacemaker implantation, but only in one (case 5) the preoperative diagnosis was established. All procedures were completed without change in the approach. There were no complications in any of the five cases. A mean of 37 months follow-up of the cases presented was performed and evolution has produced no dislocation or dysfunction of the pacemaker parameters regardless of the site of implantation of the electrodes. The parameters examined are shown in a table.
Conclusion: Long term follow up of these patients confirms the feasibility, stability and security of implanted systems with that approach.
P1023
Patients with atrio-ventricular blocks qualified for pacemaker implantation seem to be more frequent exposed on frailty syndrome
Abstract
Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults and can reduced advantages from pacemaker implantation. AIM: to evaluate influence of frailty syndrome into the quality of life (QoL) after pacemaker implantation.
Methods: 171 pts. aged > 65 years qualified for pacemaker implantation were included. Patients were divided into 2 examined group (FE - frailty syndrome exposed; FT – Frailty syndrome recognized) and control group (C) without attributes of frailty. In all a DDDR pacemaker was implanted due to sinus node dysfunction or atrio-ventricular blocks. In all frailty was evaluated by using Canadian Study of Health and Aging Clinical Frailty Scale and QoL by using Minnesota Living With Heart Failure questionnaire (MLWHFq). After 6 months of follow-up data were re-evaluated. Data were statistically analyzed (Kruskal-Wallis – Anova, Wilcoxon and Chi2 tests) according to the type of data.
Results: Exact results in QoL in points are presented in the table below – less points mean better QoL. In each three groups implantation of pacemaker statistically (p<0.05 in all) improve QoL. Frailty syndrome statistically more frequent was recognized in patients with atrio-ventricular blocks (AVB: 33.3% vs SND 16.1%; p=0.009). No statistical difference (p=0.559) was observed in frailty syndrome exposed group.
Conclusions: Frailty syndrome do not affect advantages of pacemaker implantation in patients > 65 years. Patients with atrio-ventricular blocks seem to be more frequent exposed on frailty syndrome.
Control group (C) | Frailty syndrome exposed group (FE) | Frailty syndrome (FT) | | Before implant. | After implant. | Before implant. | After implant. | Before implant. | After implant. |
|---|
| Physical factors | 18.6± 4.6 | 10.2 ± 3.7 | 18.7 ± 4.5 | 10.1 ± 3.3 | 20.3 ± 5.3 | 10.3 ± 3.7 |
| Emotional factors | 9.9 ± 4.4 | 7.5 ± 3.3 | 9.5 ± 3.9 | 7.8 ± 3.4 | 10.1 ± 4.1 | 8.6 ± 3.3 |
| Others factors | 12.7 ± 4.9 | 7.4 ± 3.5 | 13.9 ± 5.3 | 8.3 ± 4.1 | 13.7 ± 5.6 | 7.4 ± 3.5 |
Control group (C) | Frailty syndrome exposed group (FE) | Frailty syndrome (FT) | | Before implant. | After implant. | Before implant. | After implant. | Before implant. | After implant. |
|---|
| Physical factors | 18.6± 4.6 | 10.2 ± 3.7 | 18.7 ± 4.5 | 10.1 ± 3.3 | 20.3 ± 5.3 | 10.3 ± 3.7 |
| Emotional factors | 9.9 ± 4.4 | 7.5 ± 3.3 | 9.5 ± 3.9 | 7.8 ± 3.4 | 10.1 ± 4.1 | 8.6 ± 3.3 |
| Others factors | 12.7 ± 4.9 | 7.4 ± 3.5 | 13.9 ± 5.3 | 8.3 ± 4.1 | 13.7 ± 5.6 | 7.4 ± 3.5 |
Control group (C) | Frailty syndrome exposed group (FE) | Frailty syndrome (FT) | | Before implant. | After implant. | Before implant. | After implant. | Before implant. | After implant. |
|---|
| Physical factors | 18.6± 4.6 | 10.2 ± 3.7 | 18.7 ± 4.5 | 10.1 ± 3.3 | 20.3 ± 5.3 | 10.3 ± 3.7 |
| Emotional factors | 9.9 ± 4.4 | 7.5 ± 3.3 | 9.5 ± 3.9 | 7.8 ± 3.4 | 10.1 ± 4.1 | 8.6 ± 3.3 |
| Others factors | 12.7 ± 4.9 | 7.4 ± 3.5 | 13.9 ± 5.3 | 8.3 ± 4.1 | 13.7 ± 5.6 | 7.4 ± 3.5 |
Control group (C) | Frailty syndrome exposed group (FE) | Frailty syndrome (FT) | | Before implant. | After implant. | Before implant. | After implant. | Before implant. | After implant. |
|---|
| Physical factors | 18.6± 4.6 | 10.2 ± 3.7 | 18.7 ± 4.5 | 10.1 ± 3.3 | 20.3 ± 5.3 | 10.3 ± 3.7 |
| Emotional factors | 9.9 ± 4.4 | 7.5 ± 3.3 | 9.5 ± 3.9 | 7.8 ± 3.4 | 10.1 ± 4.1 | 8.6 ± 3.3 |
| Others factors | 12.7 ± 4.9 | 7.4 ± 3.5 | 13.9 ± 5.3 | 8.3 ± 4.1 | 13.7 ± 5.6 | 7.4 ± 3.5 |
P1024
Long-term follow-up of patients with cardiac implantable electrical devices implanted in childhood
Abstract
Background: Grown-up patients (pts) with cardiac implantable electrical devices (CIED) implanted in childhood have special characteristics. There are only scarce data on the long-term outcome of these pts. To this aim we have conducted a retrospective analysis of long-term observation focused on complications of CIED therapy in a group of grown-up pts with primoimplantion of the generator in childhood.
Patients and Methods: We have thoroughly analysed the documentation of 33 pts with pacemakers (31pts) and implantable defibrillators (2 pts). Congenital heart diseases were present in 8 pts (24%). Mean age of pts at the time of analysis was 29.5 ± 4.5 years, 19 were men. Mean age of pts at CIED primoimplantation was 12±5.2 years (range from 0 to 20 years). Average period of follow-up (F-U) was 17±6.1 years. Primary indications for pacemaker implantation were: complete AV block in 16 pts (49%), other AV blocks in 3 pts (9%), binodal disease in 5 pts (15%), sick sinus syndrome in 3 pts (9%), long QT syndrome in 2 pts (6%), neurocardiogenic syncope in 1 pt (3%). One pt with dilated cardiomyopathy had implantation of biventricular pacemaker. Two single chamber ICDs were implanted for secondary prevention of sudden death.
Results: Dual-chamber pacemakers were implanted in 22 pts, single-chamber pacemakers in 8 pts. Epicardial pacemaker systems were primoimplanted in 6 pts under 9 years. All other pts had primoimplantation of endocardial systems. During long-term F-U complications of CIED occurred in 22 pts (67%). The leading cause of the first complication was lead failure in 20 pts (61%), infections / decubitus were seen in 2 pts (6%). Average time from implantation to the first complication was 6.8 ± 3.6 years (median 6 years). During F-U, there were a total of 29 lead failures, 2 pts had localized pocket infection, and 1 pt had infective endocarditis. Extractions of chronic leads were performed in 11 pts. In 2 pts the complications were life threatening. The average number of interventions related to CIED therapy including generator exchanges was for the entire F-U period 3.3 ± 1.5 per patient. At the end of the F-U period, 3 pts remained without functional CIED (9%) and 1 pt underwent heart transplantation.
Conclusions: Children receiving CIED have in long-term until adulthood a high risk of complications. These are most frequently lead failures mainly due to natural body growth. However, the overall number of necessary interventional procedures (incl. generator exchanges) in these patients is appropriate to the duration of F-U.
P1025
LBBB is incomplete in the majority of patients with HF due to systolic LV dysfunction: a simple intraprocedural demonstration
Abstract
Background: In patients with HF and systolic LV dysfunction, LBBB is very often presumed to be complete, with septal activation occurring from the right-side of the apex through the RB. However, ECG aspects of most LBBB patients still suggest left-sided septal activation (r waves in V1 and q waves in DI and aVL).
Purpose: To evaluate how often left-sided septal activation is preserved in HF patients with systolic LV dysfunction and LBBB.
Methods: ECGs were obtained from 33 HF patients with systolic LV dysfunction and LBBB (~ 65.5 ± 10.7 ys old, 10 females, 12 with IHD) with preserved A-V conduction (PR<240 ms) who met the guideline criteria for either CRT-P or CRT-D implantation. During device implantation measurements of the interval between intrinsic QRS onset to RV EGM were obtained, with the right ventricular lead in apical and midseptal positions. The values of the delays (msec) were analyzed and compared by means of a paired samples T-test.
Results: The mean QRSw was 163.94 msec (±15.799; CI 95% 158.34-169.54). In the apical position the RV EGM was significantly more delayed than in the mid-septal position: 73.79 msec ±15.763 (CI 95% 68.20-9.38) vs. 51.67 msec ±8.985 (CI 95% 48.48-54.85). The mean difference during the apical-midseptal paired-samples T-test was 22.121 msec ±16.058 (CI 95% 16.427-27.815; p < 0.000). Out of 33 patients, the midseptal delay was longer in only two patients whose ECG directly suggested complete LBBB (absence of the mentioned waves).
Conclusions: In most patients with HF and systolic LV dysfunction, the LBBB is 'incomplete', with preserved left-sided septal activation. Loss of normal septal vectors on ECG is associated with 'complete' LBBB.
P1026
Initial experience implanting a new intravenous coronary sinus lead with an active fixation mechanism for cardiac resynchronization therapy
Abstract
Purpose: About 30% of patients do not improve their clinical or functional status after Cardiac resynchronization therapy (CRT). Suboptimal left ventricle lead position, post-implant lead dislodgements and undesired phrenic nerve stimulation are common causes. Overcoming these challenges is sometimes difficult, since the traditional coronary sinus leads fixate to the cardiac vein in a passive way. These stability-focused implant strategies discard potentially good electrical and anatomical sites (e.g. basal positions). Hence, an active fixation lead would help to improve implant positions, as well as to minimize lead dislodgements.
Methods: We report our experience with a new coronary sinus lead that includes a side helix, which actively fixates to the cardiac vein wall (Medtronic Attain Stability 20066). We analyze the data from the last 100 implanted non-stability leads as a control group.
Results: We implanted the new electrode in 12 patients indicated for a CRTdevice. All the implant attempts were successful and there were no complications associated to the lead during or after implant. Pacing threshold at implant was 1.5±0.8 V (average ± standard deviation), measured at a pulse width of 0.5 ms. Pacing impedance was 983±291 ohms and R wave was 10.5±5.8. After 154±139 days of follow-up, we have not seen any lead dislodgement. In 3 cases (25%) we had to attach the lead to the main coronary sinus, instead of attaching it inside a vein, achieving extremely basal pacing sites (see figure for an example). Two patients (17%) had been previously implanted with a traditional passive fixation lead that had dislodged. In contrast in the control group there were a significantly higher incidence of dislodgement, phrenic stimulacion and modifications of the threshold during follow-up.
Conclusions: We report our experience with a novel coronary sinus lead that fixates actively to the cardiac vein. In our experience, the lead is safe and effective. Electric parameters are adequate and we have not observed any lead dislodgement so far, even in those cases implanted in very basal positions.
P1027
Biventricular pacing reduces coronary flow velocity reserve in the left anterior descending artery compared with baseline rhythm in patients with chronically implanted CRT devicesAbstract
Purpose: Left Anterior Descending Artery (LAD) Coronary Flow Velocity Reserve (CFVR) has been shown to be reduced in many patients with dyssynchronous heart failure and can be improved by cardiac resynchronisation therapy (CRT). We hypothesised that the mechanisms for impaired flow reserve are multi-faceted and might be only partially overcome with CRT. We thus sought to examine the CFVR in both left epicardial coronary arteries in chronically implanted patients to determine to what extent CFVR varied in different pacing regimens.
Methods: Ten patients with implanted CRT attended for an acute electrophysiological study. Coronary flow and pressure data was acquired using a Combowire and LV contractility data was acquired using a pressure wire. Baseline flow and pressure were recorded in the LAD and circumflex (Cx) arteries and then compared with different pacing regimens (biventricular (BVP), right ventricular (RV), left ventricular (LVP) and atrial pacing (AAI)). Where patients were in atrial fibrillation or complete heart block (CHB), RV pacing was used as a baseline comparator. Steady state pacing was applied 10bpm above baseline or at 60bpm if CHB. Intracoronary boluses of adenosine were delivered twice in each pacing setting and the highest average peak velocity (APV) used to calculate the CFVR.
Results: CFVR in the LAD was significantly different between the four pacing regimens (p=0.02). The difference between baseline CFVR in the LAD (mean 2.44 (range 3.45 to 1.42 s.d 0.642)) and BVP CFVR (mean 2.14 range 2.6 to 1.24 s.d 0.44) was significant at p=0.028). There was no significant difference between the hyperaemic flow in the four pacing regimens (p=0.553) The CFVR measured in the Cx artery was not significantly different when pacing regimens were compared (p=0.91).
Conclusion: The reduced LAD CFVR noted in BVP resulted from an increase in baseline APV in the LAD rather than a reduction in the hyperaemic response. However the mean CFVR are below the normal range in both settings (normal >3.0). This suggests that whilst CRT can improve LAD flow at rest, the hyperaemic response is limited by factors not related to the mechanical sequelae of dyssynchrony.
P1028
Modifying quadripolar left ventricular pacing vectors impacts ventricular activation times in cardiac resynchronisation therapy
Abstract
Purpose: Quadripolar (Quad) left ventricular (LV) leads are used increasingly in cardiac resynchronization therapy (CRT) with no clear tools to select optimal pacing vectors. We investigated the effect of manipulating the extended bipolar (EBP) and bipolar (BP) LV vectors on ventricular activation times using non-invasive body surface mapping (BSM).
Methods: Five patients had BSM the day following implant. Parameters measured were biventricular total activation time (VVtat), LV total activation time (LVtat), right/left ventricular electrical synchrony (VVsync) and the LV dispersion of activation (LVdisp) at baseline and during echo optimized biventricular pacing with variable LV pacing vectors. EBP vectors tested were RV-D1,M2, M3 & P4. BP vectors tested were D1-M2, M3-M2, M3-P4 and D1-P4.
Results: Patients were aged 71.4±14.8 yrs, 4/5 were male and 2/5 had an ischemic etiology. The mean ejection fraction was 25.4±9.6% and mean NYHA class was 2.8±0.5; 3 patients had LBBB, 1 chronic RV pacing and 1 RBBB. The LV failed to capture in 1 patient with RV-P4, 1 with D1-M2, 1 with M3-M2, 2 with M3-P4 and 1 with D1-P4. Baseline activation times and activation times for each pacing vector are shown in the table. There was no best pacing vector. An EBP vector was the optimum to reduce activation times in 80%.
Conclusion: Adjusting Quad LV lead pacing configurations impacts activation times. Not all Quad LV pacing vectors lead to improved activation times in all patients. Significant improvement in activation times can be achieved by choosing the optimal pacing vector for each patient.
P1029
Cardiac resynchronization therapy in chagas cardiomyopathyAbstract
Purpose: Cardiac resynchronization therapy (CRT) reduces mortality in heart failure (HF) patients; however the results of CRT in patients with Chagas cardiomyopathy (CC) are unknown. We aimed to evaluate the role of CRT in CC patients.
Methods: This is a retrospective, unicentric study, including 426 patients submitted to CRT between January 2005 to December 2012. We compared all-cause mortality according to HF etiology, adjusted for gender, NYHA functional class (NYHA FC), hypertension, renal disease, diabetes, atrial fibrillation, left bundle branch block presence, left ventricular ejection fraction (LVEF) and right ventricular dysfunction.
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Results: In the total cohort, 115 and 311 patients had CC and non-CC (ischemic and idiopathic), respectively. The mean age was 61.6±12.0 years, 64.8% were males, 84.3% were in NYHA FC III /IV and the mean LVEF was 25.3±6.5. Hypertension, renal disease, diabetes and atrial fibrillation were present in 54.5%, 43.9%, 30%, and 18% respectively. During a median follow-up of 2.7 years (interquartile range, 1.5 to 5.0), 196 (46.5%) patients died. The adjusted hazard ratio describing the role of CC etiology versus non-CC for all-cause mortality was 1.78 (95% CI, 1.19 to 2.65; P=0.005). Kaplan-Meier estimates of the effect of etiology on all-cause mortality is shown in the attached Figure.
Conclusion: Chagas cardiomyopathy was associated with a nearly 2-fold increase in all-cause mortality in comparison to ischemic and idiopathic cardiomyopathies.
P1030
Electromechanical coupling in heart failure patients
Abstract
Purpose: We aimed at enhancing the understanding of the interplay between electrical activation and mechanical dyssynchrony in heart-failure (HF) patients.
Methods: Twenty-five patients candidate to cardiac resynchronization therapy or to cell therapy underwent left ventricular 3D electroanatomical contact mapping. At each location recording was performed for 2500 ms, voltages acquired at 1KHz and converted into time of depolarization (TD) maps. Electrode position was recorded at 100 Hz and post-processed using custom software to obtain maps of local shortening as well as local deformation. Time of onset shortening (TOnS), peak shortening (TPS), and peak local linear strain (LLS) were determined. Dyssynchrony Δ was defined as the time interval between the earliest and latest events. A peak-to-peak unipolar voltage dUEG≤ 5mV in a time frame of ±50 ms around TD was considered as index of scar. Analysis was performed considering all the measurements, and separately for ischemic/non ischemic regions.
Results: Analysis was feasible in all subjects. Measurements were taken at 200±60 locations per patient. The delays TD to TOnS and TD to TPS were 85±22 ms and 380±38 ms, respectively. In all cases, mechanical dyssynchrony (ΔTOnS=109±16ms; ΔTPS=176±67ms) was more pronounced (p<0.01) than electrical dyssynchrony (ΔTD=82±21 ms). TD and mechanical maps were significantly correlated in 23/25 patients: a strong positive correlation was found in the majority of patients between TD and TOnS (R = 0.66±0.19, p<0.01) and TD and TPS (R = 0.75±0.18, p<0.01). The slope of the relation between TD and TPS (slope TD-TPS = 1.5±0.5) suggested that a prolonged activation time reflects in an even higher mechanical dyssinchrony. A large inter-patient variability was observed in the relationship between the amplitude of LLS and TD. Similar findings were obtained for ischemic and non-ischemic regions. Interestingly, in the 3 patients with TD-TPS R values <0.05, the correlation improved when only the viable myocardium (dUEG>5mV) was considered.
Conclusions: This invasive direct comparison of local electrical activation and mechanical contraction demonstrated that, in the majority of HF patients, the electromechanical coupling is preserved and that mechanical dyssynchrony is aggravated as compared to the electrical dyssynchrony. This study provides evidence that in-vivo electromechanical assessment is feasible and deepens the understanding of the activation-contraction pattern in HF, with a potential impact on therapy optimization.
P1031
Red cell distribution width is superior to the NT-proBNP in the survival prediction of chronic heart failure patients with cardiac resynchronization therapy
Abstract
Background: The red blood cell distribution width (RDW) and also the NT-proBNP (N-terminal of the prohormone brain natriuretic peptide) have been shown to predict the survival of chronic heart failure patients with cardiac resynchronization therapy(CRT), however their combined impact on the survival has not been analysed.
We hypothesized that the baseline RDW level would predict the 2-year mortality of CRT patients superiorly and independently of the baseline NT-proBNP levels or other factors.
Methods: The blood count and the serum levels of NT-proBNPof 134 chronic heart failure patients undergoing CRT were measured. The baseline multivariable Cox regression model included the components of the current CRT indication criteria: ejection fraction, QRS width, NYHA functional class, left bundle branch block, beta blocker, angiotensin convertase inhibitor and aldosterone antagonist therapy. Further forward stepwise models were builtand validated by usingnet reclassification improvement (NRI) and integrated discrimination improvement (IDI)methods.
Results: The RDW and NT-proBNP separately predicted the 2-year survival of the patients independently of the variables of the baseline model (RDW≥13.6 %: likelihood ratio (LR)=2, hazard ratio (HR)=5.68 [1.90-16.92], p=0.002 and NT-proBNP≥3555 pg/ml: LR=2, HR=3.44 [1.45-8.19], p=0.005). Thepredictive value of the RDW remained significant, when the baseline model included the NT-proBNP (HR=4.29 [1.36-13.56], p=0.01; NRI=0.72 [0.37-1.07], p=0<0.0001; IDI=0.06 [0.03-0.10], p=0.0002), however the NT-proBNPfailed the prediction when the baseline model was extended with the RDW (HR=2.04 [0.82-5-05], p=0.12; NRI=0.49 [-0.00-0.89], p=0.10; IDI=0.02 [-0.00-0.04], p=0.15).
Conclusions: Both RDW and NT-proBNP predicts the survival of the patients after CRT but the RDW was superior.The RDW is gained through a single blood count measurement, thus more cost-beneficial and could facilitate the optimal patient selection for the CRT.
P1032
Cardiac resynchronization therapy optimization by ECG
Abstract
Purpose: To assess the impact of interventricular delay (VVD) optimization in CRT devices based on changes in the QRS complex width using standard ECG on hemodynamic parameters in the long-term period.
Materials and Methods: There was randomized study involving 120 patients in sinus rhythm after CRT implantation according to the conventional guidelines. Study design: all patients were randomized into 2 groups – 1) VVD optimization, n=60, 2) conventional treatment (only atrioventricular delay - AVD - optimization), n=60. Standard follow-up protocol, echocardiography as well as optimization of AV and VV delays were carried out in all patients every 6 months. Observation period was 24 months. The optimal sensed/paced AV interval was assumed to the finished symmetrical intrinsic/stimulated P wave respectively. VVD optimization was implemented by gradual change of stimulation delay time of the right/left ventricle preactivation (from zero to 40 ms) and simultaneous measurement of the biventricular QRS width on ECG. The final VVD result was assumed to the narrowest biventricular QRS complex. QRS complex was measured before CRT implantation (QRSown), then every 6 months: QRS measurement in the temporary device suppression mode (QRSno-st), measuring the biventricular QRS complex width (QRSst) during the VVD optimization procedure. Echocardiography was performed in all patients before CRT implantation and then every 6 months. The heart failure functional class (HF FC) assessing was implemented by a six-minute walk test.
Results: There were no significant differences in cardiomyopathy etiology, baseline QRS, QRSst between the groups. For 24 month follow-up there was significant reduction in the QRSst width in Group I, p=0.042. Final values of the QRSst and QRSno-st width were lower in Group I, p=0.016 and p=0.044 respectively. End-systolic and end-diastolic LV volumes significantly decreased in both groups; reduction in the end-systolic volume was greater in Group I compared to Group II, p = 0.039. Left ventricle ejection fraction (EF) increased in both groups, the degree of EF increase was higher in Group I, p=0.048. HF FC decreased in both groups; the final FC value was lower in Group I, 2.12 versus 2.64 in Group II, p=0.022.
Conclusions: VVD optimization improves cardiac hemodynamic parameters in the long-term period. The narrowest biventricular QRS complex can represent an optimal cardiac synchronization. ECG is reproducible method for dynamic CRT optimization.
P1033
The utility of biventricular acute hemodynamic optimisation to determine the optimal pacing location for cardiac resynchronisation therapy
Abstract
Background: Improved left ventricular (LV) function during LV and biventricular (BiV) CRT is facilitated by improved right ventricular (RV) function in canine and patient studies. The role of RV function in improved LV hemodynamic response during endocardial pacing is currently unknown.
Methods: 10 male patients with ischaemic cardiomyopathy with existing CRT and poor response (30% echo & 40% clinical responders) underwent an acute pacing study with BiV endocardial (ENDO) pacing via a roving catheter in multiple, random LV endocardial positions. Acute hemodynamic response (AHR) (mean dP/dtmax) was measured simultaneously in both the left and right ventricle using 2 pressure wires.
Results: Mean age was 71 yrs, mean QRS duration 145ms & mean EF 25%. BiV ENDO pacing improved the AHR in LV (+20%) & RV (+38%) compared with the best epicardial pacing AHR (LV +11%, RV +5%, p<0.001) (Figure 1A). No single LV endocardial location appeared best and was highly patient specific (1D). Compromise optimization was achieved in some patients by accepting a reduction in the LV-AHR for a significant increase in the RV-AHR (Figure 1B). RV-AHR data was twice as sensitive to pacing changes compared with LV-AHR (RV SD±18%, LV SD±8%) (1C). Correlation between LV and RV AHR was minimal (r=0.001).
Conclusion: Biventricular endocardial pacing provides incremental benefit in acute biventricular function beyond that achievable with epicardial CRT. Compromise optimization to gain a large improvement in RV-AHR at the expense of slight reduction in LV-AHR is possible.
P1034
Selvester qrs scoring system and fragmented qrs on a 12-lead ecg : are predictors of arrhyhthmic risk?
Abstract
Purpose: In the pathogenesis of ventricular arrhythmias (VA) the presence of myocardial scar (MS) is of primary importance and, according to the Selvester QRS Scoring System (SSc) and fragmented QRS (fQRS), MS burden can be assessed by the surface 12-lead electrocardiogram. The aim of our study was to investigate if SSc and fQRS can predict the incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT).
Methods: We retrospectively evaluated SSc and fQRS of HF patients with true-LBBB who underwent CRT. Every 6 months clinical evaluation, echocardiography and device interrogation were performed and episodes of VT and VF stored. Logistic regression analysis was performed to evaluate the related incidence of VT and VF according to SSc and fQRS.
Results We evaluated 183 consecutive patients (age: 70 ±10 years, 66.9% male). Over a median follow-up of 24 months, 26 (14.4%) patients experienced VT or VF. Average SSc in patients who did not suffer VA was 7 ± 4.7; average SSx in patients with previous VA was 9.3 ± 5.3 (p=0.023). VA were observed in 58 patients (37.4%) with fQRS, whereas 16 patients (61.5%) with fQRS did not experience VA (p=0.021). The presence of scar evaluated with SSc and fQRS was directly correlated with the incidence of VT/ VF (SSc: OR 1.09 (95% CI 1.01 - 1.19), p=0.028; fQRS: OR 2.68 (95% CI 1.14 - 6.29), p=0.024).
Conclusions: In HF patients with true-LBBB, SSc and fQRS are associate with a higher incidence of VA.
P1035
Usefulness of PET-CT in the diagnostic strategy in infection of cardiac implantable electronic device
Abstract
Background: The PM or ICD infection is a rare but serious complication. The diagnosis can be difficult. Lead extraction is a technically challenging and risky procedure; the good diagnosis is of major concern for the extraction decision. More recently, 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)FDG)-PET (18F-FDG PET/CT) has shown valuable in the diagnosis and assessment of different organs infection including endocarditis and cardiac implantable electronic device -related infections. (CIED-Infection). For an optimal management of device related-infections and a better definition of the device-related infection with reliable diagnosis criteria, we have prospectively evaluated the diagnosis value of 18F-FDG PET/CT for the diagnosis CIED-Infection.
Methods: We prospectively enrolled 79 patients implanted for more than a month and referred for suspected CIED infection in 4 university centers. They were ranked according to the modified Duke criteria's. The leads were extracted with a bacteriological evaluation if the diagnosis of CIED infection was retained. Patients were followed 18 months for possible late infection occurrence if the diagnosis of CIED-infection was rejected at the first evaluation. All underwent a PET-CT. The review did not intervene in the classification of patients. All PET-CT were read blindly by two different examiners and a 3rd one in case of discrepancy.
Results: 79 consecutive patients (70±15 y.o, median of PM implanted before infection = 2) were referred to our institution for evaluation of PM-related infection suspicion. CIED-infection was retained in 57 patients and one additional patient was reclassified in the infection group at 13 months FU. Infection was rejected in the 21 remaining patients. Pet-CT was positive in 45 patients, 44 with proven infection and 1 without CIED-infection but a delay healing. PET-CT was negative in 34 patients including 14 with proven infection and 20 without infection. The sensitivity of the test was 0.75 (CI: 0.62-0.86) with a specificity of 0.91 (CI = 0.71-0.99). The positive and negative predictive values were respectively 0.96 (CI = 0.85-0.99) and 0.59 (CI = 0.41-0.75). The positive likelihood ratio test was 8.3.
Conclusion: The use of PET-CT in the evaluation of a material infection is promising. A positive result is a strong argument in favor of CIED- infection, while a negative result does not support the conclusion.
P1036
Percutaneous vacuum-assisted thrombectomy device used for removal of large vegetations on infected pacemaker and defibrillator leads as an adjunct to lead extraction
Abstract
Purpose: Early experience with a less invasive, and percutaneous method of safely removing large vegetations during lead extraction in septic cardiac rhythm management (CRM) devices.
Methods: Debate exists concerning the management of vegetations involving CRM devices. Lead extraction is mandated for infections, but during extractions, vegetations may embolize, causing complications.
Surgical debridement is often recommended within the HRS Consensus Statement on Lead Extraction for vegetations >3cm (Heart Rhythm, 2009;6(7)1085:1104). Some options include cardiopulmonary bypass or minimally invasive thoracotomy as recently described by Goyal et al. (J Cardiovasc Electrophysiol. 2014; 25(6):617-621). The AngioVac system is a new device that allows percutaneous right heart bypass and ability to suction vegetations under echocardiographic guidance. This describes our first four patients, all critically ill with sepsis despite long-term antibiotics, and vegetations.
Patient and device characteristics are shown in the table. Setup of the procedure averaged 10 minutes. One intraprocedural complication, an injury to an iliac vein, occurred and was repaired with a stent. All patients survived the procedure and resolved their infections.
Case 3 stayed an extra three days to have an unrelated procedure. Case 4 was a Jehovah's Witness; the patient had a preoperative and postoperative hemoglobin levels of 9 and 3 mg/dL, respectively, contributing to the extended length of stay.
Conclusion: The AngioVac system has thus far been shown to be a safe and effective adjunctive method in the treatment of septic patients with large lead vegetations.
P1037
Repetitive inappropriate ICD shocks due to insulation failure with externalized conductor cables of a Linox SD ICD lead: a case reportAbstract
Case Report: A 54-year-old man with non-ischemic dilated cardiomyopathy underwent implantation of a primary preventive implantable defibrillator (ICD) in 2007 utilizing a dual coil Linox SD 65/16 lead. He has since had a generator change in 2012 and had received several appropriate ICD therapies for ventricular tachycardias. In January 2015, he presented with 17 repetitive ICD shocks while awake at rest without prodromi. Interrogation of the ICD showed noise on the ventricular lead triggering repetitive ICD shocks. The ICD therapies were turned off. Device interrogation showed ventricular sensing of 11.3 mV, pacing impedance of 490 ohms and shock impedance of 40 ohms, all consistent with prior testing. Pacing Threshold could not be determined reliably because pacing resulted in large amounts of ventricular noise. Chest X-ray showed no clear lead abnormalities. A lead extraction was performed and inspection of the easily extractable lead showed an insulation failure with externalized pace-sense conductor cables (see figure) proximal to the distal coil as the putative source of the noise. A novel single coil ICD lead was implanted and the patient has done well since.
Discussion: Unexpected ICD lead failures have caused serious ICD problems in the past. This case report is one of few in the literature describing insulation failure with externalization of conductor cables of a defibrillator lead from the Linox family, that were launched in 2006 with over 150'000 leads implanted worldwide. Although the mechanism of failure remains unclear, a heightened awareness with the Linox leads is warranted.
Biotronik ICD lead w/ insulation failure
P1038
The role of beta-blocker treatment in reducing the incidence of fast-VT related syncope in ICD patients with left ventricular dysfunction: Results from a multicenter study
Abstract
Introduction: In experimental models of fast and monomorphic ventricular tachycardias (FVT), it has been demonstrated that normalization of arterial pressure resulted in a decreasing activity of peripheral sympathetic nerve activity (SNA). We hypothesized that the chronic beta-blocker treatment (BB-T) could improve the clinical tolerance of FVT by attenuating both the vasodilator effect of beta-SNA on peripheral arteries and the baroreflex responses.
Objective: To determine the relationship between BB-T and the incidence of syncope in FVT (Cycle Lenght (CL): 250-320 ms) occurring in ICD patients with left ventricular dysfunction (LVD).
Methods: In this multicenter study, 226 consecutive ICD patients with LVD (LVEF: 31±10%) were followed. FVT programming was standardized, including a single ATP burst as initial therapy. Patients were seen every 3-6 months. Symptoms were correlated with ICD-stored episode data of spontaneous FVT. The BB-T was determined at each FVT presentation.
Results: We analyzed 289 FVT (291±21 ms; 77% under BB-T; median of the duration: 8 s) occurring consecutively in 52 ICD patients. The incidence of FVT-related syncope was 22 (7.6%). Although the duration of non-syncopal episodes was lower (11±7 vs. 23±9 s; p<0.001), we found a relevant overlapping in the duration of syncopal (range: 8-45) vs. non-syncopal FVT (6-56). BB-T was associated with a lower heart rate preceding FVT (85±22 vs. 94±23 bpm; p=0.009), a higher ATP effectiveness (86% vs. 57%; p<0.001), a lower duration of episodes (11±6 vs. 16±10 s; p<0.001) and a lower incidence of FVT-related syncope (4.5 vs. 18%; p<0.001).
After adjusting for other variables in a logistic regression model (LVEF, etiology, indication, functional class, medical treatments, duration and FVT CL), a duration >8 s (OR=21; p=0.003) and the BB-T (OR=0.3; p=0.012) were found as independent predictors of FVT-related syncope. Classifying the events into two groups according to the median of duration (≤8 s vs. >8s), the BB-T reduced the incidence of syncope only in FVTs of >8 s: 9.5% vs. 27% (p=0.008). Patients under BB-T had a lower adjusted rate of FVT-related syncope, mean (95% CI): 4% (0-10) vs. 18% (4-31); p=0.003 (Generalized Estimated Equations Method).
Conclusions: Among ICD patients with LVD, BB-T is associated with a reduction of FVT-related syncope.
P1039
Vasovagal syncope patient eligibility for prevention of syncope trials IV and V: a single center evaluation
Abstract
To date, no randomized controlled trial has demonstrated efficacy of medical therapy for the prevention of vasovagal syncope (VVS). However, two Canadian-led multicenter randomized, placebo-controlled, double-blind trials, Prevention of Syncope Trial IV (POST IV – Midodrine vs Placebo) and Prevention of Syncope Trial V (POST V – Metoprolol vs Placebo), are currently recruiting patients (pts). We assessed the potential utility of these treatments by determining pt eligibility for these 2 trials.
Methods: The charts of pts seen in a dedicated syncope clinic in one enrolment center between June 2013 and August 2014 were reviewed retrospectively and those with a diagnosis of VVS by either a positive tilt table test or Calgary Syncope Symptom Score (CSSS) ≥ -2 were identified. The inclusion and exclusion criteria of each trial were applied to this population.
Results: A total of 152 pts (median age 52; 67% female) with VVS were identified. First syncope in this population occurred at a median age of 19 with a median total lifetime number of 7 syncopal events. Of this group, 37 pts met the inclusion criteria for POST IV (CSSS ≥ -2; age ≥18; ≥2 syncopes in the last 12 months) and 49 met those of POST V (CSSS≥-2; age ≥40; ≥1 syncope in the last 12 months). However, exclusion criteria decreased the number of eligible patients for POST IV to 26 (eg., hypertension - 5 pts, prior inefficacy/intolerance of midodrine - 4 pts) and for POST V to 24 (eg., intolerance to beta blocker therapy - 11 pts, asthma – 7 pts, Raynaud's- 2 pts). Furthermore, in each group, pharmacological therapy would not be immediately proposed in this syncope clinic to 20 eligible pts as they were just counselled on hydration and salt intake at their first visit within the last 2 months or were doing well with this approach at follow-up at least 3 months following the initial encounter. Finally, in the groups of pts eligible for POST IV and V, the median age (31 yrs vs. 51 yrs) and the sex distribution (81% vs. 68% female) could significantly deter pharmacological therapy acceptance by those candidates with childbearing potential.
Conclusions: Although approximately 16 % of a VVS clinic population in this single-center analysis is eligible for either POST IV or POST V, such a pharmacological approach once proven effective will nevertheless likely be undertaken in only a minority of patients.
P1040
Influence of duration of Atrial Fibrillation on endothelial function
Abstract
Introduction: Endothelial dysfunction (ED) is the independent predictor of adverse cardiovascular events. Previous studies showed, that in group of patients with atrial fibrillation (AF) – most common supraventricular arrhythmia, ED prevalence may be higher than in general population.
Aim: The aim of this study was to define the influence of duration of persistent AF on endothelial function in group of patients undergoing percutaneous pulmonary veins isolation.
Methods: Venous blood samples were collected from femoral vein before the procedure. Endothelial function was assessed with biomarkers as: endothelin-1 (ET-1), thrombomodulin (TM) and vascular endothelial growth factor (VEGF). Trends for serum biomarkers' levels across increasing tertiles of persistent AF duration were calculated.
Results: A total of 61 patients (50 males – 82%) with persistent AF were included to the analysis. Median of persistent AF duration was 10 months with interquartile range (IQR) from 6 to 20 months. Three subgroups of patients were formed according to persistent AF duration as follow: 1-7, 8-14 and ≥15 months. We observed significantly lower serum level of VEGF across subgroups of patients with increasing persistent AF duration (584.9 [433.0-676.2], 395.8 [267.0-537.1], 411.6 [311.7-561.9] pg/ml, respectively; P for trend 0,023). ET-1 serum level was lower in patients with longer persistent AF duration, however this correlation did not reach statistical significance (3.34 [2.77-3.67], 3.09 [2.64-3.41], 2.83 [2.41-3.22] pg/ml; P for trend 0.060). There was no association between TM serum level and persistent AF duration (316.5 [288.4-377.8], 283.3 [261.1-316.3], 330.6 [292.0-359.9] pg/ml; P for trend 0.921).
Conclusions: Duration of persistent AF in a group of patients undergoing ablation is associated with VEGF serum level but not with ET-1 and TM serum levels. It may suggest that longer lasting persistent AF is connected with ED.
P1041
Female rats exposed to high sucrose diet exhibit down-regulation of myocardial Cx43 and increased propensity to inducible VF that are attenuated by melatonin and Omacor
Abstract
Rationale & Purpose: Mislocalization and/or dysfunction of cardiac connexin-43 (Cx43) channels have been involved in the occurrence of life-threatening arrhythmias. Our previous studies indicate that diabetes is associated with Cx43 and PKC-epsilon alterations and linked with slowed conduction. To explicate the impact of glucose metabolism disorders on development of Cx43 alterations and susceptibility of the heart to inducible VF we examined female rats that were subjected to high sucrose diet. Moreover, we tested antiarrhythmic effects of melatonin and omega-3 fatty acids and possible implication of Cx43 in this condition.
Design and Methods: The experiment was performed on 9-month-old female normotensive (Wistar) rats that were divided into four groups: 1) controls; 2) rats drinking 30% sucrose solution (HSD); 3) HSD supplemented with melatonin (40 μg/ml in drinking water); 4) HSD supplemented with omega-3 fatty acids (Omacor, PronovaBioPharma, Norway, 25g/kg per diet). Left ventricle was used for analysis of Cx43 mRNA and protein levels as well as protein expression of PKCɛ (which phosphorylates Cx43) and PKCo (which is implicated in pro-apoptotic signaling). Electrically-inducible sustained VF was examined using isolated-perfused heart.
Results: High sucrose diet resulted in an increase of body weight, adiposity, plasma triglycerides and cholesterol as well as heart and left ventricular weights. The threshold to induce sustained VF was lower in rats exposed to high sucrose diet, while both melatonin and Omacor significantly increased it. There were no changes in Cx43 mRNA expression among the groups. However, decreased expression of Cx43 protein and its phosphorylated forms in HSD rats were normalized by melatonin treatment. Omacor did not affect total Cx43 protein levels but enhanced functional phosphorylated forms of Cx43. Moreover both, melatonin and Omacor normalized diminished expression of PKCe and elevated expression of PKCd in rats exposed to sucrose diet.
Conclusions: Findings indicate that high sucrose diet results in down-regulation of myocardial Cx43 and PKC signaling that may be related to increased susceptibility of female Wistar rats to malignant arrhythmias. The adverse effects can be attenuated by the treatment with either melatonin or Omacor.
P1042
Application of dipole density versus voltage in electrophysiology: a model study
Abstract
Introduction: Voltage (V) measured with direct contact is believed to be the best measure of cardiac activation. V is a far-reaching summation of local positive and negative sources of charge that propagate across the myocardium from the action of ion channels. It is clinically desirable to measure these local sources.
Methods: Local sources were modeled as a double-layer of Dipole Density (DD) on the endocardial surface (ES) with orientation of DD perpendicular to the ES. A sphere (radius=1) was used to model the ES and the function exp(αcosθ) to model DD on the ES (DD=1 at the South Pole of the ES and exponentially decreasing to 0 at the North Pole). Exact V can be calculated everywhere for this model. V was calculated across the ES and at 186 points on a non- contact measurement sphere (radius=0.5) centered within the ES and applied in a DD inverse algorithm that reconstructed DD on the ES. Reconstructed DD was compared to the exact model of DD.
Results: V on the ES reached beyond the DD sources, with a long rightward tail, compared to the finite range of DD (Figure 1A). The RMS error between the reconstructed DD and the exact model of DD was 0.01 (1%) across the entire ES (Figure 1B).
Conclusions: This model demonstrates the basic feasibility of inverse reconstruction of DD on the ES from an array of non-contact measurements of V and opens the possibility of high resolution global mapping without the challenges of maintaining direct contact. Further study on human anatomy with biologic sources is warranted.
Dipole Density vs Voltage
P1043
Identification of the CACNA1C gene Gly406Arg mutation causing Timothy syndrome in a newborn with AV block and QT prolongation using next-generation sequencing
Abstract
Purpose: Timothy syndrome (TS) is an ion channel disease affecting multiple organs. Beside cardiac involvement, including malignant arrhythmias, QT prolongation and AV block, extracardiac symptoms in form of syndactyly, dysmorphic features and neurodevelopmental delay may be present. The disease is caused by the Gly406Arg canonical mutation of the CACNA1C gene, the main calcium channel gene of the heart. The presence of Gly406Arg mutation in the exon 8A of the gene leads to Timothy syndrome 1 (TS1) associated with syndactyly, whereas atypical Timothy syndrome (TS2) is caused by the same mutation occurring in the alternative exon 8. Our main goal was to perform genetic testing of a newborn child with a clinical phenotype suggestive of TS. Bradycardia was detected already in fetal life as indicated by a non-stress test on the 37th week of pregnancy. On the second day of life functional second degree AV block with QTc prolongation (QTc 600 ms) was noted. No syndactyly or other extracardiac symptoms were present. AV block disappeared and the QTc was shortened (440-580 ms) on mexiletin and propranolol therapy. During one and a half year of follow up, no malignant arrhythmia occurred.
Methods: Molecular genetic testing was carried out using next-generation sequencing with a validated ion channel platform. Targeted resequencing covered 69 ion channel genes.
Results: In our patient, bradycardia was detected already in fetal life as indicated by a non-stress test on the 37th week of pregnancy. On the second day of life functional second degree AV block with QTc prolongation (QTc 600 ms) was noted. No syndactyly or other extracardiac symptoms were present. AV block disappeared and the QTc was shortened (440-580 ms) on mexiletin and propranolol therapy. During one and a half year of follow up, no malignant arrhythmia occurred.
Multiple gene variants were identified in the sample, including the TS causing typical Gly406Arg mutation of the CACNA1C gene. This mutation affects exon 8A, defining the case as TS1 on genetic grounds. The major effect of other identified rare variants, affecting KCNQ1, KCNC4 and ANK2 genes, were excluded.
Conclusions: Based on the results above, we identified the canonical Gly406Arg mutation of the CACNA1C gene in our TS patient. So far, this case is the first genetically confirmed TS patient in Hungary. The observation of a TS2 phenotype with a genetic TS1 background is novel.
P1044
C34T AMP deaminase-1 gene polymorphism is associated with permanent atrial fibrillation in patients with chronic heart failure
Abstract
Background: AMP deaminase (AMPD)-1 accounts for 30% of nucleotide catabolism in the heart and regulates the energetic metabolism in cardiomyocytes. The common C34T variant in the AMPD-1 gene induces a truncated protein (Glu12Stop), and a decrease in AMP catabolism, with adenosine accumulation and a potential to disrupt the energetic balance in cardiomyocytes. Adenosine (through action potential shortening) and impaired energetics are potential promoters of atrial fibrillation (AF). To date, there is no information as to whether the C34T variant could predispose to AF.
Objectives: In patients with chronic heart failure (CHF), we assessed the association between the C34T variant and the presence of permanent AF (perm-AF).
Methods: We included 197 patients with CHF. Blood was withdrawn upon HF stabilization and the C34T variant determined by direct gene sequencing. Chi-squared and t-test were used to assess differences between patients with and without perm-AF. The independent association between perm-AF and C34T was assessed by binary logistic regression analysis adjusting for pertinent variables.
Results: Of the 197 patients (61% men, mean age 69±10), 72.6% had hypertension, 51% diabetes and 56% were prior/current smokers. CHF was of ischemic origin in 49%. Left-ventricular ejection fraction (EF) was 37.8 ± 16% and mean NYHA functional class 2.5±0.8. Eighty-four percent of patients were treated with ACEI/RAA and 85% with betablockers. Thirty-one patients (15.7%) had perm-AF. The C34T variant was present in 54 patients (27.4%). Patients with and without perm-AF did not differ except for a greater prevalence of ischemic etiology and higher tobacco use in patients without perm-AF. The prevalence of C34T was significantly higher in patients with perm-AF (45.2% vs 24.1% in no perm-AF patients, p=0.016). Multivariable logistic regression analysis adjusting for age, sex, EF, treatment and classical factors associated with a worse outcome in CHF and AF confirmed that age (HR 1.05 [1.01-1.10]) and C34T (HR 2.62 [1.14-6.02]) were the only variables independently associated with perm-AF.
Conclusions: The C34T variant in AMPD-1 was independently associated with the presence of perm-AF in a population of HF-patients. Impaired cardiomyocyte energetics and adenosine accumulation could be involved in AF promotion in patients with the C34T variant.
P1045
Liraglutide, an analog of glucagon-like peptide-1, exerts a direct positive chronotropic effect on rabbit hearts
Abstract
Purpose: Liraglutide (LG), an analog of the gut-derived incretin hormone Glucagon-Like Peptide-1, is used to enhance insulin release in anti-diabetic therapies. Among the various extra-pancreatic effects reported for LG thus far, a mild elevation of heart rate (HR) is observed in both patient studies and in animal models. We sought to study this chronotropism of LG in an ex vivo rabbit heart model.
Methods: Whole hearts harvested from adult male rabbits were perfused in a Langendorff set-up. Various doses of LG were given in bolus infusions (between 0.15mg to 24 mg) into 1 L of re-circulating perfusion solution. Cardiac electrical activities were continuously recorded from surface electrodes for subsequent analysis.
Results: Electrograms from 14 rabbit hearts were analyzed. Mean baseline HR was 186.0 ± 22.9 bpm. Two minutes after 1.2 mg of LG was infused, HR rose by 3.6% (6.3 ± 8.8 bpm, p<0.05, Panel A). LG-induced HR elevations were transient in our experimental model, with peak HR recorded within the first few minutes after the infusion. No further HR increases were observed after 5 minutes. Panel B shows the dose-response plot.
Conclusion: LG elevated HR in rabbit hearts in a dose-dependent manner. As chronotropism previously reported in clinical and animal studies was also observed in our ex vivo denervated, perfused heart preparations, we conclude that the positive chronotropic actions of LG are not mediated by enhanced insulin release or autonomic reflex phenomena, nor due to changes in blood pressure, but by direct actions on the heart.
A)Increase 1.2mg B)Dose Response Curve
P1046
The diagnostic quality of the new injectable telemedically cardiac monitor Reveal LINQ
Abstract
Background: Insertable cardiac rhythm monitoring for detection of infrequent arrhythmias has a rising clinical relevance. But the diagnostic quality is limited by automatic miss-detection of arrhythmias and the limited memory capacity.
Hypothesis: The diagnostic quality of the injectable cardiac monitor Reveal LINQ with telemedical follow up should be evaluated in the clinical practice.
Methods: In a prospective registry in 40 patients a Reveal LINQ was injected and followed up with telemedicine. Additionally all patients were follow up in the clinic every 3 month with manual follow up and evaluation of all detected episodes.
Results: In all patients the cardiac monitor could be injected without any complication. The mean sensing was 0.6mV (0.3-1.2 mV). With respect to atrial fibrillation (AF) 38/40 (95%) patients were certainly diagnosed. In 15 patients AF was automatically detected. After manually correction of the detected episodes 13/15 (87%) patients had a correct automatic AF detection. 2/15 (13%) were automatically miss-detected. In 11 patients atrial tachycardia were recorded. After manually correction only 2/11 (18%) episodes were detected correctly. 7/11 (64%) episodes were false positive. In 2/11 patients not all episodes were visible with electrocardiogram and remained un-diagnostic. In 10 patients an asystole was diagnosed. 1/10 (10%) episode was correctly detected. 9/10 (90%) episodes were false positive. In 3 patients a bradycardia was recorded. 2/3 (66%) episodes were detected correctly.1/3 (66%) episode was false positive.
Conclusions: With the injectable telemedically cardiac monitor Reveal LINQ cardiac arrhythmias (AF, bradycardia, asystole) can be detected with a specificity of over 95%. But this high diagnostic quality could only be reached with a manually correction of the recorded episodes by a physician who evaluated the electrocardiograms telemedically.
P1047
Comorbid epilepsy and developmental disorder in congenial long QT syndrome with perinatal arrhythmia
Abstract
Purpose: Congenital long QT syndrome with fatal perinatal arrhythmia (perinatal LQTS) has poorer prognosis than LQTS without perinatal arrhythmia (non-perinatal LQTS). Given the association of LQTS, epilepsy, and other neurological disorders, we speculated that the more severe perinatal LQTS phenotype would show more frequent comorbid epilepsy and neurodevelopmental anomalies than non-perinatal LQTS.
Methods and Results: Seventeen consecutive LQTS patients diagnosed before one year of age, 5 with perinatal LQTS and 12 with non-perinatal LQTS, were enrolled and the clinical courses evaluated, including neurological comorbidities. Until the last follow-up age (median, 5.5 years, 1.8–16.1), torsades de pointes or syncope occurred in three perinatal LQTS cases and in one non-perinatal LQTS case. Four perinatal LQTS (80%) were diagnosed with epilepsy and three (60%) with developmental disorder, but no non-perinatal LQTS (p=0.0021 and p=0.015, respectively). In patients with epilepsy, cerebral imaging showed unremarkable findings. Further, total development quotient assessed by the Kinder Infant Development Scale scores were significantly lower in perinatal LQTS than non-perinatal LQTS patients (p=0.0084). In the four perinatal LQTS cases with epilepsy, the mutations were located in the transmembrane loop of KCNH2 (T623I, S 624R), in the D4/S4 segment (G1631D) of SCN5A, or the D3/S4-S5 linker (P1332L) of SCN5A.
Conclusions: High comorbidity of epilepsy and developmental disorder were observed in perinatal LQTS. The mutations in patients with epilepsy were in loci previously linked to a severe cardiac phenotype of LQTS. This indicates that the neurological phenotype associated with severe cardiac phenotype due to channelopathy is more frequently manifested in perinatal LQTS.
Clinical courses of infantile LQTS
P1048
Levels of cardiac autoantibodies in patients with ventricular premature beats with structurally normal heart
Abstract
Background: 30% of patients (pts) with ventricular premature beats (VPB) show structurally normal heart. One of the possible causes of idiopathic arrhythmias is considered to be inflammatory heart disease, including of autoimmune nature.
Materials and Methods: There were included 91 pts (27 men, mean age 36,53 ± 11,49 years) with VPB not lower than II grading B. Lown with structurally normal heart. In addition to standard clinical examination, including 24-hour Holter ECG monitoring, levels of autoantibodies to synthesized peptide sequences simulating different parts of β1-adrenoceptor (β25, β8) and M2-cholinoreceptor (MRIMRIV, MRI) were estimated. 40 pts underwent cardiac MRI with assessment of myocardial edema (ME), early gadolinium (EGE) and late gadolinium enhancement (LGE).The control group comprised 31 healthy volunteers.
Results: Amount pts with VPB were not detected EGE and LGE. Levels of IgM to β25 (p=0.017), MRIMRIV (p=0.03), MRI (p=0.029) were significantly higher among pts with VPB than in the control group. According to results of 24-hour Holter ECG pts with VPB were divided in 3 groups: ≪I≫- less than 5000 VPB in a day; ≪II≫- from 5000 to 15000 VPB in a day; ≪III≫- more than 15000 VPB in a day. Among pts in group ≪I≫- were detected the highest levels of IgM to ARIMRIV (0.82 [0.68; 0.87]), MRIMRIV (0.73[0.43; 0.86]) and MRI (0.75[0.35;0.85]), p<0.05. Among pts in group ≪III≫ levels of IgM to β25 (0.58[0.37; 0.97]) and β8 (0.67[0.36; 0.89]) were higher than in group ≪II≫ (β25 0.40[0.32; 0.75] and β8-0.55[0.43; 0.84]) and group ≪I≫ (β25 -0.47[0.35; 0.86] and β8-0.61[0.43; 0.76]). Moreover in pts with number of VPB in a day more than 30000 was demonstrated a strong negative correlation between the number of episodes of nonsustained VT and IgM to ARIMRIV (r =-0.69), MRIMRIV (r =-0.78) and MRI (r =-0.73).
Conclusion: The study demonstrated that pts with VPB were significantly different from the healthy volunteers. Pts with number of VBP less than 5000 in a day demonstrated the highest levels of autoantibodies to M2-cholinoreceptor. At the same time, in pts with number of VBP more than 30000 in a day the decrease of the levels of autoantibodies to M2-cholinoreceptor was accompanied by increase in the number of nonsustained VT episodes.
P1049
Electrocardiographic and arrhythmic characterization of severe disorders of serum potassium in hospitalized patients, do we know all about them?
Abstract
Purpose and Methods: Retrospective observational study of adults patients (p) admitted at a tertiary hospital that presented severe K disorders any time during the hospitalization along the first 6 months of 2013. Cutoff values were for hypokalemia (hypo) K≤2.5 mmol/l and for hyperkalemia (Hyper) K≥6.5 mmol/l. We describe changes in ECG, atypical presentations and severe arrhythmias occurrence.
Results: We identified 310 p with severe K alterations, 124 p with Hyper and 186 with hypo. Median K was 2.3 mmol/l (IQR 2.2-2.4) and 6,9 mmol/l (IQR 6.6-7.3) for hypo and Hyper, respectively. An ECG was obtained in only 28.4% of the p at the time of K alteration (88 p). During sinus rhythm, Hyper p had a lower P wave voltage (0.5 vs 1 mm, p 0.006), wider QRS (100 vs 80 ms, p 0.002), higher positive T wave (5,1 vs 1.5 mm, p 0.001); hypo p showed higher QTc (460 vs 420 ms, p <0.001). Serious arrhythmias ocurred in 28.9% in Hyper p (8 high degree AV block, 4 VT and 1 VF) and in 7% hypo p (1 polimorfic VT, 2 VF). Four Hyper p with chronic ventricular pacing, presented wider QRS (140 vs 105 ms, p 0.033) and greater T wave height (10,3 vs 5,4 mm, p 0.047). Four Hyper p (median K 8.2 mmol/l, IQR 7.1-8.9), showed a Brugada phenocopy, all were critically ill and two presented severe arrhythmias (complete AVB, VT). Very high voltage positive T wave, median 12.7 mm (IQR 5,8-16,25), and close based T wave morphology in V4-V5 leads were not previously described (figure 1), distinguished this phenocopy from the characteristic Brugada type 1 pattern.
Conclusions: Both disorders present characteristic ECG abnormalities that enable prompt clinical identification and treatment due to potentially life-threatening events. Novel ECG patterns are described for ventricular paced hearts and Brugada like phenocopy.
P1050
Multistep electrocardiographic algorithms demonstrate inferior specificity for identifying ventricular tachycardia when applied by non-cardiologists
Abstract
Purpose: The electrocardiograph (ECG) remains the most widely available non-invasive test to rapidly diagnose ventricular tachycardia (VT) and wide-complex supraventricular tachycardia (SVT). The Vereckei aVR and Brugada algorithms have emerged as the most recognized and frequently used ECG algorithms to differentiate VT and wide-complex SVT among non-cardiologist (NC) providers. We sought to evaluate algorithm performance when applied by NCs on ECGs with a confirmed clinical diagnosis.
Methods: Three internal medicine residents interpreted a collection of 12-lead ECGs in two separate blinded interpretation sessions using the Vereckei aVR and Brugada algorithms. Every interpreted ECG required clinical confirmation of VT or SVT by the patient's overseeing attending cardiologist.
Bontempi Pm 64 Manual Transmission Fluid
Results: Each study participant interpreted 273 ECGs (162 VT, 111 SVT) from 190 patients for a total of 819 discrete interpretation events per session. Both algorithms demonstrated high sensitivity but inferior specificity for diagnosing VT (see table). The Vereckei aVR algorithm misclassified 8% and 68% of interpreted VTs and SVTs respectively. The Brugada algorithm misclassified 11% and 42% of interpreted VTs and SVTs respectively.
Conclusion: Although NCs correctly identified most actual VTs, ECG rhythm misclassification was common. These findings emphasize the need for an improved diagnostic method for NC providers to differentiate wide-complex tachyarrhythmias.
| Reviewer 1 | 62% | 94% | 15% | 62% | 63% | 1.11 |
| Reviewer 2 | 68% | 92% | 32% | 67% | 73% | 1.36 |
| Reviewer 3 | 73% | 91% | 46% | 72% | 79% | 1.72 |
| All Reviewers | 68% | 92% | 32% | 66% | 74% | 1.35 |
| *P < .05 vs. that of the Vereckei's aVR criteria by the same observer or group |
| Reviewer 1 | 62% | 94% | 15% | 62% | 63% | 1.11 |
| Reviewer 2 | 68% | 92% | 32% | 67% | 73% | 1.36 |
| Reviewer 3 | 73% | 91% | 46% | 72% | 79% | 1.72 |
| All Reviewers | 68% | 92% | 32% | 66% | 74% | 1.35 |
| *P < .05 vs. that of the Vereckei's aVR criteria by the same observer or group |
| Reviewer 1 | 62% | 94% | 15% | 62% | 63% | 1.11 |
| Reviewer 2 | 68% | 92% | 32% | 67% | 73% | 1.36 |
| Reviewer 3 | 73% | 91% | 46% | 72% | 79% | 1.72 |
| All Reviewers | 68% | 92% | 32% | 66% | 74% | 1.35 |
| *P < .05 vs. that of the Vereckei's aVR criteria by the same observer or group |
| Reviewer 1 | 62% | 94% | 15% | 62% | 63% | 1.11 |
| Reviewer 2 | 68% | 92% | 32% | 67% | 73% | 1.36 |
| Reviewer 3 | 73% | 91% | 46% | 72% | 79% | 1.72 |
| All Reviewers | 68% | 92% | 32% | 66% | 74% | 1.35 |
| *P < .05 vs. that of the Vereckei's aVR criteria by the same observer or group |
P1051
Electrocardiographic findings in peripartum cardiomyopathy - diagnosis vs. recovery
Abstract
Introduction: Peripartum cardiomyopathy (PPCM) is a rare idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. Electrocardiographic (ECG) changes are well described in several cardiac diseases. However, quantitative and especially qualitative analyses of ECG during PPCM are patchy.
Methods: Datasets of 32 patients (mean age 34±5 years) with new-onset PPCM were included. All patients received standard heart failure medication according to current guidelines. ECG at admission and after 1 and 6 months of follow-up were analysed following the modified Minnesota code.
Results: Mean NYHA functional class at admission was 3,1±0,9, mean left ventricular ejection fraction (LVEF) was 24,9±11,0%. After 6 months, mean NYHA functional class significantly improved to 1,7±0,6 (p<0,001), as well as LVEF to 47,0±11,0% (p<0,001). Detailed ECG findings are shown in table 1. Within 6 months of heart failure therapy, the patients' ECGs significantly changed in terms of heart rate, P-wave duration, PR interval and QTc interval.
Conclusion: Patients with new-onset PPCM show frequent ECG alterations at the time of diagnosis. After initiation of heart failure medication and after recovery, most of these alterations significantly decrease. Whether the ECG findings support the diagnosis of or risk stratification in PPCM has to be studied in larger populations.
P1052
High prevalence of asymptomatic atrial fibrillation in the North-East Region of RomaniaAbstract
Purpose: There is poor epidemiological data on the prevalence of atrial fibrillation (AF) in Romania.
Methods: A single ECG was performed in a sample population selected by 240 general practitioners who were directly affiliated to a tertiary cardiovascular center (CVC) in E-CORD Center European Funding Program. ECGs were done to subjects from rural and urban Nord East Romanian Region (NERR) as a screening exam, but also in case of suggestive symptoms for heart disease.
Results: Our investigated population was from NERR, comprising 3.2 million inhabitants of 6 counties, a statistically significant sample group for Romania's population (0.55% sampling error). From September 2011 to September 2014 dedicated cardiologist of CVC have been interpreted 38743 ECGs; 28879 (74%) out of them were performed in subjects with cardiovascular symptoms (dyspnea, palpitations, dizziness, syncope, chest pain) and 9864 (26%) were screening investigated in asymptomatic subjects. Mean age of studied population was 58±23 (7-87 years) with 37% (14335) older than 65 years and 40% (13284) men. A high proportion of subjects under 65 years old were investigated: 36% (13947) between 45-65 years and 27% (10461) under 45 years even if the current guidelines recommends to screen ECG only patients older than 65 years. We found AF in 3041 subjects (7.9%), with 47% (1429) men; 1111 (36.6%) out of them were newly diagnosed cases. Distribution by age decades of subjects with AF was: 2% (61 subjects) <45 years, 3% (91 subjects) 45-54 years, 13% (395 subjects) 55-65 years and the majority of 82% (2494 subjects) ≥65 years. Almost 20% (424 subjects) of AF patients were asymptomatic, in the remaining subjects 81% (2617) ECG was performed because of suggestive symptoms (dyspnea, palpitations, chest pain, fatigue, dizziness).
Conclusions: The prevalence of AF in NERR sample population corresponds to the current trend of this arrhythmia in Europe. A high proportion of AF was detected in population under 65 years. The high proportion of asymptomatic subjects with AF suggests that the real prevalence of AF could be underestimated.
P1053
Interactive 3-dimensional simulation of electrocardiography
Abstract
Background: Understanding how the electrical activity of the heart inscribes the electrocardiogram is challenging for trainees. We describe a novel tool for ECG training based on real-time interactive 3D simulations of cardiac electrophysiology. The work addresses the need for improved understanding of the relationship between ECG tracings and the underlying pathology of the heart.
Methods: A simulation of whole heart cardiac electrophysiology is based on a population of cell-nodes used to construct the intercellular activation propagation wave. A cellular automaton was developed to simulate the propagation of electrical excitation through the population of cell-nodes based on local fibre orientations. Each cell-node possesses a rest state, an excitation threshold, and a diffusive-type coupling to its neighbours. The mean electric axis is calculated over each beat cycle and is projected onto the respective lead vectors in order to generate the 12 ECG signals.
Results: Face validated simulations of normal rhythm and a wide range of pathologies including bundle branch blocks, Wolf-Parkinson-White syndrome with accessory pathways, atrial and ventricular arrhythmias (figure) have been implemented. The prototype enables direct interaction with a virtual heart and generates validated 12-lead ECG tracings in near real-time online via any web browser on standard computing devices. The spatial and temporal relationships between the heart's function and ECG signal generation have been integrated in an e-learning and assessment package.
Conclusion: A successful proof-of-concept real-time ECG simulation training tool has been developed. It will allow trainees to engage in active learning-by-doing to understand the ECG.
Simulation of VF (Screenshot, real-time)
P1054
Successful prenatal management of lethal ventricular arrhythmias in fetuses with congenital LQTS
Abstract
Background: In severe cases of congenital long QT syndrome (LQTS), ventricular tachycardia (VT) / torsade de pointes (TdP) during fetal life will cause intra-uterine fetal demise. The previous reports on the fetal treatment for these cases are few, and its drug selection has not yet been established.
Methods: We present two fetuses with LQTS whose ventricular arrhythmias and hydrops were successfully managed in utero.
Results: Case 1; A 32-year-old woman was referred to our institution at 28 weeks of gestation for fetal bradycardia. The fetal magnetocardiography (fMCG) revealed TdP and a markedly prolonged QT interval (QTc=591). The fetus was complicated with severe hydrops. A Mg infusion had a dramatic effect on the fetal ventricular arrhythmia in this case. The hydrops improved immediately. Case 2; A 35-year-old woman was referred to our institution at 24 weeks of gestation for fetal tachycardia. Her husband had a KCNH2 missense mutation (T613M) by genetic testing. The fetal echocardiography revealed a sustained tachycardia and pericardial effusion. The fetal fMCG revealed sustained VT and a markedly prolonged QT interval (QTc=511). However, a continuous Mg infusion was started trans-placentaly, and the VT did not terminate, the fetus developed severe hydrops. We started propranolol (BB) administration additionally. After the BB administration, the VT completely disappeared and the hydrops improved immediately.Sinus rhythm was maintained, and the fetus was delivered at 37 weeks of gestation.
Conclusion: Trans-placental anti-arrhythmic drug administration is an effective treatment to rescue fetuses that have developed hydrops or have a high risk of fetal hydrops. However, the drug selection for use has not yet been established, and it is necessary to accumulate future knowledge.
The fetal magnetocardiography
P1055
Contact analysis and device leaflet interaction of a nitinol based goretex patch device in the treatment of mitral regurgitation by finite element analysis
Abstract
Aims: A Nitinol based goretex patch device over a 6F screw-in pacemaker lead wire was designed, and its performance was evaluated by finite element analysis.
Methods And Results: A 1.0 cm wide x 1.2 cm nitinol based device with a goretex patch sutured on its surface was designed. The device was fixed over a 6F screw-in pacemaker lead wire. The device was initially evaluated in-vitro to reduce mitral regurgitation, which was studied after cutting the chords in-vitro. The device was positioned across the mitral leaflets. Based on the 4DCT images, a patient specific model of the mitral leaflet and apparatus was generated and validated. The left ventricle was reconstructed using segmentation technique. A finite element model of the mitral valve leaflets was generated based on 3D reconstruction. The pacemaker lead was fixed at the left ventricular apex. The contact analysis, device-leaflet interaction and the stress distribution on the mitral valves were studied after placement of the device. The device-leaflet interaction of the nitinol device and the patient specific mitral valve model was analysed. A simulation was performed to observe the virtual closure behavior of the mitral valve leaflets. The analysis was performed in Abaqus. The mitral valve stress distribution was quantified before and after implantation of the device. The mitral valve stresses were significantly lower after placement of the device across the valves.
Conclusions: The mitral valve stresses were reduced after placement of a novel Nitinol based Goretex device across mitral valves. There is potential for a novel device over endocardial pacing wire in Mitral regurgitation therapy.
Leaflet Stresses
P1056
Long runs of non-sustained ventricular tachycardia predict serious arrhythmic events in patients with non-ischemic heart failure
Abstract
Purpose: Risk stratification of serious arrhythmic events in patients with non-ischemic heart failure (HF) remains an important clinical challenge. This study aims to determine the clinical value of different noninvasive and invasive tests for predicting serious arrhythmic events in patients with non-ischemic HF.
Methods: 106 non-ischemic HF patients underwent a comprehensive clinical and laboratory evaluation, two-dimensional echocardiography, 24-hour-Holter monitoring, cardiopulmonary exercise testing (CPX), and invasive electrophysiological study (EPS), and were followed prospectively.
Results: During a mean follow-up of 493 ± 300 days, the primary end-point (syncope, appropriate therapy by implantable cardioverter-defibrillator, or sudden cardiac death) occurred in 10 patients (9.4%). Sustained ventricular tachyarrhytmia was induced at EPS in 12.4% of patients. In the multivariable analysis, alcoholic etiology (HR 9.96; 95% CI 1.8 to 55; p = 0.008), presence of exercise periodic breathing (EPB) in CPX (HR 8.4; 95% CI 1.8 to 40; p = 0.007) and non-sustained ventricular tachycardia (NSVT) > 10 beats on Holter (HR 25.4, 95% CI 4.4 to 146; p < 0.001) were the only independent predictors for the primary end-point.
Conclusions: In this cohort study of non-ischemic HF patients, NSVT > 10 beats was the most important predictor for the occurrence of serious arrhythmic events. Inducibility of ventricular tachyarrhytmia at EPS was not predictor of serious arrhythmic events.
P1057
Impact of a wireless probe on ultrasound-guided venous cannulation in the electrophysiology lab: reduction of unsuccessful attempts and accidental arterial punctures
Abstract
Introduction: Ultrasound guidance has shown to be safer and more efficient than the anatomical landmark approach and is recommended as the initial approach for venous cannulation. However, the rate of systematic adoption of this technique is low due to, among others, a perception of workflow interference due to the use of ultrasound.
Our goal was to describe the impact of using a wireless probe on the perception of workflow delay and to evaluate the benefit in terms of increase in safety and efficacy.
Methods: Patients requiring femoral venous cannulation for electrophysiology procedures were included in this single centre, prospective observational study comparing wireless ultrasound guidance (WUS) with the anatomical landmark (AL) approach. We analysed the rate of unsuccessful punctures, accidental arterial punctures and workflow interference, rated on a 0-to-5 scale by the operator.
Results: We analysed a total of 51 punctures (31 WUS-guided, 20 AL-guided) performed in 25 patients (67.5±15.4 years old; BMI of 26.5±3.9). WUS-guidance improved safety and efficacy, reducing the rate of accidental arterial punctures (0.03±0.18 vs. 0.25±044 arterial punctures per cannulation, p<0.05) and unsuccessful attempts (0.35±0.95 vs. 1.50±1.76 attempts per cannulation, p<0.01) when compared with the anatomical landmark approach. Workflow interference was perceived as mild (1.19±1.14 on a 0-to-5 scale) due to prior preparation of the probe for immediate use by the operator (Image 1), and decreased with progressive use of the WUS device.
Conclusions: The use of a wireless probe for vascular cannulation increases safety and efficacy with little impact on workflow. This may help overcome the limitations preventing a more widespread use of this technique in electrophysiology labs.
Image 1
2019 Cars With Manual Transmission
P1058
Predicting intracranial bleeding risk in unselected patients with atrial fibrillation: comparison of several bleeding risk scores
Abstract
Several clinical risk factors have been incorporated into clinical risk stratification schemas for the overall risk of bleeding in patients with atrial fibrillation (AF). However, intracranial hemorrhage (ICH) is a life-threatening complication of anticoagulation and clinicians need to weigh the risk of ICH far more than the risk of all major hemorrhages. The purpose of this study was to evaluate the predictive value of current bleeding risk stratification schemas for ICH and gastrointestinal (GI) bleeding in a cohort of unselected patients with AF.
Methods: Patients with AF were identified in a database and followed up between 2000-2010 for mortality, stroke and bleeding events. We evaluated the predictive value of several risk stratification schemas in this cohort whether patients were treated with anticoagulation or not. Among 8962 patients with AF, 789 severe bleeding events, 126 ICH and 141 GI bleeding events were recorded during a follow-up of 877±1052 days. We compared the predictive value of the HAS-BLED score with 2 other bleeding risk schemas (HEMORR2HAGES, ATRIA) using continuous and categorical (low, moderate and high risk subgroups of patients) analyses.
Results: Severe bleeding, ICH and GI bleeding events occurred more commonly in patients with higher HAS-BLED, HEMORR2HAGES and ATRIA scores. However, HEMORR2HAGES and ATRIA scores as categorical variables were not able to identify a higher risk of ICH. Of the 3 tested schemas, the HAS-BLED score performed best in multivariate analysis, with a stepwise increase in rates of major bleeding (Hazard ratio (HR) 1.17 95%CI 1.07-1.27, p=0.0003) and of ICH (HR 1.26 95%CI 1.03-1.55, p=0.02) with increasing HAS-BLED risk category. HEMORR2HAGES and ATRIA scores were not independent predictors of ICH neither as continuous nor as categorical variables. For GI bleeding, the HAS-BLED score also performed best in multivariate analysis with a stepwise increase in rates of GI bleeding with increasing risk category (HR 1.28 95%CI 1.06-1.55, p=0.01). HEMORR2HAGES was also an independent predictor of GI bleeding as a continuous (but not as a categorical) variable and ATRIA scores was not an independent predictor of GI bleeding neither as continuous nor as categorical variable.
Conclusions: Of the contemporary bleeding risk stratification schemas, the HASBLED scheme offers useful predictive capacity over other published schemas, simultaneously for severe bleeding, ICH and GI bleeding and may be simpler to apply.
P1059
Patient-related factors and the quality of oral anticoagulant therapy with vitamin K antagonists for stroke prevention in atrial fibrillation
Abstract
Purpose: Most atrial fibrillation (AF) patients (pts) receive oral anticoagulant therapy (OAC) with vitamin K antagonists (VKA) for stroke prevention. The quality of VKA therapy is influenced by various clinical and demographic factors, whilst patient-related factors are less well defined. Our objective was to explore patients' preferences and attitude towards VKA therapy and to evaluate whether patient-related factors influence OAC quality, as measured by the time in the therapeutic range (TTR).
Methods: Consecutive AF pts treated by VKA for stroke prevention for ≥1 month prior to study inclusion were recruited from the 2 university centers' out-patient clinics. At inclusion, self-reported data on patients' preferences and attitude towards VKA therapy were collected by a questionnaire. INR (International Normalized Ratio) monitoring and OAC-related consultations with physicians were provided at least once monthly. During follow-up, individual INR data were collected. TTR was calculated by the Rosendaal method. Poor TTR was defined as TTR<60%.
Results: 514 AF pts were enrolled (age: 66.8±10.2 yrs, 63.6% males, mean CHA2DS2-VASc score: 3.2±1.7); 23.3% were OAC-naïve (defined as OAC <6 months). After a median follow-up of 394 days (IQR: 228-788 days), the median TTR was 56.3% (IQR: 37.8%-75.1%). TTR<60% was found in 57.2% of pts. The majority of pts (89.9%) expressed general OAC acceptance, but 24.1% considered OAC to have a negative impact on the quality of life (QoL), mainly due to food limitations (27.9%) and requirements for INR monitoring (22.1%). Despite acceptance of VKA therapy, 79.3% were willing to switch to the novel OAC, while 85.9% were eager to stop any OAC (20.2% without prior consultation with a physician). On multiple regression analysis, adjusted for age, gender, comorbidities, medications, smoking and alcohol intake, OAC-naïve status (OR 4.2; 95%CI,2.0-8.5; P<0.001), and patients' perception of a negative impact of OAC on the QoL (OR 2.8; 95%CI,1.3-6.7; P=0.009) were identified as patient-related multivariate predictors of the poor TTR (C-statistics 0.83; 95%CI,0.76-0.91; P<0.001).
Conclusions: despite high general VKA acceptance in our study, many patients were willing to switch to a more convenient OAC solution, or even to discontinue OAC. Besides OAC-naïve status, we found that patient's personal perception of the QoL during VKA therapy strongly affects TTR. These results might help to identify AF pts who need more encouragement and education during VKA therapy, or an early consideration of alternative treatment strategies for stroke prevention.
P1060
Successive monitoring with seven-day Holter and episodic ECG recorder with automatic transtelephonic ECG transmission for asymptomatic atrial fibrillation in patients with cryptogenic stroke
Abstract
Purpose: Etiology of stroke remains unclear after standard diagnostic work-up in ~30% of patients. This prospective study aimed at investigating the diagnostic role of 7-day Holter monitoring and 4-week monitoring with episodic recorder with automatic detection of arrythmia (ER) and transtelephonic ECG transmission in patients with cryptogenic stroke.
Methods: Patients (n=48) with stroke of unclear etiology within the last 14 days, MRS 0-3, negative TEE for intracardiac thrombus, and sinus rhythm at standard ECG / in-hospital ECG telemetry were included. Following discharge, Holter was applied till diagnosis or for up to 7 days, which in case of no arrhythmia detection was followed by 4-week monitoring with ER (n=35; 8 patients declined ER).
Results: The 48 consecutive patients (46% F, 61±17 years, CHA2DS-2VASc score 3.1±1.8; baseline NIHSS 5.6±3.7), were acutely treated by thrombolysis (25% patients), thrombectomy (5% patients), and dual antiplatelet therapy (70% patients). Holter: During the 5.7±1.4 day monitoring time, AF episodes of mean duration of 21.6±18.7 hours were observed in 5 (10%) patients after 3.6±1.3 days. ER: During the 29.9±6.4 day monitoring time a total of 36471 EKG recordings (1042±1656 per patient) was sent, and AF episodes of mean duration of 5.2±8.6 hours were detected in 4 (8%) patients after 3.7±0.9 days. Frequent atrial premature complexes with short episodes of AF (≤1 minute) were present in another 3 patients.
Conclusion: AF was identified in 9 (19%) patients with cryptogenic stroke. The diagnosis was made within the first two weeks of a maximum 5 week ECG monitoring.
P1061
Effect of high-grade atrioventricular block complicating STEMI in the contemporary era
Abstract
Purpose: Previous studies have reported a reduction of the incidence of high-grade atrioventricular block (HAVB) complicating ST-segment elevation myocardial infarction (STEMI) with contemporary management. However, its adverse prognosis has not decreased. We sought to evaluate the incidence and the impact of HAVB on short-term outcomes of STEMI.
Methods: Using the data of a national multicenter registry, we divided the STEMI patients between Oct 2010 and Oct 2014 (n=4564) in 2 groups: GHAVB: HAVB at any point during the index hospitalization; G0: without HAVB during index hospitalization. The end-point was in-hospital all-cause mortality occurring after HAVB. Logistic regression modelling was used to compute adjusted odds ratio of in-hospital death.
Results: HAVB was present in 274 (6%) patients: 83.5% occurring at presentation day. HAVB complicating STEMI patients were older (70 ± 13 vs. 63 ± 14, p<0.001), less often men (65% vs. 75%, p<0.001) and more likely to have hypertension (72.2% vs. 61.0%, p<0.001) and chronic kidney disease (6.7% vs. 3.2%, p=0.002). They showed worse clinical parameters at initial admission (18.5% vs. 2.7% with Killip class IV). Reperfusion strategy (92.0% vs. 90.7% underwent primary percutaneous coronary intervention (PCI), p=0.505) and symptom-to-reperfusion time (Median: 240 (IQR 166, 394) minutes vs. Median: 250 (IQR 170, 390) minutes, p=0.661) were similar between the two groups. Right coronary artery culprit artery (68.5 vs. 34.2%, p<0.001) and multivessel disease (52.4% vs. 43.8%, p=0.011) were more frequent in HAVB patients. HAVB patients underwent more often temporary pacemaker implantation (59.1% vs. 0.9%, p<0.001). In-hospital all-cause mortality was more common in HAVB patients (26.3% vs. 4.7%, p<0.001) and those with HAVB after the admission day had higher mortality (HAVB admission day: 25.2%; HAVB after admission day: 28.6%, G0: 0.9%, p<0.001). In a multivariable model, HAVB was associated with in-hospital death (OR: 2.37, 95% CI: 1.16-4.85, p=0.018). Anterior STEMI (OR: 2.86, 95% CI: 1.62-5.04, p<0.001), severe left ventricular dysfunction (OR: 3.60, 95% CI: 1.94-6.70, p<0.001) and non PCI (OR: 4.42, 95% CI: 2.39-8.17, p<0.001) were other predictors of in-hospital death. Temporary pacemaker insertion and HAVB occurring after admission day were not associated with in-hospital death.
Bontempi Pm 64 Manual Transmission Problems
Conclusions: In this real-world cohort of the contemporary era, HAVB remains an adverse short-term prognostic marker in the setting of STEMI.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com
Remanufactured Manual Transmissions Online
| Username | Post: 3 Speed Column Shift? (Topic#273553) |
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Val-1962
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| 12-14-11 11:55 PM - Post#2168962
I am looking for some help on transmissions. My question is there any difference between transmission if one is a column shift manual and one is a floor shift manual? Is the linkage the only thing that is different?
Example: I have a 1962 C10 with an i6 and a 3speed 'rock crusher' (term my father used)column shift. I purchase a 3speed out of a 1966 nova floor shift..Will it work?
| king_alcohol
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| 12-15-11 11:01 AM - Post#2169078
In response to Val-1962
Welcome to CT, Val!
Do you want to swap the transmissions, or just convert your column shift to floor shift?
The second option would be a lot less work, but if you decide to swap the transmission, that would be a good time to inspect and possibly replace the clutch if it needs it.
There is some good information on this site about GM manual transmissions http://www.drivetrain.com/parts_catalog/manual_ tra..
I can't say for sure if your replacement transmission would drop in with no modification. Also, the nickname 'Rock Crusher' refers to a Muncie 4 speed M22.
I had a '66 with a 3 speed column shift. When I would come to a stop if i tried to shift into 1st, the gears would grind. Eventually I got the hang of it. I don't know if thats what you are experiencing, or if that makes you want to go through all the work of switching a 3 speed with ..a 3 speed.
~Dave
1966 C10 pickup short fleet Custom, 402ci, 700r4
1988 R20 Suburban, 454ci, TBI, TH400
1980 HD shovelhead hardtail chopper, open primary, kick only |
| Mikey65
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| 12-15-11 08:53 PM - Post#2169271
In response to Val-1962
I think if you are simply changing to another 3 speed transmission, it should just change out. I've noticed on later Saginaw applications where the floor shift linkage bolts to the side of the tranny case. You should be able to just remove that linkage and attach the column shift linkage to the transmission. One thing to keep in mind is that the shift arms on the side of the case may have to change out to work with your setup. For instance, I took a muncie 3 speed out of my 64 (no synchros in first) and replaced it with a 66 Sag with overdrive. It was a bolt in except for the drive line length and the shift arms on the case needed to change out. Don't know if this helps..
| Val-1962
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| 12-15-11 09:18 PM - Post#2169285
In response to Mikey65
Yes it helps allot,
I am not really trying to do any upgrades just replace the original one. I plan on rebuilding it but would like to have an extra in case I make a mistake on the rebuild.. This was my father’s truck and he recently passed away and was unable to finish the restoration on it. The only upgrade he had planed on making to the truck was changing out the inline 6 to a 283 v8… but that is project I will tackle later. Right now I just want to get it back up and running and finish the body repairs and the installation of the new wooden bed
| LILRED66
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| 12-16-11 06:42 AM - Post#2169326
In response to Val-1962
The rockcrusher is commonly known as the granny-low 4-speed and it is a top-loder, truck transmission, shifter on the top of the case. The 3-speed manual truck transmissions are side-loaders, shifter on side of tranny case. The 3-speed & 4-speed car transmissions are commonly top-loaders, so, although interchangeable, it is not a direct swap, as it relates to the shifing method & shifter linkage.
Tony Smith
4-5-6chevytrucks@sbcgloba l.net (e-mail)
http://www.flickr.com/photos/4-5-6chevytruc ks/sets.. (lots of photos)
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| hilandr451
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| 12-16-11 06:52 PM - Post#2169529
In response to LILRED66
Well, I'm no transmission guru, but I always thought the Muncie M22 was the 'rock Crusher' as well. That's what we called it back in the day anyway. I had one in my '70 Firebird I owned back in 1980-81.
All 3 speeds pre-1975 GM auto or truck, to my limited knowledge (which is up to 1975), are side loaders.
-The Hilander.
Silver 2017 Silverado 1500 double cab 2WD 5.3L,
1966 C20 Custom Camper 'Rattle can primer red' 5.7L, 700 R4 trans 410 diff. front disc, p/s
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| Val-1962
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| 12-16-11 07:48 PM - Post#2169547
In response to Val-1962
I was able to get some numbers off the transmission but i am unable to find and codes that match
on the trans.. 3799193 GM7 L281
On the shaft right behind the trans .. T GM28 L9 3707195
| king_alcohol
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| 12-17-11 09:17 AM - Post#2169681
In response to hilandr451
Me too.. we always called the m22 the rock crusher, it usually denoted high performance.
http://www.yearone.com/updatedsinglepages/id _info/..
1966 C10 pickup short fleet Custom, 402ci, 700r4
1988 R20 Suburban, 454ci, TBI, TH400
1980 HD shovelhead hardtail chopper, open primary, kick only |
| Val-1962
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| 12-17-11 08:28 PM - Post#2169864
In response to Val-1962
Well I was able to identify the transmission, it is not a “Rock Crusher” it is a 3 speed Saginaw non synchronized. Seems a bearing had gone bad in the transmission causing the grinding noise…
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Bontempi Pm 64 Manual Transmission
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