(UCLA), Los Angeles, United States of America; and 3Indiana University .... Medical, Inc., Sylmar, Ca, United States of America; and 4Thoracic Cardiovascular.
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10.1093/europace/eut174
POSTER SESSION 4 Atrial fibrillation
P928
P929
Dynamics of main ECG characteristics after conversion of persistent atrial fibrillation and flutter by new class III antiarrhythmic agent niferidile
Antazoline for rapid termination of atrial fibrillation during ablation of accessory pathways
Y.U. Yuricheva, S. Sokolov, S. Golitsyn, E. Maykov, N. Mironov, L. Rosenshtraukh, and E. Chazov
R. Piotrowski1, T. Krynski1, J. Baran1, P. Futyma2, S. Stec1, and P. Kulakowski1 1
Grochowski Hospital, Postgraduate Medical School, Department of Cardiology, Warsaw, Poland; and 2St. Joseph Invasive Cardiology Department, Rzeszow, Poland
Cardiology Research Center, Moscow, Russian Federation Niferidile (NF) is new Russian class III antiarrhythmic agent. Electrophysiological studies showed, that NF increased refractory periods much higher in atria than in ventricles, didn’t influence parameters of sinus function, intra-, interatrial and AV-conductance. Aime: to study effects of NF 10, 20 and 30 mg/kg at main ECG characteristics (QT, QTc, QRS, ff and RR intervals) after conversion of persistent atrial fibrillation (AF) and flutter (AFL) to sinus rhythm (SR). Methods: 100 pts (64 male), age 58 + 12 years, with arrhythmia lasting 4,2 + 3,9 months (1 week- 24 months) were included. 82 pts had AF and 18 AFL. Holter ECG recorder was activated 1 h before NF infusion. NF was administered as 3 i.v. bolus injections (10 mg/kg each) performed with the 15-min interval. If SR was restored within 15 min after injection, the next injection was cancelled. Successful conversion was defined as restoration of SR within 24 h after beginning of the treatment. Results: Cardioversion success rate of NF in dose of 10 mg/kg was 49%, in dose of 20 mg/kg it was 65%, and in dose of 30 mg/kg reached 88%. In 1 patient after infusion of 10 mg/kg of NF QT interval prolongated up to 700 ms and unsustained runs of polymorphyc ventricular tachycardia of 3-9 complexes were registrated during 15 min. This patient converted to normal SR in 22 h after NF infusion. Mean QT and QTc after NF infusion prolongated in dose-dependent manner. QT returned to normal meanings within 3 h in pts, who received 10 mg/kg and only within 22-23 h in pts, who received 20 or 30 mg/kg of NF. QTc interval in pts, who received 10 mg/kg reached normal value after 21 h and didn’t return to normal meanings till the end of observation period in those who received 20 or 30 mg/kg. QT and QTc intervals in pts, who was given 20 or 30 mg/kg of NF, didn’t differ significantly among themselves and exceeded appropriate meanings of those pts, who got 10 mg/kg of NF during all period of monitoring. NF caused increase of ff length, frequent transformation of AF to AFL, which typically preceded SR restoration. RR intervals after SR restoration didn’t differ significantly between 3 groups of pts within 24 h. No effect was noted on the duration of the QRS interval in pts received different doses of NF. Conclusions: NF causes dose-dependent moderate prolongation of mean QT and QTc, doesn’t influence RR and QRS intervals, regulates atrial activity and increases ff duration. I.v. NF in doses up to 30 mg/kg seems to be very effective in conversion of patients with persistent AF and AFL and proarrhythmic events are rare.
Atrial fibrillation (AF) may occur during ablation of accessory pathway (AP), making procedure more difficult or impossible to perform due to intermittent preexcitation, electrode instability or inability to map the atrial insertion of the accessory pathway (AP). Antiarrhythmic drugs may terminate AF and enable ablation. Antazoline is an antihistaminic agent with antiarrhythmic quinidine-like properties which potentially can be used in this setting. The aim of our study was to assess safety and efficacy of antazoline for termination of AF occurring during ablation of AP. We analyzed electrophysiological mechanisms of antazoline (changes in A-A interval and morphology following drug injection, recorded from the coronary sinus) and the percentage of preexcited QRS complexes before and after antazoline administration. The total dose administered and the time from the start of injection to sinus rhythm restoration were also measured. Out of consecutive 290 patients with WPW syndrome undergoing RF ablation, 12 (4.1%) (4 females, mean age 36þ/-20 years) developed AF which did not stop spontaneously and antazoline in 100 mg repeated boluses was administered intravenously. In all 12 patients the drug safely and promptly restored sinus rhythm after a mean of 425þ/-365 sec (range 43 –1245 sec) using a mean cumulative dose of 176þ/-114 mg (range 25 – 400 mg). The drug slightly prolonged R-R intervals during AF (from 383þ/-106 to 410þ/-70 ms) and reduced the percentage of fully preexcited QRS complexes (from 28% to 16%). Intracardiac recordings showed gradual increase in A-A intervals as well as regularization and decreasing fractionation of atrial activity following drug injection (mean A-A interval of 162þ/-30 ms at baseline vs 226þ/-26 ms shortly before sinus rhythm restoration, p , 0.001). Although the drug reduced the degree of preexcitation, AP was not completely blocked in any patient which enabled continuation of ablation. In conclusion, antazoline safely and rapidly converts AF into sinus rhythm during ablation of AP. Although the drug prolongs refractory period of AP, it does not block AP completely, enabling continuation of ablation. The drug gradually increases A-A intervals during AF converting it into more organized atrial activity (atrial flutter/tachycardia) before sinus rhythm resumption. On-going multicenter randomized studies will establish the role of antazoline in acute AF termination.
P930
Chronic amiodarone therapy impairs the function of the superior sinoatrial node in patients with atrial fibrillation H.S. Mun, J. Wi, J.S. Uhm, J. Shim, M.H. Lee, H.N. Pak, and B. Joung Cardiology Division, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea, Republic of Purpose: The mechanisms underlying amiodarone-induced sinoatrial node (SAN) dysfunction remain unclear. This study was performed to reveal the mechanisms of SAN dysfunction caused by amiodarone using 3-dimensional right atrial (RA) endocardial mapping. Methods: In a matched-cohort design, 18 patients taking amiodarone before atrial fibrillation (AF) ablation (amiodarone group) were matched for age, sex and type of AF with 18 patients who have undergone AF ablation without taking amiodarone (no amiodarone group). The mean duration and cumulative dosage of amiodarone was 145 (89-221) days and 28,989 (17,667-43,739) mg, respectively. Results: Amiodarone group had slower heart rate than no amiodarone group at baseline and during isoproterenol infusion. Only amiodarone group had sick sinus syndrome (N=4, 22%, p=0.03) and abnormal (.550 ms) corrected SAN recovery time (N=5, 29%; p=0.02). The median distance from the superior vena cava (SVC)-RA junction to the most cranial earliest activation site (EAS) was 10.6 (25-75 percentile range, 3.4-15.1) mm and 20.5 (10.8-25.5) mm at baseline ( p=0.04), and was 6.3 (1.5-11.5) mm and 12.8 (3.5-20.9) mm during isoproterenol infusion ( p=0.03) for no amiodarone and amiodarone groups, respectively. The distances from the SVC-RA junction to the most cranial EAS were negatively correlated with the P-wave amplitudes of leads II (r = -0.47), III (r = -0.60) and aVF (r = -0.56) ( p , 0.001 for all). Conclusions: Amiodarone therapy in AF patients causes superior SAN dysfunction, which results in downward shift of the EAS and reduced P-wave amplitude in leads II, III and aVF at baseline and during isoproterenol infusion.
P931
Hyperuricacidemia as an Independent Predictor for Paroxysmal Atrial Fibrillation T. Liu, Y. Wu, G. Xu, R. Yuan, and G. Li Second Hospital of Tianjin Medical University, Tianjin, China, People’s Republic of Purpose: Uric Acid (UA) is a cardiovascular risk marker associated with oxidative stress and inflammation. Recently, Atrial Fibrillation (AF) has been associated with inflammation and oxidative stress. The objective of this observational study was to investigate the association between UA levels and paroxysmal AF. Methods: Consecutive patients with paroxysmal AF who were hospitalized in the Second Hospital of the Medical University from September 2011 to May 2012 , were screened in this study, We excluded subjects with acute coronary syndrome, congestive heart failure, valvular heart disease, congenital heart disease, congenital heart disease, cardiomyopathy, acute inflammatory conditions, thyroid dysfunction. The final study population consisted of 106 patients, 65 patients with paroxysmal atrial fibrillation were finally enrolled, and 41 age, sex matched-subjects without AF were served as the control group. The baseline clinical data and laboratory examinations results were detected, Left Atrium Diameter (LAD), Left Ventricular EndDiastolic dimension (LVEDD) and Left Ventricular Ejection Fraction (LVEF) were determined by 2D-echocardiography. Results: On univariate analysis, serum UA, LAD, LVEF, urea nitrogen and estimated glomerular filtration (eGFR) level were significantly increased in patients with paroxysmal AF compared with controls. After multivariate logistic regression analysis, the serum uric acid level (OR: 5.935, p , 0.05) and LAD (OR: 1.144, p , 0.05) were independent risk factors for the occurrence of paroxysmal AF. Conclusions: We demonstrated hyperuricacidemia is an independent risk factor for the development of paroxysmal AF. Future larger studies should further evaluate this potential association as well as the underlying mechanisms.
Published on behalf of the European Society of Cardiology. All rights reserved. # The Author 2013. For permissions please email: journals.permissions@ oup.com
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P932
P933
Adherence to anticoagulation guidelines in non-valvular atrial fibrillation patients remains poor despite admission to a tertiary cardiology unit Heterogenesity of breakthrough from right atrium to superior vena cava: implication for safe superior vena cava isolation
G.S. Kew1, MABEL. Tan1, and T.W. Lim2 1
National University of Singapore, Yong Loo Lin School of Medicine, Singapore, Singapore; and 2National University Heart Centre, Department of Cardiology, Singapore, Singapore
Background: Atrial fibrillation (AF) is a well known cause of strokes and all major society guidelines recommend oral anti-coagulants such as vitamin K antagonists (VKA) for patients with concomitant risk factors to prevent them. However, compliance with these guidelines is historically poor. Methodology: A retrospective review of all patients admitted into a tertiary cardiology unit from January to March 2010 was conducted to identify patients with atrial fibrillation or flutter. These patients were followed for 20 months after discharge for adverse outcomes related to AF Results: Of 1826 unique cardiac patients screened, there were 163 (8.9%) with non-valvular AF or atrial flutter (mean age: 69.8 + 13.3 years; 58.9% male). AF was previously diagnosed in 119 (73.0%) patients and of these 54 (45.3%) were on warfarin, but 22 (40.7%) of them had an INR within the therapeutic range (INR ,2 in 22 [40.7%] and .3 in 10 [18.5%]). An admission diagnosis of AF or atrial flutter was made in 45 (27.6%) patients. Mean CHADS2 score was 2.33 +1.50. Of the 119 patients with CHADS2 2, only 46 (38.7%) were discharged with warfarin. Common reasons for not starting patients on VKA include history of bleeding (n= 24, 32.9%), no reason documented (n= 17, 23.3%) and patient preference (n= 12, 19.2%). Among patients with CHADS2 1 (n=44), 16 (36.4%) were on warfarin. Prior to admission, 50 patients had AF with CHADS2 2 and were not on VKA. Of these, 8 (16.0%) were offered warfarin on discharge, compared to 15 (55.5%) out of 27 patients with newly diagnosed AF, who were more likely to be offered VKA (OR=6.56, p=0.001) The choice of alternative drug therapy in patients not on VKA (n=109) was aspirin (n=63, 57.8%) and clopidogrel (n=29, 26.7%). Ischemic stroke was found in 14 (8.5%) patients 20 months post discharge, and only 1 (7.1%) patient was on VKA. Patients discharged with warfarin were less likely to have a stroke (OR=0.11, p=0.036). Conclusions: Few patients who require anticoagulation receive it in accordance with guidelines even among patients admitted to a tertiary cardiology unit. Even if patients were on VKA, majority of them had an INR outside the therapeutic range on admission. There are many impediments to the effective use of VKA for stroke prevention among patients with AF.
A. Suzuki1, Y. Yamauchi2, A. Yagishita2, H. Sato2, T. Miyamoto2, T. Obayashi2, S. Umezawa1, A. Niwa1, K. Hirao3, and K. Aonuma4 1 Hiratsuka Kyosai General Hospital, Kanagawa, Japan; 2Musashino Red Cross Hospital, Department of Cardiology, Tokyo, Japan; 3Tokyo Medical and Dental University, Department of Cardiology, Tokyo, Japan; and 4University of Tsukuba, Department of Cardiology, Ibaraki, Japan
Introduction: Recent report demonstrated that the number of breakthroughs from the right atrium(RA) to superior vena cava(SVC) was relatively small. Some reports also suggested the heterogenesity of SVC sleeve and lesser myocardium in posterior aspect in animal model. Methods: We evaluated consecutive 40 patients with atrial fibrillation who underwent SVC isolation. After successful pulmonary vein isolation, SVC isolation were performed because of longer SVC sleeve than 30mm or documentation of SVC trigger. To indicate the breakthrough location(divided into four aspects: septal, anterior, lateral, and posterior), electroanatomical mapping were performed using CARTO system during SVC isolation targeting the regions showing the earliest activation. Results: The first earliest activation site before ablation were septal site in 26 of 40 patients(65%). All of 40 patients(100%) had septal breakthrough, while anterior, lateral, and posterior breakthrough in 36(90%), 36(90%), and 30(75%) patients, respectively. 38(95%) patients achieved SVC isolation by segmental ablation with the maximum power setting of 25 watts. Only two patients(5%) needed whole SVC circumferential ablation to achieve SVC isolation. No patient failed to obtain SVC isolation. 11 patients(27.5%) needed radiofrequency application to the site of phrenic nerve capturing. All of 11 patients successfully achieved SVC isolation without phrenic nerve injury by using low power setting of 15 to 20 watts. Conclusions: SVC isolation could be safely obtained by understanding its heterogenesity and using low power application.
P934
Mapping and ablation of atrial tachycardia after valve surgery plus miniMAZE procedure
P935
Long-term success can be achieved with duty-cycled circular multipolar radiofrequency ablation after a failed cryoballoon ablation in paroxysmal or persistent atrial fibrillation
Y.M. Xue, X.Z. Zhan, H.T. Liao, X.H. Fang, H. Deng, W. Wei, and S.L. Wu A. Kiss, E. Nagy-Balo, I. Edes, and Z. Csanadi
Guangdong Cardiovascular Institute, Guangzhou, China, People’s Republic of University of Debrecen, MHSC-Faculty of Medicine, Institute of Cardiology, Debrecen, Hungary
Objective: To study the mapping methods and analyse the mechanisms of atrial tachycardias(AT) in patients after valve surgery plus mini-MAZE procedure and eliminate the arrhythmias by catheter ablation. Methods: Twenty-eight patients (14 males, mean age 48 + 11 ys) with post-MAZE AT refractory to antiarrhythmic drugs(AADs) were included. They underwent the mini-MAZE procedure for atrial fibrillation in addition to mitral valve surgery. There were 10 patients undergoing concomitant aorta valves replacement and one patient with complex congenital heart disease undergoing atrioseptoplasty and epithesis for double-outlet of right ventricle. Electrophysiological studies were guided by CARTO system (13 patients), Ensite system (14 patients) or conventional mapping method (one patient). Results: The patients were presented (578 + 357)days after the surgery. One patient with sinus bradycardia had recurrent incessant atrial tachycardia(AT), but the AT was terminated by catheter position and never could be induced any more. She underwent a repeat procedure but failed just as the course in the first time, and was treated with DDDR pacemaker plus amiodarone. Twentyseven patients had 41 kinds of stable AT, including 13 around mitral valve annulus, eleven around tricuspid valve annulus, six related to pulmonary veins or antrum, four related to roof line of left atrial(LA), two at the basis of left atrial appendage, one at anterior wall of LA, three related to right atrial incision and one at upper crista terminalis. Thirty-six kinds of AT(87.8%) were eliminated and by catheter ablation. Five patients (the 3rd, 5th, 7th, 11th, 21th patient respectively) with macro-reentry AT around mitral valve annulus could not be treated. They underwent cardioversion and 3 patients maintained sinus rhythm with amiodarone. After a median of 636 days(72˜1561days) of follow-up, nineteen patients were arrhythmia free without AADs. One had recurred AT and 2 had paroxymal atrial fibrillation. No procedure related complications occurred. Conclusions: The recurrent AT after mini-MAZE mostly related to mitral valve and tricuspid valve. Catheter ablation could effectively eliminate the arrthythmias. Ablation aimed to blocking mitral isthmus after valve replacement was difficult and need to proceed a “learn-curve”.
Purpose: Cryoballoon (CB) and multipolar circular radiofrequency (RF) pulmonary vein ablation catheters (PVAC) have been introduced into clinical practice to simplify pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Short- and mid-term results reported with each of these single-shot technologies were comparable to those achieved with point-by-point RF ablation. However, the efficacy of these simplified techniques long-term and with a consecutive, combined use has not been established. We evaluated the long-term success rates achieved with the PVAC ablation performed as a redo procedure for arrhythmia recurrence after an initial CB ablation. Methods: Patients who had a PVAC ablation as a redo procedure for atrial arrhythmia recurrence at least 3 months after a failed initial CB ablation were included in the study. All patients had at least 3 months follow-up after the PVAC ablation. Patients were monitored for atrial arrhythmia recurrence using ECG Holter and event recorder. Initial success rate was calculated with a 3-month blanking period. Results: Redo ablation with the PVAC was performed in 32 patients (8 female, age:55 + 13) with paroxysmal (n=25) or persistent (n=7) AF. Full isolation of the PVs were achieved in all patients. 25 of 32 (78%) patients remained free of atrial arrhythmia during a 17,5 +11,7 months FU. (See figure). All arrhythmia recurrences were observed within but none beyond 1 year after PVAC ablation. Conclusion: The consecutive use of different single-shot ablation techniques can provide a high long-term success rate in patients with paroxysmal or persistent AF.
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P936
P937
Impact of atrial fibrosis on wave propagation in human atrial fibrillation evidence for regional channel, pivot, slow conduction at delayed enhanced sites Transseptal approach for ablation of left sided arrhythmias without routine use of intracardiac echocardiography
A. Jadidi1, S. Kim2, H. Cochet3, H. Lehrmann1, C.I. Park1, S. Miyazaki3, M. Haissaguerre3, P. Jais3, and T. Arentz1 1
Universitaets-Herzzentrum Freiburg-Bad Krozingen, Arrhythmia Department, Bad Krozingen, Germany; StJMed, St. Paul, MN, Saint Paul, United States of America; and 3Hoˆpital Cardiologique du Haut-Le´veˆque, Universite´ Victor Segalen Bordeaux II, Bordeaux, France
2
M. Jensen-Urstad1, H. Bastani1, F. Braunschweig1, N. Drca1, K. Gudmundsson1, G. Kenneback1, J. Schwieler1, F. Tabrizi2, J. Tapanainen1, and P. Insulander1 1 Karolinska University Hospital, Department and 2Arrhythmia Center, Stockholm, Sweden
of
Cardiology,
Stockholm,
Sweden;
Background: The transseptal approach is used for ablation of atrial fibrillation (AF) but may also be used as an advantageous alternative to the retrograde approach for ablation of other left sided substrates. Methods: 2551 consecutive transseptal procedures between 2000 and 2011 were included. 1529 were AF ablations, 1015 ablations of left sided supraventricular tachycardias and 37 ablation of ventricular tachycardias. The procedures were done by 11 different electrophysiologists and included the learning curve for all of them. The punctures were done under fluoroscopy, pressure monitoring, and commonly with contrast injection from the transseptal needle. For 18 procedures intracardiac echo (ICE) was used to guide the transseptal puncture. Results: A total of 16 tamponades (Tx) requiring pericardial drainage were registered. All Tx were treated successfully. 13 were possibly related to the transseptal puncture while 3 were not. No other serious complications were registered. This gives a complication rate of 0.5 % (0.6 % for all Tx). 10 Tx were encountered during the electrophysiologists first 100 punctures (complication rate 1%) and 3 after the first 100 (complication rate 0.2 %). Tx in relation to substrates: AF 10 (0.7 %), supraventricular tachycardias 1 (0.1 %), and VT 1 (2.7 %). Conclusion: Transseptal puncturing can safely be done under fluoroscopy and pressure monitoring without routine use of ICE.
Introduction: We assessed the impact of atrial fibrosis (delayed enhancement MRI (DE)) on AF wave propagation in pts with persistent AF. Methods: LA sites of dense DE and patchy DE at MRI of 10 patients (64þ/-6yo, 7 long persist. AF) were segmented/registered with the LA NavX geometry, to assess propagation during AF at sites of dense vs patchy vs no DE. AF wavelets were mapped at DE and CFAE boundaries using 2 high density 40-pole catheters, allowing to map simultaneously a surface area of 30cm2 (AFocus II, SJM and Pentaray, BW). In each LA region, we categorized wave propagation by evaluation of 10 AF beats: 1. slow conducting channels, 2. pivots, 3. wave collision and 4. conduction block. In addition, the mean regional beat-to-beat conduction velocity was assessed during AF. Results: A total of 300 AF beats were analysed at dense DE, patchy DE and non-DE LA regions. Wave propagation during AF differed significantly: At dense DE areas and their borders, 74% of wavelets showed slow conduction (0.1- 0.5m/s) with evidence of pivot and channel conduction. At dense DE, we found functional collisions at 21% of mapped beats. Regions without dense DE correlate to continuous CFAE sites and show higher conduction velocity (0.62- 0.85m/s, p , 0.01) with evidence of functional wave collision at 41% of mapped AF waves/beats (p , 0,05). Less than 20% of dense DE areas display continuous CFAE. Mean EGM voltage is lower at dense DE vs other sites (0.63þ/- 0.5mV vs. 0.85þ/-0.7mV, p , 0.001). Conclusions: A minority of DE regions display continuous CFAE. Slow conduction, channel and pivoting occur with high frequency at LA sites with DE. These sites may represent the arrhythmogenic atrial substrate in patients with persistent AF.
P938
P939
Prevalence of unidentified risk factors in patients with apparently lone atrial fibrillation: a case-control study Extracellular matrix alterations in patients with paroxysmal and persistent atrial fibrillation. biochemical assessment of collagen type I turnover I.S. Saloustros, EK. Kallergis, E.K. Kanoupakis, H.M. Mayrakis, S.P. Petousis, M.V. Vernardos, and P.V. Vardas, E.KALLERGIS University Hospital of Heraklion, Department of Cardiology, Heraklion, Greece Purpose: Structural alterations and fibrosis have been implicated in the generation and perpetuation of AF. We investigated whether the serum markers of collagen turnover differed in various forms of atrial fibrillation (AF) and in sinus rhythm (SR) in humans. Methods: Serum C-terminal propeptide of collagen type I (CICP), C-terminal telopeptide of collagen type I (CITP), matrix metalloproteinase-1 (MMP-1), and tissue inhibitor of matrix metalloproteinases-1 (TIMP-1) were measured as markers of collagen synthesis and degradation in 70 patients with AF and 20 healthy controls in SR. Results: CICP and CITP were significantly higher in AF patients than in controls (91.37 + 27.26 ng/ml vs. 67.30 + 11.05 ng/ml, p , 0.001 and 0.38 + 0.20 ng/ml vs. 0.25 + 0.08 ng/ml, p , 0.001, respectively). Persistent AF patients had higher levels of CICP, but not CITP, compared to those with paroxysmal AF, (105.06 + 27.57 ng/ml vs. 79.84 + 21.23 ng/ml, p , 0.001). Patients with persistent AF had lower levels of MMP-1 but increased levels of TIMP-1 compared with patients with paroxysmal AF, (11.90 + 4.79 ng/ml vs. 14.98 + 6.28 ng/ml, p=0.03 and 154.90 + 44.91 ng/ml vs. 129.75 + 37.92 ng/ml, p , 0.001, respectively). TIMP-1 levels were significantly lower in control subjects compared with both paroxysmal and persistent AF patients (102.10 + 15.13 ng/ml vs. 129.75 + 37.92 ng/ml vs. 154.90 + 44.91 ng/ml, respectively, p , 0.001). Conclusions: Serum markers of collagen type I turnover differed significantly between patients with AF and SR. Furthermore these markers also differed significantly between paroxysmal and persistent AF patients, suggesting that the intensity of the extracellular synthesis and degradation of collagen type-I may be related to the burden or type of AF.
N. Calvo, P. Ramos, S. Montserrat, B. Coll-Vinent, M. Domenech, R. Borras, A. Berruezo, M. Sitges, J. Brugada, and L. Mont Hospital Clinico Universidad de Barcelona, Barcelona, Spain Background: In up to 30% of patients with Atrial Fibrillation (AF) its aetiology remains unknown. Our aim was to identify new risk factors of lone AF (LAF). Methods: This was a 2:1 case-control study which included cases with LAF and healthy controls matched by age and sex. Clinical and anthropometric variables were recorded. Berlin questionnaire (screening tool to identify Obstructive Sleep Apnea syndrome (OSA)), a polysomnography in patients with high risk for OSA, an echocardiography, a questionnaire to assess lifetime exercise activity, and 24h Ambulatory Blood Pressure monitoring were performed. Serum levels of CRP, IL1b, IL 6, IL9, MMP-2, Timp-1, ANP and BNP were determined. Results: A total of 114 cases and 57 controls were enrolled. Cases were taller than controls (OR 1.06 [CI 95% 1.01 - 1.11] ), had a larger waist circumference (OR 1.06 [CI 95% 1.02 1.11], larger indexed left atrial size (OR 1.16 [CI 95% 1.07 - 1.25] ) and higher levels of ANP (OR 1.03 [CI 95% 1.01 - 1.04]) and BNP (OR 1.04 [CI 95% 1.01 - 1.06]). OSA was a risk factor for LAF (OR 5.041 [CI 95% 1.44-17.45]).Sport practice was not a risk factor for AF (OR 0.73 [CI 95% 0.35 -1.56]). However, a cumulated endurance sport heavy activity of more than 2000h was associated with AF (OR 4.52 [CI 95% 1.83 - 11.14]). Conclusion: Height, LA size, waist circumference, and OSA are risk factors for lone AF. Low intensity sport activity does not increase the risk of FA, but a cumulated endurance sport activity of more than 2000h hours is a strong predictor of AF.
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P940
Focal impulse and rotor modulation (FIRM) for atrial fibrillation is successful even in patients with unfavorable demographics for conventional ablation
P941
Short term results of left atrial appendage exclusion with Lariat in patients with atrial fibrillation and contraindications for anticoagulation
T. Baykaner1, P. Clopton1, D. Krummen1, A. Schricker1, G. Lalani1, K. Shivkumar2, J. Miller3, and S. Narayan1, The CONFIRM Study Group
M.G. Chelu1, A. Nazeri1, S.A. May1, H. Afshar-Kharaghan2, M. Saeed1, M. Razavi1, A. Rasekh1, and A. Massumi1
1
1
University of California and VA, San Diego, United States of America; 2University of California Los Angeles (UCLA), Los Angeles, United States of America; and 3Indiana University School of Medicine, Indianapolis, United States of America
Background: Atrial Fibrillation (AF) ablation is less successful in patients with hypertension, left atrial (LA) dilation, heart failure, obesity and sleep apnea (OSA), but for unclear reasons. We hypothesized that these demographics increase the number or relocate stable AF rotors and focal sources, but that Focal Impulse and Rotor Modulation (FIRM) should still be successful as it targets AF sources regardless of location or number. Methods: In this prespecified analysis of CONFIRM, 107 AF patients (76 persistent, 62+9 years) received conventional ablation without (n=71) or with FIRM (n=36). Patients were evaluated quarterly for recurrent AF (implanted ECGs: 88% FIRM-guided patients; 44% overall). Results: Stable sources arose in 97% patients (2.1 + 1.0 each). Numbers of concurrent AF sources rose with BMI ( p , 0.001) and LA diameter ( p=0.014), falling LV ejection fraction (p=0.02), OSA ( p=0.016) or diabetes mellitus ( p=0.039). Right atrial sources were predicted by obesity (BMI 30 p , 0.001) and persistent AF ( p=0.06). Freedom from AF was higher for FIRM vs conventional patients for each demographic (table). Patients with obesity (BMI 30 vs ,30), OSA, hypertension, and severe LA enlargement (47 mm) had .70-80% single procedure success from FIRM versus 35-50% from conventional ablation (P , 0.05). Conclusion: FIRM ablation is consistently successful in AF patients with obesity, hypertension and sleep apnea. These demographics are associated with greater numbers and right atrial sources, explaining the lower success of conventional LA ablation. FIRM identifies sources directly regardless of location or number.
Characteristic
FIRM. Freedom from AF
Conventional. Freedom from AF
P
Obesity (BMI . 30) Obstructive Sleep Apnea Paroxysmal AF Persistent AF Heart Failure Diabetes Mellitus Hypertension Left Atrium .47 mm
91% 85% 83% 82% 71% 73% 87% 78%
46% 39% 63% 36% 50% 55% 46% 33%
,0.001 ,0.001 0.63 ,0.001 0.46 0.47 ,0.001 0.01
Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, United States of America; and 2Baylor College of Medicine, Houston, United States of America
Purpose: Atrial fibrillation (AF) is associated with a 5-fold increase in thromboembolic stroke risk. Left atrial appendage (LAA) closure may reduce the risk of thromboembolic events in AF, because the LAA is the main source of emboli. The purpose of this study was to evaluate the safety and short-term efficacy for stroke prevention of a novel percutaneous LAA closure device in patients with AF and contraindications to anticoagulation therapy. Methods: Percutaneous LAA exclusion with the Lariat snare device was attempted in 36 patients with AF, a CHADS2 score of 2 or more (CHADS2 score 3.3 + 1.4), and contraindication to anticoagulation (HAS BLED score 3.6 + 1.0). Access to the inside and outside of the LAA was obtained by transseptal and epicardial access, respectively. Two magnet-tipped wires adjoined from within the LAA and pericardial space were used as a rail to advance a snare, containing suture, over the LAA base from within the pericardial space. The snare was deployed to close the LAA, guided by a contrast-filled balloon placed at the LAA os. The short-term success of the procedure was confirmed by left atrial angiography and transesophageal echocardiogram (TEE) color Doppler flow. The persistence of the LAA closure was evaluated by follow-up TEE. The incidence of periprocedural and short-term complications was assessed by review of medical records. Results: Left atrial appendage exclusion was achieved in 33 patients and was maintained at 83 + 67 days. The procedure could not be completed in 3 patients because of pericardial adhesions. Two patients had right ventricle perforation requiring surgical exploration and repair. Three patients required prolonged hospitalization: 1 because of pericardial effusion requiring repeat pericardiocentesis and 2 because of noncardiac comorbidities. Six patients developed pericarditis within 1 month of the procedure; 2 of these patients also had associated pericardial effusion requiring drainage. None of the patients had a stroke at 339 + 183 daysa’ follow-up. Conclusions: Persistent LAA closure can be achieved percutaneously in the majority of patients with an acceptable incidence of complications. Additional studies are needed to determine whether LAA exclusion results in long-term risk reduction for thromboembolic events in patients with AF and contraindications to anticoagulation.
P942
P943
Atrial fibrillation prevalence, incidence, clinical outcomes and related hospitalization costs in a modern pacemaker population B. Faulknier1, M. Richards2, W. Hou3, J.D. Snell3, N. Dalal3, and R.K. Thakur4, The BRADYCARE Investigators
Correlation of vascular wall stiffness with the left atrial size in hypertensive patients with atrial fibrillation
1
West Virginia University Physicians of Charleston, Charleston WV, United States of America; 2 Northwest Ohio Cardiology Consultants, Toledo, OH, United States of America; 3St. Jude Medical, Inc., Sylmar, Ca, United States of America; and 4Thoracic Cardiovascular Healthcare Foundation, Lansing, MI, United States of America Introduction: Atrial fibrillation (AF) has long been recognized as a risk factor for morbidity and mortality. There are few studies that have reported prevalence, incidence or the impact of AF on healthcare costs (HCs) and clinical outcomes in a modern pacemaker (PM) cohort. Methods: The BRADYCARE Registry is a multicenter observational study of PM patients ( pts). For this analysis, pts receiving a new, non-CRT, St Jude Medical PM were included. At enrollment pts provided detailed baseline pt characteristics and histories. Planned follow-up was every 6 months for 1 year. Hospitalizations (hosps), deaths and other measures, such as the clinical diagnosis of new AF, were monitored. The combined outcomes (CO) of all-cause hosp and death for the two groups were compared using a Cox proportional hazards regression model after a univariate analysis to identify significant covariates. HCs were determined in 2011 US dollars for all cause hosps based upon Medicare reimbursement available to each facility for associated Diagnosis Related Group (DRG) codes for inpatient hospital services and Ambulatory Payment Classification (APC) codes for outpatient services using MediRegs software (Wolters Kluwer, Boston, MA.) Results: The cohort of 2,982 PM pts (75 + 11 yrs, 54% male, with primary indications: 25% AV block and 67% sinus node disease, 47% with a prior history of AF, 12% single chamber, 88% dual chamber PM) were analyzed. Over mean 12.1 +3.6 months, 402 (14%) pts were hospitalized, 320 (10.7%) pts were diagnosed with new AF, and 177 (5.9%) died. The CO of allcause hosp or death was higher for pts with a history of AF compared to those without (21% vs. 13%, P , 0.01. When adjusted for age and SAS score, the combined endpoint yielded a Hazard Ratio of 1.4 (95% CI: 1.2 – 1.7, P ,0.01). The mean all cause hosp HC over the study period for pts with a history of AF was $1,336, 1.42 times higher than that compared to those of pts without a history of AF, $943 (P , 0.01). Conclusions: Nearly half of pacemaker patients in this study had a prior history of AF, and another 11% developed AF during a short period of follow-up. Even after adjusting for relevant comorbidities, pts with a history of AF incur increased risk of all-cause hosp and death, and 42% greater all cause hospitalization healthcare costs compared to those without AF.
L. Mohammadi, V. Podzolkov, A. Tarzimanova, and M. Pisarev I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation Objectives: To study the correlation between vascular wall stiffness and left atrial size in hypertensive patients with atrial fibrillation (AF). Materials and methods: The study included 80 hypertensive patients. Thirty four of them had persistent AF (I group); 16 had permanent AF (II group), and 30 were in sinus rhythm (control group). To evaluate the vascular wall stiffness, computed oscillometric brachial artery blood pressure measurement was performed in all the patients. Systemic hemodynamic variables, pulse wave velocity (PWV), and systemic vascular resistance (SVR) were measured. Heart structure and function were assessed using M-and B-mode echocardiography images (Acuson Aspen, USA). Results and discussion: Pulse wave velocity was found to be significantly higher both in patients with persistent AF (0.95 + 0.07 m/s) and with permanent AF (1.02 + 0.1 m/s) compared with the control group (0.90 + 0.24 m/s, P ,0.05). Systemic vascular resistance in patients with permanent AF was 1358.5 + 219.5 dyn*s/cm5, which was significantly higher than in patients in sinus rhythm (1143.5 + 392 dyn*s/cm5, P ,0.05). Transthoracic echocardiography revealed significant increase in left atrial size in patients from group I (45 + 17 mm) and group II (51 + 9 mm) when compared with the group without cardiac arrhythmias (36.5 + 16 mm, P ,0.05). Significant direct correlation was found between PWV and left atrial size in hypertensive patients with persistent AF (r = 0.6, P ,0.05). Conclusions: Significant increase in PWV and SVR was found in hypertensive patients with persistent and permanent AF when compared with the hypertensives in sinus rhythm. Significant direct correlation between PWV and left atrial size was found in patients with persistent AF.
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P944
Negative affectivity of type D personality predicts the increased recurrences rate risk in lone atrial fibrillation patients E.H. Hatzinikolaou-Kotsakou, E. Reppas, T.H. Beleveslis, G. Moschos, M. Kotsakou, P. Latsios, and K. Tsakiridis
P945
Clinical success of conventional vs. contact force-controlled radiofrequency catheter ablation of atrial fibrillation: clinical outcome after 12 months A. Berkowitsch, S. Lehinant, D. Paijitnev, H. Greiss, S. Zaltsberg, C. Hamm, M. Kuniss, and T. Neumann Kerckhoff Clinic, Bad Nauheim, Germany
Saint Lukas Hospital, Electrophysiology Department, Thessaloniki, Greece Background: Type D ( distressed ) personality-a joint tendency towards negative affectivity (NA) and social inhibition (SI) –has been observed that might affect the atrial fibrillation recurrences rate ( AFRR) in patients with lone atrial fibrillation (LAF). Hypothesis: We hypothesized that both Type D personality and its individual traits (NA and SI) predict AFRR in a population with LAF. Methods: Over a follow-up period of 4.8 + 0.8 years we recorded the incidence of atrial fibrillation recurrences in a cohort of 185 consecutive patients ( mean age 48 + 11 years), who were known with LAF .At baseline, these patients completed the Type D Personality Scale (DS-14, German Version), a validated self-describing standard questionnaire. Results: NA and SI was diagnosed in 31.8% and 34.5% of the patients respectively. From the total cohort , 22.3% had both NA and SI and therefore were classified as having a Type D personality. In Cox regression analysis, Type D personality proved significantly and independently predictive for AFRR , with an adjusted HR of 2.19 ( 95% CI 1.07-4.48, P=0.031). When The dimensions of Type D were entered as individual variables into regression models adjusting for age ,gender, and arrhythmia duration, only NA significantly predicted AFRR (HR 2.27 (95%CI 1.15-4.78, p=0.029) , whereas SI was not associated with AFRR. (HR 1.10 95%CI 0.57-2.28, p=0.745) Conclusions: Our results confirm Type D personality is as a potential risk for lone atrial fibrillation recurrences rate. Importantly, however, we found that the increased risk of AFRR with type D personality is solely driven by NA ( representing experience of increased negative distress), whereas SI (representing inhibition of negative emotions ) is not associated with AFRR.
Purpose: Aim of this study was to determine the efficacy of conventional vs. contact force-controlled (CFC) RF ablation. Methods: Thirty-eight pts ablated with CFC irrigated tip catheter (TactiCathTM , Endosense, Switzerland (n=20) or SmartTouchTM , BiosenseWebster, USA (n=18)) (group 1) were matched to another group of AF pts (n=38) ablated with conventional irrigated tip catheter (group 2). All 76 procedures were first ablation procedures 3 D-mapping guided (Carto IIITM , BiosenseWebster or NavXTM , SJM). PVI defined as ablation endpoint was verified by entranceand exit block in each PV. Pts were followed-up routinely every 3 months, including a 7-day Holter ECG. In case of symptoms, pts were instructed to obtain ECG for evaluation. Primary endpoint was first documented recurrence of AF/LAT after a blanking period of 1 month. Results: The majority of both groups presented as long-lasting AF (group 1:74% vs group 2:62%) with a history of AF 2.5 years. The ablation strategy in both groups did not differ: PVI as the ablation endpoint was achieved in all pts by ipsilateral wide area circumferential ablation. In 50% of the pts additional substrate modification was performed (roof line and/or mitral isthmus line). Skin-to-skin procedure time was significantly reduced in group 1 (median 3.5 vs. 4.2 h, p , .006). Median contact-force during PVI was 19 (17/23) g. Pericardial tamponade occurred in one patient in group 1 during ablation on the posterior wall at the LSPV, interestingly without increase of CF. AF free survival was significantly increased in group 1 (78.9%) vs. group 2 (44.7%) with a maximum follow up of 12 months (log rank tes, p=.045). Conclusions: PVI using contact force-controlled RF ablation demonstrates favorable rates of clinical outcome with significant enhancements to key procedural metrics. The contact force information itself does not completely avoid complications like tamponades.
P946
P947
Contact force guided pulmonary vein isolation reduces the rate of adenosine-mediated pulmonary vein reconnection, OCCAS-AF a multicenter pilot study Luminal esophageal temperature predicts esophageal lesions after second-generation cryoballoon pulmonary vein isolation
A. Jadidi1, C.I. Park1, H. Puererfellner2, C.I. Dechillou3, P. Jais4, E. Pruvot5, J. Albenque6, O. Xhaet7, D. Shah8, and T. Arentz1 1
A. Konstantinou1, S. Bordignon1, B. Schmidt1, M. Boehmig2, M.C. Boehmer2, B. Schulte-Hahn1, B. Nowak1, A.U. Dignass2, J.K.R. Chun1, and A. Fuernkranz1 1
Cardioangiologisches Centrum Bethanien, Frankfurt/M, Germany; and 2Medizinische Klinik I, Markuskrankenhaus, Frankfurt/M, Germany
Purpose: to investigate the incidence of esophageal lesions after pulmonary vein isolation (PVI) using the novel second-generation cryoballoon (CB2) and the role of luminal esophageal temperature (LET) measurement as a predictor of lesion formation. Methods: 32 consecutive patients underwent PVI using the 28mm CB2. Target application time was 2x240 seconds. LET was continuously measured during ablation. Freezing was only interrupted if weakening/loss of phrenic nerve (PN) function or very low LET (, 5 8C) was observed. Results: 92% PVs were isolated after one cryoenergy application. Complete PVI was achieved in all patients. The lowest measured LET was -128C (despite cryoapplication interruption). Post-procedural gastro-esophagoscopy was performed after 1-3 days in all patients and showed lesions in 6/32 (19%) patients. A minimum LET of 128C predicted esophageal lesions with 100% sensitivity and 92% specificity (area under the ROC curve 0,97; CI 0,93-1,02, p=0,001). Persistent PN palsy occurred in 2 patients (6%) during ablation at the right inferior PV. Repeat gastro-esophagoscopy confirmed healing of lesions after 16 + 14 days. Conclusion: CB2-PVI is associated with significant esophageal cooling resulting in lesion formation in 19% of patients. LET measurement accurately predicts lesion formation and may enhance the safety of the novel device.
Universitaets-Herzzentrum Freiburg-Bad Krozingen, Arrhythmia Department, Bad Krozingen, Germany; Elizabethinen Hospital, Linz, Austria; 3CHU Nancy, Institute of Lorraine Heart and Blood Vessels Louis Mathieu, Nancy, France; 4Hoˆpital Cardiologique du Haut-Le´veˆque, Universite´ Victor Segalen Bordeaux II, Bordeaux, France; 5CHUV and University of Lausanne, Department of Cardiology, lausanne, Switzerland; 6 Clinic Pasteur of Toulouse, Toulouse, France; 7University Clinics of Mont-Godinne, Yvoir, Belgium; and 8University Hospital of Geneva, Department of Cardiology, Geneva, Switzerland 2
Introduction: PV reconnection is the main mechanism of ablation failure and AF recurrence. In a multicenter study we assess if CF-guided RF ablation for PVI can reduce both Adenosine-mediated & long-term PV reconnection (PVR) rate and influence long-term clinical outcome in pts undergoing PVI. Methods: The threshold of catheter-tissue contact force (CF) necessary for durable PV isolation was determined in 40 pts at 30W RF energy using SmartTouch CF sensing ablation system. The OCCAS-AF multicenter study aims to include a total of 228 patients (parox. & persist. AF). Adenosine-mediated & late PVR rates and AF freedom will be compared between pts ablated using (1) CF-guided PVI vs. (2) conventional RF PVI (without use of CF). Results: Adenosine-mediated PV reconnection (PVR) occurs in 87% (CI: 0,76 to 0,94) at ablation sites with a mean CF , 12g (FTI , 560gs). We therefore target in the pilot study, a mean CF .12g, to compare the rate of acute Adenosine-mediated PV-Recovery (fig A, B). We observed a total of 35 time- & Adenosine-mediated PV-Reconnections at 153 isolated PVs (23%) in 25/40 (63%) pts undergoing PVI without use of CF. In contrast, when targeting a mean CF . 12g during ablation, we observed 3 PV-Reconnections at 70 isolated PVs in 3/18 (16%) patients ( p , 0,05, fig C). Conclusions: The current pilot study demonstrates that Contact Force-guided PVI (targeting a mean CF . 12g), reduces rate of Adenosine-mediated PV-Reconnection during index PVI procedure. Long-term FU results of OCCAS-AF will allow to judge the impact of CF-guided PVI on AF freedom.
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P948
P949
Probucol prevents atrial remodeling by inhibiting reactive oxygen species production and NF-kappaB activation in alloxan-induced diabetic rabbits
Pharmacological treatments before and after catheter ablation for atrial fibrillation in Japan
H.Y. Fu, T. Liu, C.L. Liu, G.P. Li, J. Li, L.J. Cheng, X.H. Wang, and M. Yuan
Y. Murakawa1, A. Nogami2, M. Shoda3, K. Inoue4, S. Naito5, K. Kumagai6, Y. Miyauchi7, T. Yamane8, N. Morita9, and K. Okumura10, J-CARAF Investigators
Tianjin Institute of Cardiology, Tianjin, China, People’s Republic of
1
Purpose: This study sought to assess the effects of probucol on atrial remodeling and atrial fibrillation (AF) promotion in alloxan-induced diabetic rabbits and to elucidate the underlying mechanisms. Methods: 40 Japanese rabbits were randomly assigned to a normal control group (C, n=10), alloxan-induced diabetic group (DM, n=10), probucol-treated group (CPR, n=10) a and probucol-treated diabetic group (DPR, n=10). Rabbits in the DPR and CPR groups were orally administered Probucol (1000mg/day) for 8 weeks. Plasma malonaldehyde (MDA) levels were measured. The protein expression of nuclear factor kB (NF-kB) and transforming growth factor-b(TGF-b) in left atrial tissue were analysed by western blot, the mRNA expression levels of tumour necrosisfactor-a(TNF-a) were analysed by RT-PCR methods. Isolated Langendorff perfused rabbit hearts were prepared to evaluate atrial refractory effective period dispersion (AERPD), interatrial conduction time (IACT) and vulnerability to AF. Atrial interstitial fibrosis was evaluated by Sirius-Red staining. Results: The DPR rabbits exhibited significant alleviation of oxidative stress displayed as decreased plasma MDA .Probucol administration increases stability of vulnerable atrial fibrillation compared with diabetic rabbits (P , 0.05) .Probucol significantly downregulated atrial NF-kB, TGF-b protein expression and TNF-a mRNA expression in atrial tissue of DPR rabbits . Histological analysis revealed suppression of DM-related histological changes (interstitial fibrosis) by probucol. Conclusions: Probucol attenuated atrial remodeling and prevented AF development in alloxan-induced diabetic rabbits. Its inhibition on reactive oxygen species production, NF-kB, TGF-b and TNF-a overexpression may contribute to its anti-remodeling effects.
MDA(nmol/ml) IACT(ms) AERPD(ms) AF inducibility
DM group (n=10)
Control group (n=10)
control-Probucol (n=10)
DM-Probucol (n=10)
22.17 + 4.15# 36.55 + 6.4# 28.37 + 7.52# 8/10#
17.69 + 3.59 25.75 + 2.76 11.62 + 5.60 1/10
18.14 + 2.62* 26.62 + 2.32* 13.66 + 6.48* 2/10*
18.32 + 1.63* 23.87 + 1.64* 15.62 + 7.65* 3/10*
Values are mean + SD; #compared with Control group P ,0.05 ; *compared with DM group P ,0.05
Teikyo University School of Medicine, Fourth Department of Internal Medicine, Kawasaki, Japan; 2Yokohama Rosai Hospital, Division of Cardiology, Yokohma, Japan; 3Tokyo Women’s Medical University, Department of Cardiology, Tokyo, Japan; 4Sakurabashi Watanabe Hospital, Cardiovascular Center, Osaka, Japan; 5Gunma Prefectural Cardiovascular Center, Division of Cardiology, Maebashi, Japan; 6Fukuoka Sanno Hospital, Heart Rhythm Center, Fukuoka, Japan; 7Nippon Medical School, Department of Cardiology, Tokyo, Japan; 8Jikei University School of Medicine, Department of Internal Medicine, Division of Cardiology, Tokyo, Japan; 9Tokai University, Hachioji Hospital, Division of Cardiology, Tokyo, Japan; and 10Hirosaki University Graduate School of Medicine,Division of Cardiology, Hirosaki, Japan J-CARAF registry is a nationwide survey to reveal current status of atrial fibrillation (AF) ablation in Japan. The aim of this report is to assess the pharmacological treatment in AF patients. Methods: Japanese Heart Rhythm Society (JHRS) requested electrophysiology centers in Japan to register the data of cases performed AF ablation in September 2011 using questionnaire on the website. Results: One hundred and sixty-five centers reported data of 932 AF ablation cases (age; 62 + 10 years, male; 76.8%, paroxysmal AF; 65.7%). The number of antiarrhythmic drug (AD) used prior to AF ablation in each subject was 1.19 + 0.93. Ia AD, Ib AD, Ic AD, amiodarone, or bepridil was used in 27.1%, 5.0%, 46.0%, 7.1%, or 23.4% of patients, respectively. In 20.3% of patients, AF ablation was performed without preceding treatment with AD. At the time of discharge after AF ablation, no AD was given in 440 patients (47.2%), while 46 patients (4.9%) ware treated with two ADs. Patients with paroxysmal AF were more frequently followed without AD than those with non-paroxysmal AF (56.9% vs. 28.8%, p , 0.001). Ia AD, Ib AD, Ic AD, amiodarone, and bepridil were prescribed to 8.0%, 2.8%, 21.6%, 5.4%, and 18.4% of 932 patients, respectively. Conclusions: In Japan, Class Ic ADs and bepridil were preferred for the treatment of AF even after AF ablation. Type of AF was significantly associated with the pharmacological choice after AF ablation.
P950
P951
The effect of ibutilide on novel indexes of ventricular repolarization in patients with persistent atrial fibrillation Utilization of ablation procedures in the United States P. Korantzopoulos1, K. Letsas2, A. Kotsia1, G. Baltogiannis1, K. Kalantzi1, K. Kyrlas1, and J.A. Goudevenos1
J. Viles-Gonzalez1, S. Pant2, A. Deshmukh2, NJ. Patel3, P. Grover1, A. Chothani4, N. Shah3, K. Mehta5, R.D. Mitrani1, and H. Paydak2
1
University of Ioannina Medical School, Department of Cardiology, Ioannina, Greece; and 2Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
Purpose: Ibutilide is a class III antirrhythmic agent with proarrhythmic potential. In the case of persistent atrial fibrillation (AF), ibutilide has poor effectiveness for direct cardioversion but significantly increases the success rates of electrical cardioversion. Recent evidence suggests that the proarrhythmic effects of various drugs may be due to an increase in the dispersion of repolarization. In this pilot study we examined the effect of ibutilide on novel indexes of repolarization in patients with persistent AF. Methods: We studied consecutive patients scheduled for elective electrical cardioversion. Patients taking drugs or having conditions that affect the QT interval were excluded. The final study population consisted of 20 patients (mean age: 67.1 + 9.9 years, 10 men). Intravenous ibutilide (1mg þ1mg) was administered before the electrical cardioversion while close ectrocardiographic (ECG) monitoring was performed. ECG indexes such as corrected QT interval (QTc), the interval from the peak until the end of T wave (Tpe) and the Tpe/QT ratio were measured before ibutilide infusion and 10 minutes after the end of administration. Results: The mean duration of persistent AF was 94 + 51 days, the mean left ventricular ejection fraction 58 + 7%, and the left atrial diameter 41.7 + 4.3 mm. Seven patients were cardioverted pharmacologically and did not proceed to electrical cardioversion. Two patients developed short non-sustained episodes of torsades de pointes ventricular tachycardia. All but one of the aforementioned ECG indexes increased significantly after ibutilide administration. In specific, the QTc interval increased from 442 + 29 ms to 471 + 37ms ( p=0.037), the Tpe interval in precordial leads from 96 [80-108] ms to 101 [91-119] ms ( p=0.021), the Tpe interval in lead II from 79 [70-88] ms to 100 [87-104] ms ( p , 0.001), the Tpe/QT ratio in precordial leads from 0.23 [0.18-0.26] ms to 0.26 [0.23-0.28] ms ( p=0.028), and the Tpe interval dispersion from 25 [23-30] ms to 35 [27-39] ms ( p=0.012). However, the Tpe/QT ratio in lead II did not change significantly ( p=0.508). Conclusions: Ibutilide administration increases the duration and the dispersion of ventricular repolarization. The studied novel ECG indexes of repolarization represent prognostic factors of arrhythmic risk in several clinical conditions. Therefore, their prognostic value and the role of their variations in the setting of drug-induced proarrhythmia needs further study.
1
University of Miami, Leonard M. Miller School of Medicine, Miami, United States of America; 2University of Arkansas Medical Sciences, Little Rock, United States of America; Staten Island University Hospital, Staten Island, United States of America; 4Washington Hospital Center, Washington, United States of America; and 5Drexel University, Philadelphia, United States of America 3
Introduction: Radiofrequency ablation (RFA) as a therapy for arrhythmias has evolved over the last decade to become considerably safe and effective. Data regarding the utilization, cost and safety of RFA for various arrhythmias outside of selected centers of excellence is limited. Methods: Using the Nationwide Inpatient Sample (NIS) between the years 2000-2008, we used diagnosis codes to identify atrial fibrillation (AF), atrial flutter (AFL), paroxysmal supraventricular tachycardia (PSVT) and ventricular tachycardia (VT) patients treated with ablations. We investigated the trends, in-hospital mortality and total cost of care for each hospitalization. Weights provided with the NIS were then used to generate national dischargelevel estimates. IBM SPSS 21.0 was used for statistical analysis. Results: There were a total of 47259 AF, 38,881 AFL, 37227 PSVT, 13942 VT ablations performed from 2000 to 2008. There has been an overall increase in frequency of these procedures performed from 2000-2008 for all the arrhythmias. The average percentage increase for AFIB, AFL, PSVT and VT are 46%, 12.7%, 4.6% and 5.5%. The overall in-hospital mortality over the study period has remained nearly stable for AF, AFL and PSVT ablation. Relative percentage increase (RPC) was 0.2%, 0.1%, 0.1% respectively. However, in-hospital mortality for VT ablation was comparatively higher and increased over the study period (RPC: 1.6%). The total charges for ablation procedures have increased likewise for all arrhythmias in more or less parallel fashion. Total charges are highest for the AF, followed by VT, AFL and PSVT. Conclusions: Utilization of ablation for various arrhythmias has significantly increased from 2000-2008, most remarkably for AF. The in-hospital mortality has not changed over the years except for VT ablation. Total charges have increased for all arrhythmias in parallel, AF ablation cost being higher followed by VT, AFL and PSVT.
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P953
Remotely controlled steerable sheath facilitates circumferential right pulmonary veins isolation during atrial fibrillation ablation with magnetic navigation Plasma copper homeostasis in patients with recent-onset atrial fibrillation and structurally normal hearts
The Princess Grace Hospital Centre, Monaco, Monaco
M.N. Negreva1, A.P. Penev1, and A.A. Aleksandrova2 1
D. Latcu, A. Errahmouni, S.S. Bun, N. Rijo, E. Allouche, and N. Saoudi
2
Medical University of Varna, Varna, Bulgaria; and Bulgarian Academy of Sciences, Institute of Neurobiology, Sofia, Bulgaria
Purpose: To study the dynamics of plasma copper content and activity of copper major transportation protein – ceruloplasmin in patients with recent-onset (,48 hours) atrial fibrillation (AF). Methods: Blood samples were collected from 33 patients (60.03 + 1.93 years, 17 males) without structural heart diseases. Copper content and ceruloplasmin activity were measured in plasma baseline prior to medical treatment with propafenone, on 24th hour and on 28th day after the conversion to sinus rhythm (SR). The same indices were determined in 33 healthy controls (59.27 + 1.72 years, 17 males). The copper content and the ceruloplasmin activity were quantified by atomic absorption spectrometry and colorimetric enzymatic assay respectively. Results: Most patients were hospitalized on 7th hour after the onset of AF (from 2nd to 24th hour). Baseline, patients’ copper content and ceruloplasmin activity were decreased compared to controls (1.065 + 0.038 vs 1.163 + 0.028 mg/L, p , 0.05; 0.033 + 0.001 vs 0.068 + 0.001 A530/mg pr, p , 0.001 respectively). 24 hours after SR restoration, copper concentration was not substantially different (1.087 + 0.045 vs 1.163 + 0.028 mg/L, p . 0.05), whereas the ceruloplasmin activity was diminished (0.045 + 0.001 vs 0.068 + 0.001 A530/mg pr, p , 0.001). On 28th day we established a significant difference in neither of the indices (1.119 + 0.030 vs 1.163 + 0.028 mg/L, p . 0.05; 0.064 + 0.002 vs 0.068 + 0.001 A530/mg pr, p . 0.05). Conclusion: Our results provide evidence for an imbalance of copper homeostasis in patients with recent-onset AF and structurally normal hearts. The decreased plasma copper content and ceruloplasmin activity during first hours of arrhythmia and their subsequent elevation following the AF interruption give us grounds to assume that these changes are closely related to the disease pathogenesis.
Purpose: The latest generation of magnetic navigation (MN) system (Niobe ES, Stereotaxis; Stx) allows faster remote manipulation of a soft catheter by means of a steerable magnetic field. It may be coupled with a catheter advancement system that fully controls both the catheter and a robotic deflectable sheath (RSh; V-CAS Deflect, Stx) or with a standard fixed-curve sheath and a catheter-only advancement system (CAS; Quick-CAS, Stx). We aimed to evaluate the 2 approaches for atrial fibrillation ablation (AF abl). Methods: Twenty-four consecutive patients ( pts; 14 men, 56 + 10 y) underwent AF abl (15 paroxysmal - PAF, 9 persistent - Pers) with MN coupled with the use of RSh were prospectively included and were compared with a control group (gr) of 21 AF abl pts (17 men, 59 + 10 y; 9 PAF, 12 Pers) with MN with a CAS in our center before the availability of RSh. Abl strategy was circumferential pulmonary vein ablation (CPVA) in PAF with lasso-proven PV isolation as an endpoint. RSh loop in the LA was systematically used for targeting the ostia of the right PV. Additional lesions targeting fractionated electrograms as well as LA roof and in some cases L isthmus lines were performed for Pers AF. An electroanatomic mapping system was used for all procedures (Carto 3, Biosense-Webster). Procedural parameters such as setup duration (from venous puncture to operator transfer to the control room), mapping time, procedure duration, fluoroscopy time, radiofrequency (RF) delivery time were acquired. Ablation step duration was defined as the time from the beginning of the first RF pulse to the end of the last one and was separately acquired for the left and the right veins. Results: There was no significant difference between the 2 gr concerning age, sex distribution, AF type or LA size. Setup duration was shorter in the RSh gr (42.8 + 6.7 vs 51.4 + 5.4 min, p=0.0004). Mapping and image fusion times were similar (33.3 + 6.2 in RSh gr vs 34.5 + 6.6 min in CAS gr, p=0.39). Ablation step duration for the left PVs was similar (44.3 + 12.8 in RSh gr vs 48.2 + 13.9 min in CAS gr, p=0.29), but was shorter for the right PVs in the RSh gr (49.8 + 10.2 vs 66.2 + 11.5 min, p=0.0001). Procedure duration was similar (257 + 64 RSh gr vs 222 + 90 CAS gr, p=0.08). Total fluoroscopy time was longer in the RSh group (16+4 vs 11+5 min, p=0.003), with limited additional operator exposure (during the setup; 6+2 RSh gr vs 5+5 min CAS gr, p=0.03). Conclusion: Using a remotely controlled steerable sheath with a loop in the LA fastens circumferential right PV isolation during atrial fibrillation ablation with magnetic navigation.
P954
P955
Intermitent apneic oxigenation (AO) during radiofrecuency pulmonary vein catheter ablation under general anaesthesia: feasibility and acute results M.L. Castilla1, R. Coulier2, M. Rodriguez1, J. Almendral1, E. Castellanos1, M. Ortiz1, and A. Lopez1 1
Madrid Hospital Group, CEU - San Pablo University, Madrid, Spain; and 2Rey Juan Carlos University, Madrid, Spain
Purpose: Some studies suggest that jet ventilation during general anesthesia improves results of radiofrequency (RF) catheter ablation of atrial fibrillation (AF) by providing better catheter stability. AO routinely used during some surgical procedures could provide similar effects. We study the feasibility of an strict AO protocol for this purpose. Methods: We include 8 patients undergoing AF pulmonary veins ablation (7 men, 1 woman), under general anesthesia, and with cycles apneic oxygenation (AO) for no more than 10 minutes alternating with conventional mechanic ventilation (MV). We stopped AO before completing 10 minutes if there were no optimal gasometric conditions. Standard AF ablation procedure was followed by the electrophysiologic team. We study ablation parameters, comparing between AO and MV. Results: We study 387 RF applications, of which 135 (34,9%) were possible to be in OA, and 252 (65,1%) were in MV. Only in one occasion, AO was stopped because of hypoxemia. See TABLE (data expressed in "average (typical deviation)"). Procedure was stopped because of inestability of catheter in 24 RF applications (8,73% RF applications during VM and 4,44% of total OA lesions, p=0,127). If we differentiate between vein location, we could see: 1) AO: 100% cases in LSPV; 2) MV: 27% LSPV, 32% LIPV, 23% RSPV, 18% RIPV. Conclusions: - AO according to an strict protocol is fesasible and safe for a considerable proportion of ablation lesions during RF pulmonary vein ablation. - Some observations suggest the existence of better catheter stability during AO. - Further studies are necessary to see if these results could translate in clinical benefits.
AO MV
max impedance fall (Ohm)
max impedance oscillation (Ohm)
max EGM voltage decrease (reference: initial EGM) (%)
7,09 (3,3) 6,33 (4,0) p=0,46
5,11 (2,7) 7,50 (6,6) p=0,001
48% 48% p=0,96
AO: apneic oxygenation; MV: mechanic ventilation; EGM: electrogram. Data expressed in average (typical deviation)
CHA2DS2-VASc score is associated with the recurrence of atrial arrhythmia after catheter ablation for typical atrial flutter Y.M. Park, D.I. Lee, H.C. Park, J.E. Ban, J.I. Choi, H.E. Lim, S.W. Park, and Y.H. Kim Anam Hospital, Korea University, Seoul, Korea, Republic of Introduction: CHA2DS2-VASc score was initially developed for the stroke risk stratification in atrial fibrillation (AF) patients. This study investigated the impact of CHA2DS2-VASc score on the recurrence of atrial arrhythmia (AA) in patients who underwent catheter ablation for typical atrial flutter (AFL). Methods: A total of 53 patients (mean age; 53.8 + 15.1 years, 45 males) who underwent catheter ablation for typical AFL were analyzed. Patients with valvular heart disease or incisional tachycardia were excluded. Post-ablation atrial arrhythmias were identified by 12-lead ECG and 24-48 hours holter or event recorder. The patients were divided into 2 groups according to CHA2DS2-VASc score ( 2 or 1). Results: All 53 patients received successful bidirectional block at the cavotricuspid isthmus (CTI). Mean CHA2DS2-VASc score was 1.47 + 1.46 and 23 patients (43.4%) showed CHA2DS2-VASc score 2. Sixteen patients (30.2%) showed recurrence of AA during follow up period of 30.8 + 12.9 months; AFL recurred in 9 patients (17%), AF in 11 patients and AFL with AF in 4 patients (7.5%). Patients with CHA2DS2-VASc score 2 showed higher recurrence rate of AA when compared with CHA2DS2-VASc score 1 [47.8% (11/23) vs. 16.7% (5/30), p = 0.014). ROC curve analysis revealed that CHA2DS2-VASc score 2 predicted the recurrence of AA with a sensitivity 66.7% and specificity 69.7%. Conclusions: The CHA2DS2-VASc score is helpful to identify patients at higher risk of recurrence of AA after catheter ablation for typical AFL. Prospective study is warranted to compare ablation of AFL only versus AF ablation at the time of AFL ablation in patients with CHA2DS2-VASc 2.
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P956
P957
Sustained atrial fibrillation is sustained by stable rotors, with passive activation into the pulmonary veins Effects of electrical stimulation of carotid baroreflex and renal denervation on atrial electrophysiology
G. Lalani, S. Narayan, A. Schricker, and D. Krummen, The CONFIRM Study Group University of California and VA, San Diego, United States of America
D. Linz1, F. Mahfoud1, K. Wirth2, H.R. Neuberger1, U. Schotten3, and M. Boehm1 1
Saarland University Hospital, Department of Internal Medicine III, Cardiology, Homburg, Germany; 2Sanofi-Aventis, Frankfurt/Main, Germany; and 3Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands Background: Electrical baroreflex stimulation (BRS) and renal denervation (RDN) reduce blood pressure and global sympathetic drive in patients with resistant hypertension. Whereas RDN decreases sympathetic renal afferent nerve activity, leading to decreased central sympathetic drive, BRS modulates autonomic balance by activation of the baroreflex, resulting in increased vagal activation. Increased vagal tone potentially shortens atrial refractoriness resulting in a stabilization of reentry circuits perpetuating atrial fibrillation (AF). Methods and results: In normotensive anasthetized pigs (n=12), we compared the acute effect of BRS and RDN on blood pressure, atrial effective refractory period (AERP) and inducibility of AF. Heart rate (HR) and blood pressure were comparably reduced 30 min after bilateral RDN or during 10 minutes of electrical BRS. BRS resulted in a rapid and pronounced shortening of AERP (from 162+8 ms to 117 + 16 ms, p=0.001) associated with increased AF-inducibility from 0% to 82%. This shortening in AERP was completely reversible after stopping BRS. After administration of atropine, AF-inducibility during BRS was attenuated. Ventricular repolarization was not modulated by BRS. In RDN, AF was not inducible, however, it did not prevent BRS-induced shortening of AERP. Conclusions: RDN and BRS resulting in comparable blood pressure and heart rate reductions differently influence atrial electrophysiology. Vagally mediated shortening of AERP, resulting in increased AF-inducibility, was observed with BRS but not with RDN.
Introduction: While pulmonary veins (PV) can trigger atrial fibrillation (AF), their role in sustaining AF is less clear. We set out to study the functional relationship between stable rotors and focal sources, shown by multiple laboratories to sustain human AF, and PV activity during sustained paroxysmal and persistent AF. Methods: In 43 consecutive AF patients (34 persistent) presenting for initial (n=25) or repeat ablation, we mapped AF using 64-pole basket catheters in each atrium and phase mapping (RhythmViewTM, Topera Inc., San Diego, CA) to identify sources. Concurrently, we determined if AF electrograms at the PV antrum showed activation from each PV to the left atrium (‘PV active’) or left atrium to PV (‘PV passive’) before ablation. Results: Sustaining rotors were seen in all patients (100%, 62þ9 years, LA 53 þ 11mm) for 2.9 þ 1.3 concurrent sources per patient. Figure shows a left atrial rotor that drove the left atrium and the PVs (‘passive PV activity’). Of 132 PVs with assignable activation sequences, 119 PVs were passive. Of n=13 active PVs, fewer were in persistent vs paroxysmal AF (8/111 vs. 5/21 PAF; p=0.02). Overall, 11/43 (26%) patients had 1 active PV, with no difference between persistent vs paroxysmal AF (7/34 vs 4/9; p=NS). In patients at first ablation, 8/69 PVs were active. At repeat ablation, 6/18 patients had PV reconnection. In these 6 patients, 5/ 14 PVs were active. Conclusion: In the majority of patients, stable rotors or focal sources sustain AF and the PVs are passive. This is true both for patients undergoing first ablation or with recurrent AF despite prior ablation. Further studies should define the functional relationship between PVs and AFsustaining sources.
P958
P959
Does atrial fibrillation begets heart failure? Time-course of apelin levels after sinus rhythm restoration in pts with persistent AF
R. Dierckx1, R. Houben2, M. De Proft1, E. Boel1, W. Timmermans1, F. De Pauw1, M. Goethals1, S. Verstreken1, J. Bartunek1, and M. Vanderheyden1
I. Saloustros, E.K. Koutalas, E.K. Kanoupakis, E.K. Kallergis, H.M. Mayrakis, S.P. Petousis, M.V. Vernardos, S.M. Maragkoudakis, and P.V. Vardas
1 OLV Hospital Aalst, Cardiovascular Center, Aalst, Belgium; and 2Applied Biomedical Systems BV, Maastricht, Netherlands
University Hospital of Heraklion, Department of Cardiology, Heraklion, Greece
Background: Clinical experience suggests that atrial fibrillation (AF) is a frequent comorbidity in heart failure (HF) patients with left ventricular systolic dysfunction and that volume overload may increase AF susceptibility. However, the causal relationship between AF and volume overload and vice versa remains unclear. Therefore, the goal of this study was to determine whether periods of greater intrathoracic fluid congestion are related to increased AF event frequency and vice versa. Methods and results: Findings from sixty three patients (64% male, age 61 + 12 years ) with NYHA II-III HF (EF 28 + 12 %), due to either ischemic or non-ischemic cardiomyopathy were retrospectively analyzed. All patients had a Medtronic cardioverter-defibrillator (ICD) implanted with Cardiac Compass monitoring function. Intrathoracic fluid status was assessed by measuring the transpulmonary electric bioimpedance and expressed by the optivol fluid index (FI). A FI threshold crossing event (Optivol þ ) was defined as FI 60 Ohm. During a mean follow-up of 649 + 370 days, 36 (57%) patients had documented atrial fibrillation. 5.92 + 5.27 Optivol þ events per 100 patient days were observed lasting for 27.3 + 34.0 days (15.25 + 14.95% of the total time). Maximum FI during this crossings was 119.94 + 34 Ohm. In these patients, the mean AF burden was 4.01 + 8.19 hrs. In 89 Optivol þ alarms (31.8%) one or more episodes of AF preceded (group A) whereas in 9 cases (group B) AF episodes followed FI threshold-crossings. During the FI threshold-crossings group A patients had significantly higher AF burden as compared to group B patients (14.5 + 11.49hrs versus 0.01 + 0.02hrs; p . 0.01). Conclusions: A substantial number of FI threshold-crossings are preceded by episodes of atrial fibrillation. These findings not only support the view that worsening pulmonary congestion is associated with increased AF frequency but also suggest that AF events may be responsible for triggering episodic pulmonary congestion more often than previously suspected. Also, we speculate that the short episodes occurring after the FI threshold-crossing may be the result of volume overload.
Purpose: The endogenous peptide apelin may feature in intercellular communication and the propagation of action potential in normal cardiomyocytes. We measured apelin levels before and after electrical cardioversion (CV) in persistent AF pts in order to explore the role of this peptide in the mechanisms of atrial fibrillation (AF). Methods: In 30 pts with preserved LV function and persistent AF, apelin was measured 10 min immediately prior to sedation for CV . Apelin levels were also determined 1 week and 1 month after CV in all pts. The control group comprised 15 healthy subjects in sinus rhythm (SR) with no history of atrial arrhythmias. Pts were prospectively followed - up for recurrence of AF up to 1 month. Results: Apelin levels were significantly lower in persistent AF pts (407 + 198 vs 1387 + 880 respectively, p , 0.001) than in control subjects. Of the 30 pts with persistent AF who participated in the study, all were successfully cardioverted to sinus rhythm, but immediate reinitiation of arrhythmia occurred in one . Furthermore, AF recurred within the study period in 6 additional pts. During the post-CV period apelin levels increased and at 1 month after sinus rhythm restoration, differed significantly compared to baseline values (717 + 333 vs 400 + 188, respectively, p , 0.001), (Figure 1). Interestingly, in the 7 pts with AF recurrence, apelin levels remained practically unchanged at the end of follow-up compared to baseline values (457 + 161 vs 428 + 242, respectively, p , 0.603). Conclusions: In a population with persistent AF we found reduced apelin levels. In addition, the restoration and maintenance of SR resulted in a gradual increase of apelin levels while AF recurrence has a different effect, suggesting that there might be abnormalities in atrial endocrine function in the setting of AF. Additional larger studies are needed to test and confirm our results and clarify the role of apelin in AF pathophysiology.
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P960
Amiodarone is associated with higher mortality rates in patients with atrial fibrillation and a low CHA2DS2Vasc score
P961
Arrhythmic complications after electrical cardioversion of acute atrial fibrillation
G. Vanerio, P. Fernandez Banizi, and J.L. Vidal Amaral T. Gronberg1, I. Nuotio2, M. Nikkinen3, A. Ylitalo4, T. Vasankari2, J.E.K. Hartikainen3, and K.E.J. Airaksinen2
Casmu Arrhythmia Service, Montevideo, Uruguay
1
Amiodarone is the most effective antiarrhythmic agent available to treat atrial fibrillation. Management of patients with atrial fibrillation includes thromboembolism risk evaluation with the CHA2DS2Vasc score, as it includes several important variables it is also powerful mortality predictor. Objective: Analyze the effect of amiodarone on survival in patients with atrial fibrillation using the CHA2DS2Vasc score as a mortality risk stratifier. Patients and Methods: We studied 3088 patients from our atrial fibrillation registry and performed stroke risk stratification with the CHA2DS2Vasc score. The population was divided into two groups; a score below 2 was the cutoff point. Kaplan-Meier survival curves were performed regarding mortality and amiodarone use, and the log rank test was used to compare curves. Results: A CHA2DS2Vasc score between 0-1 was observed in 724 patients (23%) and .1 in 2364 (76%). 196/ 724 (27%) of the low risk group and 791/2364 (33%) in the higher CHA2DS2Vasc group. received amiodarone 50/724 (6.9%) and 534/2364 (22%) died in both groups respectively. In the low risk group, mortality was 25/528 (4.7%) for those that did not receive amiodarone and 25/196 (12.7%), for those on amiodarone. In the high risk group mortality was 371/1523 (24%), for those without amiodarone versus 162/791; (20%) that received amiodarone. The Kaplan-Meier curves (figure 1) were significantly different between the two groups, a significant higher mortality of those on amiodarone in the low risk group (Log Rank, Mantel-Cox p=0.006) was observed and no difference in the high risk group (Log Rank, Mantel-Cox p=0.099). Conclusions: Patients with atrial fibrillation that received amiodarone with a CHA2DS2Vasc score between 0-1 had lower survival rates.
University of Turku, Turku, Finland; 2Turku University Hospital, Turku, Finland; 3Kuopio University Hospital, Kuopio, Finland; and 4Satakunta Central Hospital, Pori, Finland
Purpose: The aim of the study was to determine the incidence and risk factors of arrhythmic complications after electrical cardioversion (CV) of acute atrial fibrillation (AF). Methods: During 2003-2010, 7660 CVs were performed to acute (, 48 hours) AF in 3143 patients. The main outcome measure was the incidence of arrhythmic complications after 6906 (90.2 %) electrical CVs in 2868 patients. Secondly, the predictors of bradyarrhythmias and later need of permanent pacemaker in these patients were also assessed. Results: Altogether 63 (0.9 %) electrical CVs resulted in bradyarrhythmia in 54 patients. Asystole (. 5 sec) occurred immediately after 51 CVs leading to a short resuscitation in 7 cases and 2 patients needed extrinsic pacing after the CV. In 9 cases asystole was followed by bradycardia. Bradycardic venricular rate (, 40/min) alone was seen after 12 procedures. No ventricular arrhythmias needing intervention were detected. Old age (OR 1.1; 95%CI 1.05-1.10, p , 0.0001), female sex (OR 2.5; 95%CI 1.4-4.8, p = 0.004) and unsuccessful CV (OR 2.2; 95%CI 1.1-4.6, p = 0.03) were the independent predictors of bradycardic complications (Figure). Slow ventricular rate, use of digoxin, beta blocker or antiarrhythmic medication did not increase the risk of bradycardic complications. Pacemaker was implanted in 24 (44.4 %) patients after a median delay of 66 days. Conclusions: Bradycardic complications are rare and usually benign after CV of acute AF. They seem to reflect sinus node dysfunction and result often later in implantation of permanent pacemaker.
P962
N-terminal pro-brain natriuretic peptide plasma level in patients with persistent atrial fibrillation: is there a role of this biomarker in arrhythmia recurrence after electrical cardioversion? F. Imperadore1, V. Curci2, and M. Schinella2 1 Santa Maria del Carmine Hospital, Department of Cardiology, Rovereto, Italy; and 2Santa Maria del Carmine Hospital, Laboratory Department, Rovereto, Italy
Background: Atrial fibrillation (AF) is a common arrhythmia, with frequent recurrences within the first month after successful electrical cardioversion (EC). Persistent AF leads to electrical, structural and neurohormonal remodelling of the atria, including increased N-Terminal pro-Brain Natriuretic peptide plasma level (NT-proBNP). Purpose: To assess the clinical value of NT-proBNP concentration in patients with persistent AF before EC and whether it might have a role in AF recurrence. Methods: The study group consisted of 93 patients (mean age 71 + 9 years) with persistent AF who underwent syncronized bifasic EC. Blood was taken prior to EC and NT-proBNP measured by an electrochemiluminescence immunoassay (normal reference range , 125 pg/mL). All patients were taking antiarrhythmic agents after EC. Left atrial diameter, area, volume and ejection fraction were determined by echocardiography on the same day. Patients in the study group had no symptoms of heart failure and they have preserved left ventricular systolic function (mean ejection fraction 59 + 11%). As for AF recurrence a 3 months follow-up period was performed. Data were expressed as mean + standard deviation and compared with the Student’s t test. Correlation between data was tested using the Pearson’s analysis. A p value , 0.05 was considered statistically significant. Results: Out of 93 patients, 18 (19%) had EC failure and 75 (81%) had successful EC. 26 of 75 patients (35%) reverted to AF over follow-up period. The patients with AF recurrence showed a trend towards higher NT-proBNP plasma levels (1580 + 1042 versus 1473 + 1350 pg/mL, p = 0.3) than patients with stable sinus rhythm. There was a trend towards a larger left atrial diameter (50 + 6 versus 47 + 6 mm, p = 0.05), a larger left atrial area (29 + 6 versus 27 + 5 cm2, p = 0.1) and volume (106 + 29 versus 97 + 28 cm3, p = 0.1) in patients with AF relapse in comparison to those without. Besides, there was a significative positive correlation between NT-proBNP values and left atrial diameter (r = 0.22, p , 0.0001), left atrial area (r = 0.27, p , 0.0001) and volume (r = 0.25, p , 0.0001) in patients with AF recurrence. Conclusions: NT-proBNP plasma levels are increased in patients with persistent AF. Patients who reverted to AF after EC had a trend towards higher baseline NT-proBNP values than those remained in sinus rhythm. Besides, left atrial diameter, area and volume were larger in patients with AF relapse in comparison to those without and relation of NT-proBNP to them could suggest a its role in the atrial remodelling process.
P963 Why patients with atrial fibrillation and low or moderate thromboembolic risk still develop stroke? N. Diaconu1, A. Grosu1, C. Gratii1, V. Racila1, and G. Pavlic2 1 Institute of Cardiology, Chisinau, Moldova, Republic of; and 2Institute of Neurology and Neurosurgery, Chisinau, Moldova, Republic of
Introduction: Stroke caused by atrial fibrillation (AF) has a more severe evolution, followed by irreversible neurological sequels and high mortality, that’s why its prevention by identification of risk factors and adequate antithrombotic treatment is of significant importance in the management of AF patients. Objective: to determine the influence of AF and of additional thromboembolic risk factors on stroke development and evolution with comparison of several schemas’ stroke predictive value. Methods: retrospective study of all ischemic stroke patients admitted during one year in a municipal hospital. Results: The study included 735 patients with ischemic stroke of whom 519 had primary stroke (70.6%). AF was determined in 206 cases (28.4%), these patients being older (70.1 + 0.65 vs. 64.3 + 0.46 years, p , 0.001), mainly females-57.8% (119/206) and having more vascular risk factors. AF patients have had more severe signs of cerebral lesion on admission (79% vs. 37%, p , 0.01), also with a higher hospital mortality rate (30.6% vs. 13.2, p , 0. 001). According to CHADS2 score, about 37.4% of patients with AF and stroke were included in the low and moderate stroke risk groups, but still have had stroke. Upon analysis 46% of them were women, 38% were aged between 65-75 years, and 36.7% were having coronary heart disease, including 16% old myocardial infarction and 7.7 – intermittent claudicating. By including these factors in the CHA2DS2-VASc score, 0% had a low risk, and 4.1% had a moderate one. (tab.1) Conclusions: Patients with AF without previous thromboembolic events have a high risk of stroke with more severe evolution and consequences. Female gender, age between 65-75 years and vascular disorders should be taken into consideration when calculating the thromboembolic risk, CHA2DS2-VASc being the most sensible score in determining thromboembolic risk in patients with non-valvular AF.
Scores
Low risk
Moderate risk
High risk
Framingham CHADS2 CHA2DS2-VASc p
8,6 4,85 0 p , 0,05
30,9 21,8 2,9 p , 0,05
60,6 73,3 97,1 p , 0,05
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P964
The true atrial fibrillation burden after the Cox-Maze-III Cryo procedure in high risk patients with long-standing persistent atrial fibrillation - first report of event recorder documented continuous
P965
Evaluation of the temperature curves characteristics of isolated versus non-isolated pulmonary veins using the novel Achieve mapping catheter for cryoablation R.P. Martins, N. Behar, R. Bacquelin, J. Lacaze-Gadonneix, A. Behagel, P. Mabo, and D. Pavin
T. Hanke, U. Stierle, M. Baldewig, H.-H. Sievers, and E.I. Charitos
University Hospital of Rennes - Hospital Pontchaillou, Department of Cardiology and Vascular Disease, Rennes, France
Cardiac and Thoracic Surgery Clinic, Luebeck, Germany Purpose: Atrial fibrillation therapy in patients with concomitant structural heart disease and a long history of atrial fibrillation remains challenging with respect to postoperative morbidity and ablation success. Thus far, rhythm documentation has only been performed by intermittent snapshot strategies. This is the first report of continuous heart rhythm documentation after concomitant and stand alone classical biatrial ablation (full Cox-Maze-III-Cryo lesion set) AF surgical therapy, with a new wireless implantable loop recorder or pacemaker device. Methods: 28 patients (mean age 70.9 + 9.9y) with a history of persistent AF (mean AF duration 88.8 + 86m, mean LA-diameter 4.84 + 0.64cm, mean EF 49.3 + 15.6%,pre op AF burden 100% in all patients) were followed with continuous heart rhythm documentation after Cox-Maze-III-cryoablation therapy. Further cardiac surgery consisted of CABG, MVR, AVR, TVR and Aortoplasty. Results: All patients were off antiarrhythmic drugs. There was 1 procedural failure with remaining persistent AF. AF burden dropped to a mean of 1.6 + 2.9% (failure excluded), median 0.1% for all patients, zero AF burden occurred in 10 patients, 1 cardioversion was performed. EF and LA diameter did not change significantly after surgery. 12 patients received Coumadin, 9 patients Aspirin, no neurological event occurred. Conclusions: As for the first time documented with continuous heart rhythm monitoring, a high procedural success in patients with long standing persistent AF, as shown by a very low AF burden, can be achieved with the complete biatrial Cox-Maze-III lesion set. AF burden ought to be used as a hard indicator of procedural success in all ablation therapies, including catheter ablation.
Purpose: The Achieve catheter was designed to facilitate real-time assessment of pulmonary vein isolation (PVI) during cryoablation. We sought to analyze the correlation between various parameters of temperature (T8) curves and efficacy of cryoablation. Methods: Patients undergoing 28-mm cryoballoon PVI using the Achieve catheter were included. For each vein, only the first application (lasting 5 min) was analyzed. Freezing and rewarming curves were exported and processed to analyze: the minimal T8 reached, the dT8/dt (maximal absolute change in T8 over one second period during freezing), the curve time constant, the T8 after 30 sec of freezing (T30) and the rewarming time (time from the end of the application to reach 08 (R0) and 188 (R18)). Results: 37 pts (28 males, 60+9 yo) were included. Out of 141 PVs studied, 109 (77.3%) were isolated after the first application. The minimal T8 reached was significantly different between isolated and non-isolated PVs (-49.8 + 6.78C vs -46.5 + 7.48C, p=0.01). The dT8/dt and the curve time constant were similar between non-isolated and isolated PVs. A trend for lower T30 was found in the group of PVs successfully isolated after the first application. Rewarming times were significantly longer for successfully isolated PVs compared to non-isolated PVs. At the end of the procedure, 100% of the PVs were isolated after 1.2 + 0.6 applications (from 1 to 4). Conclusion: Lower T8 and longer rewarming times were found in isolated PVs using the Achieve catheter if a total occlusion is warranted during freezing. No other T8 curve parameters (dT8/dt, time constant, T30) were different compared to non-isolated PVs.
P966
Magnetically guided irrigated platinum-iridium versus irrigated gold-tip ablation of atrial fibrillation: procedural parameters and outcome
P967
Incremental prognostic value of the combination of 4q25 and ZFHX3 gene single nucleotide polymorphisms in patients who underwent radiofrequency catheter ablation for atrial fibrillation J. Shim, J.H. Park, J. Wi, H.S. Mun, J.S. Uhm, J.Y. Kim, B.Y. Joung, M.H. Lee, and H.N. Pak
K.J. Gutleben, B.G. Muntean, D. Horstkotte, and G. Noelker Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany Purpose: Currently 2 different types of ablation catheters are available for magnetically guided (MG) ablation procedures. Gold-tip catheters are supposed to be superior to platinum-iridiumtip catheters in terms of energy transmission and reduced incidence of thrombus formation. This has never been proven for MG catheters in a clinical setting. Methods: 131 patients (96 male, 61.6 + 10.6 years, 100 persistent, 131 paroxysmal AF) were randomly assigned to 2 groups. Group 1 underwent MG pulmonary vein antrum isolation for atrial fibrillation (AF) using a platinum-iridium-tip catheter (Navistar Thermocool RMT, 3.5mm Biosense Webster). In group 2 a gold-tip catheter was applied (Trignum G, 5mm, Biotronik). Procedures were guided by intracardiac echo and rotational angiography based LAreconstructions integrated into 3D mapping systems (Carto 3 RMT, Biosense Webster; Ensite Fusion, St Jude Medical). Results: There were no significant differences in baseline characteristics between both groups. Procedure time was 223 + 76 in group 1 and 220 + 61 minutes in group 2 ( p=n.s.). Fluoroscopy and total ablation times (minutes) were 11.4 + 19.1 and 2281 + 1387 in group 1 and 10.5 + 7.6 and 3206 + 1405 in group 2, respectively ( p=n.s. and p , 0.001). No major complications occurred. In a 5.1 + 1.9 months follow-up available from 110 patients including 7-day Holter and clinical visits success rates were 82.8 and 85.1% ( p=n.s.). Conclusion: In our preliminary experience gold-tip catheters and platinum-iridium-tip catheter seem to be comparable in magnetically guided AF ablation. However, the gold-tip catheter is associated with longer ablation times. Prolonged follow-up will be available and presented at the meeting.
Yonsei University Health System, Seoul, Korea, Republic of Introduction: Previous reports have demonstrated the association between Single Nucleotide Polymorphism (SNP) of the 4q25 gene and Atrial Fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA). This study evaluated whether 4q25 SNPs in combination with ZFHX3 have incremental prognostic value in AF recurrence after RFCA. Methods: A total of 683 consecutive patients (mean age 57 + 11 years, 76% male) with drug-refractory paroxysmal (68%) or persistent (32%) AF who underwent RFCA were included. SNPs of the 4q25 gene, rs2200733, and ZFHX3 gene, rs2106261, were genotyped and compared with phenotypes of patients including volume parameters by computed tomography. Results: The patients were assigned to 3 groups according to the number of variant alleles (Group A: no variant; n=15, Group B: 1 variant; n=158, Group C: 2 variants; n=439). When we compared 3 groups, there were no significant differences in age, gender, paroxysmal AF, CHADS2 score, left atrium (LA) size, and medications. However, venous LA volume was significantly greater in patients with variant allele (Group A vs. B & C; 16.9 vs. 22.3 & 22.9 mL/m2; p=0.023 & 0.020, respectively). The clinical recurrence after 3 months of blanking period after RFCA was observed in 26.2% during the median 15 months of follow-up. Kaplan-Meier survival analysis showed incremental prognostic value according to the number of variant allele (Figure, Log Rank p=0.015). Conclusions: A graded risk of AF recurrence was observed with an increasing number of risk alleles at 4q25 and ZFHX3 gene which was associated with larger venous LA volume. Our findings suggest that multimarker allele combinations can be used as a clinical tool for selection of patients for AF ablation.
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P969
Serum brain natriuretic peptide predicts the reverse remodeling of the left atrium after catheter ablation for atrial fibrillation Termination of chronic atrial fibrillation by ablation as possibility of reverse remodeling of Left Atrium K. Kumagai, Y. Nakatani, N. Tsukada, K. Sasaki, and S. Osima Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan Purpose: The pre-procedural prediction of Atrial Fibrillation (AF) termination by catheter ablation in patients with non-paroxysmal AF has not been evaluated fully. The aim was to evaluate the pre-procedural predictors of non-paroxysmal AF termination by ablation associated with the possibility of reverse remodeling of the LA. Methods: Seventy consecutive patients (62 + 8 years) with persistent or long-standing persistent AF underwent catheter ablation. They were divided into two groups; Group 1: those with AF terminated by ablation (n=14) and Group 2: those with AF terminated by cardioversion after ablation (n=56). Results: The Left Atrial Appendage (LAA) contraction velocity determined by transesophageal echocardiography was significantly decreased in Group 2 as compared to Group 1 (0.24 + 0.11 m/s vs. 0.42 + 0.23 m/s, P , 0.001). A Kaplan-Meier analysis revealed that the Group 1 patients had a higher AF free survival rate than those in Group 2 during 12 + 4.1 months of follow-up (P=0.048). The LA reverse remodeling ratio in Group 1 was significantly greater after ablation than that in Group 2 (25.8 + 13 % vs. 15.0 + 15 %, P=0.015). In a multivariate Cox proportional hazards model, the LAA contraction velocity was an independent predictor of non-paroxysmal AF termination by ablation (hazard ratio 1.032; 95% CI 1.006 to 1.060; P=0.018). Conclusions: The LAA contraction velocity was the only noninvasive pre-procedural predictor of non-paroxysmal AF termination by ablation. AF termination by ablation may indicate a smaller substrate to maintain AF, implicating the possibility of reverse remodeling of the LA.
P970
Objective quality assessment of atrial fibrillation ablation: a novel scoring system J.S. Chinitz, R.A. Kulina, S.R. Gangireddy, M.A. Miller, J.S. Koruth, S.R. Dukkipati, V.Y. Reddy, and A. D’avila Mount Sinai School of Medicine, Cardiovascular Institute, New York, United States of America Introduction: Assessment of atrial fibrillation (AF) ablation results using recurrence rates is limited by subjectivity of reported symptoms, non-uniform monitoring protocols, definitions of recurrence, and by not accounting for procedural safety. A novel scoring system based on 6 objective measures of efficacy and safety is presented, which may standardize comprehensive analyses between different approaches. Methods: The AF ablation (AFA) score equation is displayed below. The number of procedures performed and the pulmonary vein reconnection rate (PVRR, defined as the number of PVs with electrical connection to the left atrium/total number of PVs assessed during redo procedures) are included as markers of ablation quality, and the redo rate (number of 1st repeat ablations/patients undergoing first AFA) is used as an indicator of post-ablation arrhythmia burden. Complications are weighted according to their functional impact relative to death. The AFA score was calculated for patients undergoing radiofrequency ablation (RFA), Cryoballoon and visually-guided Laser balloon ablation for paroxysmal AF. Results: In 203 consecutive RFAs, redo rate was 0.19, PVRR 0.24, with 7 non-life threatening complications; the AFA score was 278 (follow up = 614 + 221 days). Among 30 Cryoballoon procedures, redo rate was 0.20, PVRR 0.30, and no complications occurred, yielding an AFA score = 60. Among 29 Laser balloon ablations (redo rate= 0.16, PVRR= 0.125, 0 complications), AFA score = 102. Conclusion: The AFA score, incorporating 6 objective markers of procedural and clinical outcome, is an alternative to recurrence rate to describe the quality and success of AFA. Adoption of this quantitative score could facilitate comparison between various approaches and assist monitoring of quality improvement over time.
T. Kimura, K. Inagawa, Y. Katsumata, T. Nishiyama, N. Nishiyama, K. Fukumoto, Y. Aizawa, Y. Tanimoto, K. Tanimoto, and S. Takatsuki Keio University School of Medicine, Department of Cardiology, Tokyo, Japan Purpose: A higher level of serum Brain Natriuretic Peptide (BNP) is known as a risk for relapsing Atrial Fibrillation (AF) after catheter ablation. The BNP level is usually normalized after a successful session, however, sometimes remains still high. We aimed to clarify characteristics of the BNP response after ablation and reveal the correlation with the reverse remodeling of the Left Atrium (LA). Methods: A total of 322 non-valvular AF patients (267 male, paroxysmal AF: 209, CHADS2: 1.0 + 1.4) who underwent catheter ablation for AF were analyzed. Data of serum BNP and the LA size in transthoracic echocardiography were collected before ( pre) and 21.9 + 17.0 months after ablation ( post). AF recurrence was defined by AF records of a telemonitoring electrocardiogram during 6.7 + 2.2 months after ablation with 3 months of a window-period, or redo sessions and AF attacks during 21.5 + 17.2 months of the follow-up. Patients were divided into 2 groups by the difference between the post- and pre-BNP level (ABNP); patients with the negative ABNP as the Responders and with the positive ABNP as the Non-responders. Results:The Responders were 253 patients (78.6 %). The pre-BNP of 107.3 + 111.8 pg/dL was decreased to 30.6 + 31.1 pg/dL of the post-BNP (ABNP: -76.7 + 101.6 pg/dL), whereas 39.9 + 61.1 pg/dL was increased to 68.9 + 116.5 pg/dL (ABNP: 29.0 + 60.0 pg/dL) in 69 Non-responders. The Responders were 150 paroxysmal AF (71.8%) and 103 persistent AF (91.2%) (odds ratio (OR); 16.362, P=0.0001). The pre-LA size of the Responders was larger than the Non-responders (4.0 + 0.6 cm vs. 3.7 + 0.5 cm, P=0.0001), whereas the post-LA sizes were not different (3.7 + 0.6 cm and 3.6 + 0.6 cm, P=0.406), showing the better reverse remodeling in the Responders (ALA: -0.2 + 0.5 cm vs. 0 + 0.4 cm, P=0.001). The Responders also had a shorter deceleration time of the mitral inflow prior to ablation (196.2 + 53.3 vs. 213.0 + 43.6 cm/sec, P=0.020). The AF recurrence was not different between the Responders and the Non-responders by the telemonitoring (174 (68.8%) vs. 53 (76.8%), OR; 1.684, P=0.194), and by the long follow-up with 1.3 + 0.6 redo sessions (28 (11.1%) vs. 9 (13.0%), OR; 0.208, P=0.648). Conclusions: The BNP normalization after catheter ablation reflected the degree of the LA reverse remodeling.
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P971
Impact of atrial fibrillation on platelet gene expression W. Wysokinski1, R.D.M. Mcbane1, A.J.T. Tafur1, W.Y. Wu1, N.A. Ammash1, D.G. Grill1, and J.M. Mruk2 1
Mayo Clinic and Foundation, Rochester, MN, United States of America; and 2University of Kansas School of Medicine-Wichita, Wichita, KS, United States of America
Background: Platelets retain cytoplasmic RNA and are capable of protein biosynthesis. Changes in hemodynamics, as is seen in non-valvular atrial fibrillation (NVAF) may impact platelet RNA and protein biosynthesis. Methods: To address the hypothesis that hemodynamic changes of cardiac rhythm impact the platelet transcriptome, platelet genes expression was assessed in NVAF patients before and 3 months after radiofrequency ablation (RFA) and in individuals with normal sinus rhythm (NSR). RNA from isolated platelets was reverse-transcribed (Invitrogen) and assayed for 21 genes (TaqMan) using real-time qPCR and expressed as mean cycle threshold (Ct) (ABI Prism 7700 Sequence Detection System). Results: All but one (cathepsin) platelet genes had significantly lower expression in 103 NVAF patients (age 59.6 + 10.3 years) compared to 55 (59.3 + 10.9) NSR controls (Table displays 9 out of 21 genes with significant change after RFA; ¥ the lower Ct value the higher target gene expression). Eleven genes expression increased significantly after RFA; patients with persistent NSR had a tendency towards further increase of gene expression. Conclusion: The cardiac rhythm directly impacts platelet-predominate gene expression. Atrial fibrillation induced changes in platelet related genes may contribute to the thrombotic propensity of this dysrhythmia.
Gene Description
Gene Expression (Mean Delta CT)* AF n=103
platelet factor 4 GRB2-related adaptor protein integrin alfa2bbeta3 glycoprotein Ib Progesterone receptor component Tubulin DD96 membrane associated protein Cofilin , non-muscle Insulin-like growth factor binding protein
3.0 + 0.9 4.2 + 0.7 5.9 + 1.7 5.9 + 0.9 6.0 + 0.7 6.0 + 1.5 6.9 + 1.1 7.5 + 1.2 14 + 2.5
NSRn=55
2.5 + 1.5 3.4 + 1.0 4.1 + 1.2 5.2 + 1.4 4.7 + 1.1 5.1 + 1.6 6.2 + 1.7 6.6 + 1.4 12 + 2.6
p
0.002 ,.001 ,.001 ,.001 ,.001 0.004 ,.001 ,.001 ,.001
NVAF with follow up after RFA Before RFAN=65
After FRAN=65
p
Definite/Possible NVAFN=28
No NVAF N=37
p
2.8 + 1.7 4.2 + 1.0 6.4 + 3.0 5.8 + 1.5 6.1 + 1.0 5.6 + 1.5 7.0 + 2.2 7.7 + 1.9 17 + 4.7
1.6 + 4.7 4.7 + 3.4 6.9 + 4.5 4.4 + 5.5 5.6 + 3.2 6.5 + 1.7 6.2 + 3.7 6.3 + 4.8 8.3 + 12
,.001 0.006 0.012 0.008 0.022 ,.001 0.040 ,.001 ,.001
1.8 + 2.1 4.9 + 1.5 7.2 + 2.2 5.0 + 2.2 5.8 + 1.0 6.7 + 1.7 6.8 + 1.6 6.4 + 2.2 9.0 + 5.2
1.4 + 1.9 4.5 + 1.2 6.7 + 1.9 4.0 + 2.5 5.6 + 1.0 6.3 + 1.7 5.8 + 1.6 6.3 + 2.5 7.5 + 6.0
0.47 0.35 0.39 0.16 0.44 0.40 0.02 0.78 0.45
P972
4-year follow-up after ablation of paroxysmal atrial fibrillation: cryoballoon versus radiofrequency catheter ablation M. Kuhne1, S. Knecht1, B. Schaer1, D. Altmann2, P. Ammann2, S. Osswald1, and C. Sticherling1 1
University Hospital Basel, Basel, Switzerland; and 2Kantonsspital, St. Gallen, Switzerland
Purpose: Cryoballoon pulmonary vein (PV) isolation (Cryo-PVI) has emerged as a alternative technology for ablation of atrial fibrillation (AF). Information on long-term follow-up after Cryo-PVI compared to PVI using radiofrequency energy (RF-PVI) is not available. Methods: Cryo-PVI was performed in 25 patients using a 28-mm cryoballoon ablation catheter (Arctic Front, Medtronic). Each PV was treated with a minimum of 2 applications. Twenty-five patients undergoing RF-PVI using an open-irrigation RF ablation catheter and a 3D-electroanatomic mapping system served as a control group. The procedural endpoint was PVI confirmed by a circumferential mapping catheter. Follow-up was performed 3, 6 and 12 months after the procedure, and then at least every 12 months. Results: Fifty patients (age 59+9 years, ejection fraction 0.59 + 0.06, left atrial size 41+5 mm) with paroxysmal AF were included. After a single procedure and a follow-up of four years, 13 of 25 patients (52%) were free from arrhythmia without antiarrhythmic drugs, both in the Cryo-PVI group and the RF-PVI group. When including repeat procedures with a mean of 1.5 + 0.7 procedures per patient, 21 of 25 patients (84%) in the Cryo-PVI group and 20 of 25 patients (80%) in the RF-PVI group (1.4 + 0.6 procedures per patient) remained in stable sinus rhythm, respectively ( p . 0.99). One patient in the RF-PVI group experienced left atrial flutter. This was also counted as a recurrence. Conclusion: Single-procedure efficacy of PVI is approximately 50% after a follow-up of 4 years and this is independent of the energy source used. When including repeat procedures in 36% of patients, the success rate is increased to approximately 80%.
P973
Prediction of early recurrence of atrial fibrillation after catheter ablation by CHA2DS2-VASc score and association with late recurrences J. Kornej1, J. Kosiuk2, A. Arya2, C. Piorkowski2, P. Sommer2, S. Rolf2, D. Husser2, G. Hindricks2, G. Lip1, and A. Bollmann2 1
University of Birmingham, Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; and 2University of Leipzig, Heart Center, Department of Electrophysiology, Leipzig, Germany Background: Early recurrence of atrial fibrillation (ERAF) after catheter ablation is an important predictor for late rhythm outcome. However, there are limited data about the role of CHADS2 and CHA2DS2-VASc scores in prediction and significance of ERAF in a large population. Methods: The study population comprised 2.069 consecutive patients (66% male, 60 + 10 years, 62% paroxysmal AF, mean CHADS2 1.2 + 0.9 and CHA2DS2-VASc 2.1 + 1.4) with symptomatic AF who underwent RF catheter ablation at the Heart Center Leipzig. Early recurrences of atrial arrhythmias (ERAF) were defined as any atrial arrhythmia occurring within the first week after ablation and were detected using in-hospital and 7-day Holter ECG monitoring. Results: 726 patients (35.9%) suffered ERAF after catheter ablation. On univariate logistic regression analysis, age, female gender, persistent AF, chronic renal disease as well as both CHADS2 and CHA2DS2-VASc scores were significantly associated with ERAF. On multivariate analysis, persistent AF (OR 1.4, CI 1.2 - 1.8, p , 0.001) and CHA2DS2-VASc (OR 1.1, CI 1.03 – 1.2, p=0.004) were independent predictors for ERAF. Recurrences at 3 (OR 3.8, CI 2.8 – 5.2, p , 0.001), 6 (OR 3.4, CI 2.6 – 4.4, p , 0.001) and 12 (OR 2.9, CI 2.1 – 3.9, p , 0.001) months were significantly associated with ERAF, but 564 patients (66.9 %) with ERAF suffered no LRAF during later follow up. Conclusion: ERAF within the first week after catheter ablation occurred in more than one third of the patients. CHA2DS2-VASc score as well as persistent AF were strong predictors for ERAF. ERAF was associated with late recurrences, but the majority of patients with ERAF remained free of atrial arrhythmias during follow up.
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P974 Hybrid ablation of long standing persistent atrial fibrillation utilizing minimally invasive surgical and endocardial catheter approach: one year results D.E. Pajitnev1, M. Kuniss1, M. Schoenburg2, Z. Szalay2, S.W. Zaltsberg1, H. Greiss1, E. Akkaya1, T. Walther2, C.W. Hamm1, and T. Neumann1 1 Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany; and 2Kerckhoff Clinic, Department of Heart Surgery, Bad Nauheim, Germany
Introduction: Unfortunately the efficacy of catheter ablation of long standing persisting atrial fibrillation (LSPAF) remains poor even after multiple ablation procedures. With a novel hybrid ablation strategy with combined epicardial and endocardial approach high short term success rates were demonstrated. The objective of this study was to evaluate safety and efficacy outcomes one year after hybrid ablation. Methods: 25 consecutive patients ( pts) (2 female, age 52+1 years, LA size 46+1 x 62+1 mm with LSPAF were included. The epicardial ablation was first performed via an endoscopic subxyphoid access utilizing Numerisw Coagulation Device, nContact Surgical Inc. It was secondly followed during the same day by conventional endocardial ablation utilizing EnSite NavX VelocityTM system, SJM Inc. During the endocardial procedure voltage mapping was performed and detected gaps were closed. Esophageal temperature was continuously monitored. Pts were prospectively followed at 1, 2, 3 months with 48 h holter ECG and every 3 months thereafter. Pts free of AF after 3 months underwent implantation of loop event recorder, RevealTM , Medtronic Inc. Results: AF was persisting since 53+9 months and 16+2 months after last cardioversion attempted. 9 pts (36%) have already undergone repeated AF catheter ablations. All pts were highly symptomatic with EHRA class 4. The mean duration of epi- and endocardial procedure were 134+6 min. and 193 + 13 min. respectively, utilizing 32+3 min. of the fluoroscopy time (37 + 11 Gy/cm2). In first 5 pts endocardial voltage mapping has shown incomplete posterior box lesions with necessity of endocardial closure. After the modification of the initial epicardial ablation scheme complete posterior box lesions were achieved in 20 pts. Endocardial closure of anterolateral and septal gaps with additional application of anterior roof lines led also to complete isolation of the whole roof region and all PVs. After this step 5 pts converted primary into SR and 10 into atrial tachycardia. After the application of anterior mitral valve lines another 5 of these 10 pts converted into SR. Electrical cardioversion was performed in 15 pts. 7 pts developed a postpericardiotomy syndrome, which was managed conservatively. One pt has developed bleeding from the transdiaphragmal access site, which required surgical revision. After a median follow up of 301 (IQR 159-481) days 21 (84%) pts were free of AF without AADs. Conclusions: A hybrid ablation of LSPAF in pts with severe atrial enlargement represents a feasible treatment option with high mid-term success rates. Further evaluation of long-term results is required.
P975
Left atrial size in perimitral atrial flutter after extensive encircling pulmonary vein isolation Y. Kaneko, T. Nakajima, T. Irie, M. Ota, T. Iijima, M. Tamura, T. Iizuka, S. Tamura, A. Saito, and M. Kurabayashi Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan Purpose: To investigate an association between the development of perimitral atrial flutter (PMFL) after extensive encircling pulmonary vein isolation (EEPVI) and anatomical parameters of left atrium (LA). Methods: We enrolled 76 patients with atrial fibrillation who underwent successful EEPVI and compared echocardiographical and morphological measurements after EEPVI including circumferential length of mitral annulus (MA-L) and box-like line encircling bilateral EEPVI line (EEPVI-L), and length of mitral isthmus (MI-L) on CARTO, between 11 patients with (14.5%, PMFL(þ)-group) and 65 patients without a spontaneous development and/or an induction of PMFL after EEPVI (85.5%, PMFL(-)-group). Results: Shown in Table. LA volume was significantly correlated with MA-L(R=0.326, p=0.01), EEPVIL(R=0.593, p , 0.0001) and MI-L(R=0.408, p , 0.0001). LA volume . 53.5 ml predicted a development of PMFL with a sensitivity of 73 % and a specificity of 65 %. Conclusions: LA size is associated with the size of the reentry circuit of PMFL and may contribute to the development of PMFL. These information may be useful for planning ablation strategy.
Comparison between two groups
Age (yrs) Sex (M/F) Pamal/persistent AF Session No (1st/2nd) Echo parameters LVEF (%) LAD (mm) LA volume (ml) TMF E (cm/sec) TME A (cm/sec) a’ (cm/sec) CARTO parameters MA-L (mm) EEPVI-L (mm) MI-L (mm)
Multivariable analysis
PMFL(þ)-G
PMFL(-)-G
p value
68.5 + 9.2 9/2 7/4 9/2
62.5 + 9.1 5/14 51/14 64/1
0.06 0.89 0.17 0.003
59.0 + 15.6 39.5 + 4.5 64.8 + 21.1 73.2 + 30.4 47.8 + 20.3 5.9 + 2.5
61.5 + 13.9 37.7 + 5.7 46.9 + 16.8 61.8 + 19.1 61.8 + 19.1 7.5 + 2.2
0.62 0.26 0.02 0.41 0.08 0.10
123.3 + 13.7 193.9 + 34.1 27.2 + 9.2
121.1 + 15.3 165.321.8 22.3 + 6.0
0.64 0.03 0.13
Hazard ratio
95% CI
NS
1.072
1.016-1.0131
P976
The combined use of adenosine and pacing for pulmonary vein isolation line evaluation (APPLE trial)
p value
0.003 NS NS
NS NS
P977
A pilot study on the contact sensor equipped catheter in atrial fibrillation ablation P. Marchese, M. Gujic, I. Horduna, S. Johar, S. Haldar, D.G. Jones, T. Wong, V. Markides, and S. Ernst
S.H. Kim1, Y.S. Oh1, T.S. Kim1, W.S. Shin2, J.H. Kim2, S.W. Jang2, M.Y. Lee2, and T.H. Rho1 Royal Brompton and Harefield NHS Trust, London, United Kingdom 1
Seoul St. Mary’s Hospital, Seoul, Korea, Republic of; and 2Catholic University of Korea, Seoul, Korea, Republic of Background: Adenosine and pulmonary vein pacing has been used for the evaluation of pulmonary vein (PV) isolation respectively and the usefulness between two methods was compared. Methods: Patients undergoing PV isolation for atrial fibrillation were consecutively enrolled. After PV isolation, a 20 mg bolus of adenosine was injected and PV reconnection was investigated. Then, PV pacing was performed using circular catheter and the capture of left atrium (LA) were analyzed. Results: Fifty-five patients (35 male; age 60 + 10 years) were included in the study. After adenosine, dormant conduction was recorded in 11 (20%) patients and 15 sites. During PV pacing, LA capture was observed in 11 (20%) patients and 15 sites. In 5 patients, the dormant PV conduction was identified both with adneosine and PV pacing. And, except 2 patients, the sites of dormant conduction were variable in 9 patients. Conclusions: For the confirmation of PV isolation, adenosine and PV pacing showed similar sensitivity (20%), but the response to two different methods was variable in ecah patient. Furthermore, the sites of dormant conduction even in same patient were mostly different. Therefore, the combined use of these methods may be effective for the detection of dormant PV conduction.
Aim: To assess the contact force (CF) using the Smart Touch catheter (Biosense Webster) to perform pulmonary veins isolation (PVI) in 13 consecutive AF pts. Methods and results: Operators #1 and #2 performed the ablations with their usual style of lesion deployment irrespective of CF, whereas #3 attempted to achieve at minimum 5 g CFs. The PVs areas were schematically divided in 12 segments (figure 1a). The impact of beat by beat changes and changes due to respiratory motion were observed (fig 1b). Data is presented as median (g, 25th-75th centile). Overall operator #3’ CFs were higher [12.0(8.0-15.0) vs 8.0(5.0-13.0), p , 0.001] than #1&2 at all sites. Both #1&2 achieved lower CF around lateral PVs [6.0(4.0-10.0) vs 10.0(6.0-17.0),p , 0.001];there were no differences for #3. If beat to beat changes of more than 10 g were observed, than the resulting CF was higher for all operators. The CFs were lower in absence of oscillatory respiratory pattern for all operators. There were no significant correlation between the CF and the total amount of energy delivered. "weaker" ablation points (25th centile CF values below 5 g) were only found in operators #1&2 (red, figure 1). There were no complications related to the PVI procedure. At 6 months follow-up no AF relapses have been recorded. Conclusions: The new CF ablation catheter is useful to prevent complications and limits the amount of low or no contact ablation that may result in inadequate lesions. The CFs resulted inversely related to the amplitude ofbeatby-beat oscillations and directly related to the presence of a respiratory pattern. There was no correlation between the CFs and the energy delivered. Larger populations and longer follow-up studies are needed to investigate this further.
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P978
Correspondence between echocardiographic indices of left atrial size and left atrial volume derived from 3D electroanatomic mapping in patients with atrial fibrillation
P979
High bi-atrial organization in patients with long-standing persistent atrial fibrillation terminated within the left atrium A. Buttu1, E. Pruvot2, A. Forclaz2, P. Pascale2, S.M. Narayan3, P. Maury4, A. Rollin4, and J.M. Vesin1 1
S. Havranek1, V. Bulkova1, J. Simek1, T. Palecek1, and D. Wichterle2 1 Charles University Prague, 1st Faculty of Med., 2nd Dept of Medicine-Dept of Cardiology & Angiology, Prague, Czech Republic; and 2Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
Purpose: Left Atrial (LA) enlargement is a predictor of worse outcome after Catheter Ablation (CA) for Atrial Fibrillation (AF). We investigated the correspondence between 3 echocardiographic indices of LA size and LA volume obtained by electroanatomic mapping in patients undergoing CA for AF. Methods: We performed single centre analysis in 181 pts (122 males; aged 59 + 10 yrs; paroxysmal AF in 42% of pts). Left Atrial Diameter (LAd) was measured in parasternal long-axis view. LA volume was assessed by ellipsoid formula (LAVe), biplane area-length method (LAVb), and electroanatomic 3D reconstruction of LA (LAVc) using 161 + 54 CARTO points and CT image registration in 66% of cases. Results: Mean + SD values were found as follows: LAd 47 + 6 mm, LAVe 70 + 25 ml, LAVb 87 + 27 ml, and LAVc 127 + 39 ml. Correlation coefficients between LAVc versus LAd (r = 0.7), LAVe [LAVe (ml) = 6.1 þ 0.5.LAVc (ml); r = 0.79] and LAVb [LAVb (ml) = 4.4 þ 0.76.LAVc (ml); r = 0.74; Figure] were comparable (mutually NS). Weak relationships did not improve after multivariate adjustments for age, gender, and AF type. LAVe and LAVb underestimated LAVc with comparable bias (95% CI) of 18 (-15 – 51) and 21 (-13 – 55) ml, respectively. Conclusions: Echocardiographic LA volume was not superior to simple LA diameter in estimation of true LA size. Echocardiography systematically underestimated CARTO-derived LA volume. Magnitude of this bias was greater for enlarged LA.
Swiss Federal Institute of Technology, Lausanne, Switzerland; 2University Hospital Center Vaudois (CHUV), Department of Cardiology, Lausanne, Switzerland; 3University of California, San Diego, San Diego, United States of America; and 4Inserm-UPS U1027, University Hospital of Toulouse - Rangueil Hospital, Department of Cardiology, Toulouse, France Sustained atrial fibrillation (AF) is maintained by sites displaying high dominant frequency (DF). In patients ( pts) with long-standing persistent AF (LS-pAF), their spatial distribution and the presence of a left-to-right atrial DF gradient remain poorly known. We hypothesized that the pre-ablation bi-atrial frequency characteristics of LSpAF pts terminated within the left atrium (LT) are different from that of non terminated (NT) ones. Methods: 23 consecutive pts (59 + 7y, LS-pAF duration 19 + 12m) underwent stepwise catheter ablation (stepCA) consisting in pulmonary veins isolation, left atrial (LA) defragmentation, and right atrial (RA) ablations for non terminated AF. A quadripolar catheter (CAT) was placed into the RA appendage (RAA), a decapolar CAT into the coronary sinus (CS) and a duodecapolar CAT into the LA divided into 8 segments. For each segment, 20sec of bipolar recording was acquired. The DF was defined as the largest peak in the power spectrum (3-15 Hz). The inter-atrial DF gradient was defined as the DF difference between LA and RA appendages. Results: LS-pAF was terminated in 83% (19/23) of the pts: 17 LT, 2 during RA ablation and 4 NT. The figure shows that before ablation bi-atrial DF values of LT pts are significantly lower than that of NT pts for each LA segment as well as for the RAA (p , 0.05). No significant LA-to-RA DF gradient was observed both for LT (0.3 + 0.5 Hz, p=ns) and NT (0.5 + 0.03 Hz, p=ns) pts. No significant difference in DF values was observed between LA segments. Conclusions: The lower DF of LT pts is suggestive of a higher organization within both atria compared to NT pts. Our findings suggest that low bi-atrial DF values, but not inter-atrial DF gradient, might be of interest for selecting LS-pAF candidates for sinus rhythm restoration by step-CA.
P980
P981
Human vs Robot: a comparison of catheter contact force application for AF ablation (a MAST-AF substudy)
Optimizing cryo-balloon ablation: what have we learned from online signals visualization?
G.S. Chu1, N. Masca2, T.P. Almeida3, P.D. Brown1, F.S. Schlindwein3, and G.A. Ng2
D.E. Pajitnev, T. Neumann, S.W. Zaltsberg, H. Greiss, J. Sperzel, E. Akkaya, A. Berkowitsch, H.F. Pitschner, C.W. Hamm, and M. Kuniss
1
University of Leicester, Department of Cardiovascular Sciences, Leicester, United Kingdom; 2NIHR Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom; and 3University of Leicester, Department of Engineering, Leicester, United Kingdom Hypothesis: The magnitude and variability of applied catheter force may differ between robot-assisted and manual AF ablation. This may be dependent on the anatomical region of ablation. Method: MAST-AF (Manual vs Amigo SmartTouch AF Study) is an ongoing prospective randomized trial (NCT01583855) comparing the Amigo Remote Catheter System (Catheter Robotics Inc.) with manual AF ablation, using a force-measuring catheter and Carto 3 (SmartTouch, Biosense Webster). WACA was performed in all patients whilst blinded to force readings, and PVI was confirmed post-ablation. All RF applications were delivered at 40W. WACA lesions were systematically grouped by region using a clock face model, then analysed retrospectively by another physician who was blinded to the technique used. Mixed-effects models were fitted to log-transformed data, using planned contrasts to compare the two groups at each region, and over all regions. Results: From 10 robotic and 8 manual cases, 3329 ablation points were analysed, totalling 662,471 force data elements. ANOVA indicated a significant difference in force between regions, with a trend towards higher values anterior to the R pulmonary vein ostia (RWACA 1-5; see figure) for Amigo cases. No statistically significant difference was seen between the overall mean force applied during LWACA - 8.2g (Amigo) vs 7.3g (manual); nor RWACA - 10.2g (Amigo) vs 9.3g (manual). The standard deviation of the applied forces did not differ significantly, regionally nor overall, between the two groups (data not shown). Conclusion: In most regions, catheter force application characteristics are similar with both robot and manual procedures. Higher force values occur when ablating with the Amigo system adjacent to the aorta, mandating extra care when operating in this area.
Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany Introduction: PVI with cryoballoon (CB) is a generally established treatment of patients ( pts) with paroxysmal atrial fibrillation (PAF). The inability of assessing PV signals during CB freeze using conventional lasso catheter may be of disadvantage. A novel guiding and mapping catheter (AchieveTM ) has been introduced, aiming real time visualization of PV signals during freeze. Our aim was to assess possible clinical advantages of additional information available from the AchieveTM catheter. Methods: Consecutive pts with PAF and indication for PVI were included. After a single transseptal access PVI was performed utilizing 28 mm cryoballoon (ArcticFrontTM , Medtronic Inc.). Mapping of the PV signals before, during and after each freeze was performed with AchieveTM catheter (Medtronic Inc.). PVI with CB was defined as complete elimination of all fragmented signals at PV antrum with verification of entrance- and exit-block in each vein. After ablation all pts were prospectively followed with 7 days holter ECG every 3 months. As a primary endpoint we have defined the availability of PV signals during freeze (online) in each PV. As a secondary endpoint we have defined a predictive value of the time from freeze start to PV isolation (time to effect, TTE) and temperature at PV isolation (Ti) as well as nadir temperature (Tn). Results: We included 101 pts (60 male, age 58+1 years, EF 62% + 1%, LA size 39+1 mm). The mean procedure duration was 172 + 15 min with a fluoroscopy time of 22 + 1.2 min. Online LSPV signals could be recorded in 43 pts (43%), RSPV in 29 pts (29%), LIPV in 29 pts (29%) and RIPV in 19 pts (19%). After a median follow up of 14 months 70 pts (69%) were free of AT/AF. Due to a relative low rate of online signals visualization we were not able to show any correlation between TTE, Ti and clinical success. Only nadir temperature was predictive for recurrences. Only 2 from 30 pts (6%) with Tn , -458C have developed AF recurrences. Among remained 71 pts with Tn . -458C at least in one targeted PV recurrences were observed in 29 pts (41%), p=.012. Conclusions: Unfortunately the rate of real time visualization of PV signals remains low (1943%). TTE and temperature at PV isolation seems not to be predictive for clinical success. Freeze temperatures , -458C should be aimed in all PVs to ensure clinical success.
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P982
P983
Disparate distribution of catheter tissue contact forces at right versus left pulmonary veins in patients undergoing pulmonary vein isolation C.I. Park, H. Lehrmann, R. Weber, C. Keyl, J. Schiebeling, J. Allgeier, C. Herrera-Siklody, T. Arentz, and A. Jadidi
Conduction recovery in patients with recurrent atrial fibrillation after pulmonary vein isolation using multi-electrode duty cycled radiofrequency ablation
University Heart Center, Dept. of Cardiology, Freiburg - Bad Krozingen, Germany Introduction: Sufficient catheter tissue contact force (CF) is crucial in order to achieve durable transmural lesions. We prospectively evaluated the spatial distribution of CF between right and left pulmonary vein as well as the acute PV-Reconnection sites (PVR). Methods: 40 patients with symptomatic AF (33% persistent, 80% male, 61 + 10 years) underwent wide 3Dguided circumferential PVI with the new SmartTouchTM CF sensing catheter. Patients were ablated with operators being blinded to the CF/FTI data. The acute PVR sites (occuring spontaneously or under Adenosine injection) were annotated on the 3D-map. The spatial distribution of PVR sites was analyzed with regard to CF and relation to adjacent anatomic structures. Results: 153 PVs were ablated and isolated from the LA in 40 patients (7 patients with common ostium PV) by delivering 2064 points of RF ablation (right: 1156 and left: 908). We observed a significantly higher mean CF around right vs left PVs: Mean CF 10.4 g (Q1, Q3: 6.1, 15.6) vs 8.4 g (Q1, Q3: 5.1, 13.1), p , 0.05. Regional analysis revealed in almost all segments consistently higher CF values around right vs left PVs (left panel). A total of 35 PVR sites were observed spontaneously and under Adenosine injection. PVR occured significantly more often around the left than right PVs: 57% (20/35) vs 43% (15/35), p , 0.05. On both sides, the anterior part of PV and carina regions accounted for 80% of PVR sites. Conclusions: When using the transseptal access to perfomr PVI, we observed significantly higher CF parameters on the right than left PVs. PV-Reconnection sites occured significantly more on the left PV, particularly on the anterior-ridge and the carina region.
J. Balt, C. Karadavut, A.A.W. Mulder, JGL. Luermans, M.C.E. Wijffels, and L.V.A. Boersma Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands Background: The PVAC catheter is specifically designed for pulmonary vein isolation (PVI). Electrical reconnection of pulmonary veins is believed to result in AF recurrence. The purpose of the present study was to establish the location and extent of PV-reconnection after PVI with the PVAC catheter. Methods and Results: 82 patients (79% male, age 60 + 9 yrs) that underwent a redo-procedure for recurrent AF after PVAC ablation were included. The number of reconnected PV’s and site of reconnection was noted. The number of reconnected PV’s was 0, 1, 2, 3 or 4 in 0 (2.4%), 14 (17%), 23 (28%), 28 (34%) and 15 (18%) patients, respectively. Reconnection of left superior, left inferior, left common, right superior and right inferior PV was found in 66%, 63%, 83%, 57% and 67%, respectively ( p=0.48). In the left PV’s, reconnection was located significantly more often anterior than posterior; LSPV anterior 32/70 vs posterior 13/70 ( p , 0.01), LIPV anterior 26/70 vs posterior 9/70 ( p , 0.01). In the right PV’s reconnection was distributed equally in all quadrants. Two different modes of RF delivery during the PVAC procedure (bipolar:unipolar in a ratio of 2:1 [n=35] vs. 4:1 [n=47] resulted in comparable rates of PV reconnection. During follow up (median 296, range 109 – 1072 days) no AF/AT was documented in 57 patients (70%). Conclusions: Almost all patients (98%) with recurrence of AF after PVAC ablation show reconnection of at least one PV. All PV’s are equally likely to show reconnection. In the left PV’s, reconnection was found more often anteriorly than posteriorly. During pulmonary vein isolation with the PVAC catheter, prevalent sites of reconnection deserve close attention to increase success rate.
P984
P985 Balloon cryoablation is superior to circumferential RF pulmonary vein ablation in patients with paroxysmal atrial fibrillation
Exercise tolerance can improve with sinus rhythm restoration by the catheter ablation for persistent atrial fibrillation Y. Katsumata, S. Takatsuki, T. Kimura, N. Nishiyama, K. Fukumoto, K. Tanimoto, T. Sadahiro, Y. Ohgino, U. Tamura, and K. Fukuda Keio University School of Medicine, Tokyo, Japan Background: Although Atrial Fibrillation (AF) might have a negative hemodynamic effect which can lead to the decreased exercise tolerance and fatigability on exertion, restoration of sinus rhythm by the catheter ablation in patients with persistent Atrial Fibrillation (AF) remains controversial. The purpose of this study was to investigate whether restoration of sinus rhythm by the catheter ablation improved the exercise tolerance in patients with persistent AF. Methods: This study included 24 patients who underwent the catheter ablation for persistent AF from January 2012 to October 2012 (57.8 + 1.8 y/o, 22 males, AF duration 28.2 + 7.2 years). The exercise tolerance by the cardiopulmonary exercise test was performed before and 3-6 months after the catheter ablation. Results: The baseline peak oxygen uptake ( peak VO2), maximum stress dose, and VE-VCO2 slope were 24.9 + 1.0 ml/kg/min, 137.4 + 6.3 W, and 27.0 + 0.6, respectively. The baseline peak VO2 significantly correlated with BNP (R=-0.47, P=0.018), but didn’t correlate with the duration of Af (R=-0.22, P=0.29), CHADs score (R=-0.12, P=0.55), the rest herart rate (R=0.36, P=0.07), eGFR (R=0.27, P=0.19), the left atrial diameter (R=0.23, P=0.32) and the left atrial appendage flow velocity (R=0.04, P=0.85). Sinus rhythm was maintained in 21 patients (88%) over a 6-months follow-up (SR group), including 8 patients with oral antiarrhythmic drugs. The peak VO2 over 3 months increased significantly in SR group ( pre 25.3 + 1.1 ml/ kg/min, post 28.0 + 1.0 ml/kg/dl; P=0.036), and the maximum stress dose showed a tendency to increase ( pre 139.3 + 6.5 W, post 154.9 + 6.3 W; P=0.061). On the other hand, the VEVCO2 slope over 3months didn’t change ( pre 27.3 + 0.6, post 26.8 + 0.5; P=0.31). And the improvement rate of the peak VO2 over 6 months in SR group significantly correlated with the baseline VO2 or the baseline DVO2/DW (R=-051 P=0016, R=-0.63 P=0.002, respectively). These favorable changes were not observed in the remaining 3 patients with persisted AF after the catheter ablation. Conclusion: Elimination of AF by the catheter ablation was associated with improvement of the exercise tolerance, which could emerge 3-6months after the catheter ablation.
A. Wozniak, B. Sredniawa, P. Pruszkowska, O. Kowalski, R. Lenarczyk, J. Kowalczyk, A. Sedkowska, S. Pluta, and Z. Kalarus Medical University of Silesia, SCHD, Dpt. of Cardiology, Congenital Heart Disease & Electrotherapy, Zabrze, Poland Balloon Cryoablation (CRYO) has become an alternative technique to circumferential Radiofrequency (RF) pulmonary vein ablation in the percutaneous treatment of patients (pts) with Paroxysmal Atrial Fibrillation (PAF). Superiority of either technique has not been demonstrated yet. Purpose: To compare ablation procedures, their efficacy and safety between two Left Atrial (LA) ablation techniques (RF vs CRYO) in a 6-month Follow Up (FU). Methods: Study population consisted of 74 pts (57M; aged 55,9 + 10,3 yrs) with symptomatic PAF refractory to antiarrhythmic drugs, in whom first LA ablation was performed with one of two techniques: 43 pts composed the RF group (36M; aged 55,9 + 8,8 yrs) and 31 pts- CRYO group (21M; aged 55,8 + 12,2 yrs). Pts in both groups did not differ with respect to demographic data, co-morbidities and PAF characteristics. Routine mid-term FU was performed 6 months after the procedure with 12-lead ECG, ECHO and 7-day ECG Holter. Recurrence was defined as the presence of any AF episode .30s confirmed by either medical files, ECG or Holter monitoring, whereas clinical efficacy as the absence of clinical signs/symptoms and documented PAF episodes .30s (including asymptomatic) during FU. Results: The mid-term clinical efficacy was significantly higher in the CRYO group, what is shown in the table along with some procedural parameters. Overall complication rates were comparable with insignificant differences in their type in both groups. Fewer pts, although insignificantly, required analgesia during the CRYO than RF ablation: 58,1% vs 72,1%, respectively. Conclusions: Mid-term results of single LA ablation procedures demonstrate significantly higher clinical efficacy as well as shorter procedure and energy delivery duration in balloon cryoablation in comparison with circumferential RF pulmonary vein ablation in the treatment of PAF pts, with a comparable safety and better tolerance profile. Cryoballoon ablation should be considered the firstline technique in certain pts with PAF.
Procedure duration (min) Fluoroscopy duration (min) Energy delivery duration (min) Mid-term clinical efficacy n (%)
RF (n=43)
CRYO (n=31)
p
176.5 + 39.3 20.4 + 7.0 48.7 + 15.4 48.8%
148.1 + 26.7 26.3 + 9.1 35.5 + 9.2 77.4%
,0.001 ,0.01 ,0.001 ,0.05
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P986
Feasibility of percutaneos left atrial appendage occlusion combined with atrial fibrillation ablation
P987
Is septal muscle potentials guided ablation of the left atrial septum beneficial or harmful in patients with persistent atrial fibrillation?
S. Grossi, F. Bianchi, A. Sibona Masi, S. Lebini, and M.R. Conte
Y.M. Park, D.I. Lee, H.C. Park, J.E. Ban, J.I. Choi, H.E. Lim, S.W. Park, and Y.H. Kim
Mauriziano Hospital, Department of Cardiology, Turin, Italy
Anam Hospital, Korea University, Seoul, Korea, Republic of
Purpose: Patients ( pts) with atrial fibrillation( AF) are reported to have a five-fold increased risk of stroke. Anticoagulant therapy (OAT) carries the risk of major bleeding, is contraindicated in subgroups of patients and sometimes ineffective. The best treatment would be sinus rhythm (SR) maintenance. Since ablation therapy in persistent AF is associated with only a 28,4% long-term arrhythmia free survival, we do think that the best therapy in "triple" high risk patients (thromboembolic, bleeding and AF recurrence risk) would be the combination of ablation therapy plus percutaneous left appendage occlusion (LAO) in a single procedure. Our purpose is to evaluate feasibility of this approach. Methods: Pts referred for ablation of non-valvular AF , with CHA2DS2VASC 2 at high bleeding risk ( previous spontaneous major bleeding and/or high HASBLED ) or previous thromboembolic event /left atrial appendage (LAA) thrombus in spite of OAT . All patients were treated with OAT during the 4 weeks preceding the procedure . Intracardiac thrombosis was excluded by transesophageal echocardiogram (TEE). Ablation was performed via single transeptal puncture, left atrium (LA) mapping with Fast Anatomical Map, pulmonary veins isolation plus linear ablation; sheath exchange and angiography of LAA followed by LAA occlusion with Amplazter Cardiac Plugw during fluoroscopy and TEE. Results: 19 pts were enrolled. Characteristics: Mean age 72 + 5,5, 59% males, mean CHA2DS2VASC 3,4 + 1,2, mean HASBLD 3,1 + 1,3; 79% persistent AF, redo procedure 35%; 23% had an ICD, 25% had a previous stroke in OAT, 47% a previous LAA thrombous in OAT and 41% a previous major bleeding. Acute success of LAO was 90% (17/19). Total fluoroscopy exposure was 12 + 6 minutes including 2,3 + 1,5 spent for ablation. A trend in exposure reduction was noted between first procedures and last (learning curve). Total procedure time was 86 + 9,5 with 19,8 + 4,3 min spent for LAO. Major complications: 1 cardiac tamponade, and 1 vascular major complication. Conclusions: Appendage percutaneous occlusion is feasible when combined to atrial fibrillation ablation. It should be consider in patients at high bleeding and thromboembolic risk.
Background: Additional ablation at the septum of the left atrium (LA) could be beneficial due to elimination of triggers, or preventing septal macroreentry, but incomplete ablation at the LA septum may be arrhythmogenic. We hypothesized that complete elimination of potentials recorded at the circumferential septal muscle bundle (SMB) in the LA is beneficial in patients with persistent atrial fibrillation (AF). Methods: This study included 174 patients (56.5 + 10.0 years old) who underwent pulmonary vein isolation and linear or fractionated electrograms guided ablation for persistent AF. The patients were divided by adjuvant ablation strategy at the LA septum; no ablation at LA septum (group I, n=72), ablation at LA septum with complete elimination of SMB potentials (group II, n=50) and ablation at LA septum without elimination of SMB potentials (group III, n=52). Results: Baseline characteristics were not significantly different among three groups. One year clinical success after catheter ablation was not significantly different (61.1% vs. 60.0% vs. 53.8%, p=0.70) but long-term clinical success showed the trend of difference after a mean follow up period of 49.6 + 21.6 months (37.5% vs. 30.0% vs. 21.2%, p=0.14). Furthermore, Kaplan-Meier analysis revealed that patients with group III showed earlier recurrence than those with group I or II with borderline significance (median arrhythmia free survival duration; 17.1 vs. 18.0 vs 14.2 months, respectively, p = 0.06 by log rank) (Figure 1). Conclusions: Complete elimination of SMB potentials may be beneficial in maintaining sinus rhythm during long-term follow up in patients with persistent AF.
P988
P989
Predictors of atrial fibrillation recurrence after catheter ablation P.H.D. Carlos Kalil1, P.H.D. Eduardo Bartholomay1, M.D. Anibal Pires Borges1, M.D. Guilherme Gazzoni1, M.D. Edimar De Lima1, M.D. Rafael Moraes1, M.D. Renata Etchepare1, M.D. Carolina Sussenbach1, P.H.D. Luis Carlos Bodanese1, and P.H.D. Renato Kalil2 1 Hospital Sao Lucas of PUCRS, Porto Alegre, Brazil; and 2Institute of Cardiology of Rio Grande do Sul - University Foundation of Cardiology, Porto Alegre, Brazil
Introduction: Radiofrequency catheter ablation by electroanatomic mapping has become an important therapeutic option for the treatment of Atrial Fibrillation (AF). The complexity of the procedure, the different techniques used in the ablation, the diversity of patients with AF and their different pathogenies difficult the reproduction and indication of AF catheter ablation. We aim to detect possible variables associated to AF recurrence after procedure. Methods: We performed a prospective cohort study that included consecutive patients who underwent AF ablation treatment by electroanatomic mapping. Inclusion criteria were: age . 18 years-old; presence of paroxysmal, persistent or longstanding persistent AF; AF registered in electrocardiogram (ECG), exercise testing or Holter monitors (lasting more 15 minutes); presence of symptoms associated to the AF episodes; AF refractivity to at least two antiarrhythmic drugs, being one of them amiodarona, or the impossibility of antiarrhythmic drugs. Results: We included 94 patients (age 55,5 + 12,1 years-old, 84% male) with a median follow-up of 13,4 months. The recurrence-free rate after the procedure was 70,6%. There were 4,9% of complications. Patients with paroxysmal þ persistent AF had a recurrence rate of 26,9% versus 50% in patients with longstanding persistent AF ( p=0,04). Multivariate analyses showed that only the left atrium (LA) size . 46 mm was an predictor for AF recurrence after procedure with a HR = 6,23 (IC 95% 3,08-12,62); p , 0,001. The recurrence rates of AF in relation to the LA size are shown in the table. Conclusion: This study demonstrates that increased LA size was the only predictor of AF recurrence. LA size (mm)
n
Recurrence of AF; n(%)
HR
p
34-39 40-42 43-46 47-55
28 25 25 24
2 (7,1) 1 (4,0) 10 (40,0) 20 (83,3)
-
-
0,55 8,17 16,54
0,626 0,007 ,0,001
LA: left atrial; AF: atrial fibrillation; HR: hazard ratio.*p for trend , 0,001
Improved procedural efficacy of pulmonary vein isolation using the novel second-generation cryoballoon K.R.J. Chun, A. Fuernkranz, S. Bordignon, M. Gunawardene, B. Schulte-Hahn, V. Urban, B. Nowak, and B. Schmidt Cardioangiologisches Centrum Bethanien, Frankfurt a.M., Germany Introduction: The cryoballoon technology has the potential to isolate a pulmonary vein (PV) with a single energy application. However, using the first-generation cryoballoon (CB-1G) repeated freezing or additional focal ablation is often necessary. The novel secondgeneration cryoballoon (CB-2G) features a widened zone of optimal cooling comprising the whole frontal hemisphere. The aim of this study was to investigate the impact of the novel design on procedural efficacy of cryoballoon PV isolation (CB-PVI). Methods and results: Single transseptal CB-PVI using an endoluminal spiral mapping catheter was performed in 60 consecutive patients (CB-1G, 28 mm, 300 seconds application time: 30 patients; CB-2G, 28 mm, 240 seconds application time: 30 patients).When compared to the CB-1G, using the CB-2G increased single-shot PVI rate from 51% to 84% (P , 0.001) and decreased procedure duration (128 + 27 vs. 98 + 30 minutes; P , 0,001), and fluoroscopy exposure time (19.5 + 7.4 vs. 13.4 + 5.3 min; P = 0,001). Effective CB-2G PVI could be performed with increased real-time PVI visualization rate (49% vs 76%; P , 0.001). Time to PVI (TPVI) was shorter in the CB-2G group (79 + 60 vs. 52 + 36 seconds; P = 0.049). Procedurerelated complications occurred in 2 patients in the CB-1G group and 1 patient in the CB-2G group. Conclusions: The CB-2G significantly improved procedural efficacy compared to the CB-1G and provided reliable TPVI measurement. TPVI may be used to adjust application time and number individually in future studies. Final conclusions regarding the safety profile of the CB2G requires additional research.
ii138
P990
Atrial pacing with active fixation in the coronary sinus is feasible, safe and shows good and stable electrical parameters P.N.W.M. Breuls1, and J.T.H. Schmidt1
J.C.J.
Res2,
L.J.P.M.
Van
Woerkens1,
E.J.
Van
Den
Bos1,
P991
Fortuitous cardioversion of cardioversion of atrial fibrillation during ICD implantation A. Vischer, M. Mutschelknauss, M. Kuhne, S. Osswald, C. Sticherling, and B. Schaer
1
Albert Schweitzer Hospital, Department of Cardiology, Dordrecht, Netherlands; and 2Erasmus Medical Center, Department of Cardiology, Rotterdam, Netherlands Patients with Sick sinus syndrome (SSS) frequently have episodes of paroxysmal atrial fibrillation (PAF), which originates usually form the left atrium. Pacing from the left atrium via the coronary sinus (CS) may reduce the episodes of PAF. Therefore we performed a pilot study to evaluate the feasibility of left atrial stimulation from the coronary sinus in symptomatic patients with SSS and PAF. Methods: After obtaining venous access, the coronary sinus was cannulated with a deflectable catheter, such as Medtronic 10600. Angiography of the the coronary sinus and main side branches was performed with the occluding balloon catheter. A 4F lumenless electrode (Medtronic 3830) was positioned in the wall of the CS and tested for proper atrial sensing without R-wave far field sensing and atrial capture at reasonable thresholds, without ventricular capture at 10 Volt. If not, each time the lead was repositioned to a spot closer to the CS ostium. Results: This procedure was attempted in 57 patients and successful in all. Follow-up (FU) was 53 + 24 (range 2-93) months. No pt was lost during FU, but 10 pts went into permanent AFib. Acute and latest thresholds were 1,3 + 0.7 V (range 0.4-3.3 V) and 0.9 + 0.4 (range 0.4- 2.2) V. Pacing impedance at implant was 622 + 45 Ohm. Sensing: P values are 3.2 + 1.9 mV at implant, and 2.9 + 1.8 mV at the latest FU. Ten patients developed permanent atrial fibrillation. In a few pts the sensing value has to be adapted to avoid R wave oversensing. Complications such as dissections of CS, dislocations and/or high thresholds were absent: There was a good /excellent patient tolerance, which is undistinguishable of right atrial lead implants. Conclusions: This pilot study shows that placing an active pacing lead in the wall of the coronary sinus to obtain left atrial pacing is feasible and safe. Moreover, electrical measurements are within the limits of a standard atrial implant.
Atrial fibrillation, drugs and tools
University Hospital Basel, Department of Cardiology, Basel, Switzerland Aims: Patients with Implantable Cardioverter Defibrillators (ICD) and Atrial Fibrillation (AF) are at higher risk for inadequate ICD therapy, ventricular arrhythmias and overall death. However, restoration of sinus rhythm during ICD testing in patients with AF carries the potential risk of thrombembolic complications. We aimed to analyse the short- and long-term efficacy and safety of internal cardioversion (DC) of AF at Defibrillation Threshold testing (DFT) during ICD implantation. Methods and Results: 64 consecutive patients referred to a tertiary hospital in Switzerland for ICD implantation between 02/2002 and 03/2010 with AF or atrial flutter who underwent internal cardioversion during defibrillation threshold testing were included. All patients were sufficiently anticoagulated (INR .2) for .3 weeks or underwent transesophageal echocardiography prior to cardioversion. Shock testing converted 53/64 patients into sinus rhythm. Follow-up visits were performed at one and three months after ICD implantation and every six months thereafter. Of those patients who were converted into sinus rhythm, 45/53 patients (84%) experienced a recurrence of atrial fibrillation/flutter after a median of 54 days (IQR 34 - 193 days). There was no significant difference in the time of recurrence whether or not patients took Amiodarone, were alive at the end of follow-up or depending on the underlying heart disease. No patient experienced an ischemic stroke periinterventionally. Conclusion: Attempting cardioversion during defibrillation threshold testing appears to be safe, but sinus rhythm is not maintained in the majority of patients.
P992
CHA2DS2VASc score and the thromboembolic risk of electrical cardioversion of acute atrial fibrillation
P993
Vacuum therapy in electrocardiology E. Pilat1, R. Mlynarski1, A. Mlynarska2, and J. Wilczek1
T. Gronberg1, J.E.K. Hartikainen2, I. Nuotio3, A. Ylitalo4, M. Nikkinen2, and K.E.J. Airaksinen3
1
1
Late wound healing and wound infections after implantation of cardiovascular implantable electronic devices (CIED) are huge problems. In most of those cases lead extraction is a recommended treatment with reimplantation on the opposite site. Sometimes extraction can be impossible or risky. Vacuum assisted closure (VAC) can be an alternative method of treatment in selected patents. Methods: 23 pts (14M; aged 66 + 11) after implantation of a pacemaker (9 pts), ICD (5 pts) or ICD-CRT (9 pts) were included. For all of them the VAC therapy was used to support wound healing. Pts were excluded if vegetation was suspected on lead(s) or endocarditis . Dressings: White and Granu Foam (KCI) or VivanoMed (Hartmann) were trimmed to fit the wounds. ACTICOAT (Smith&Nephew) were used in some cases to protect the device site from bacterial colonization. Therapy need 4-5 short procedures (applying - dressing exchanges (2-3x) finishing). Adequate antibiotics were used in each. The success of the procedure was defined as complete wound healing with negative bacteriological culture. Results: In 5 (21,7%) pts late wound healing (or recurrent hematoma) and in 18 (78,3%) pts wound infections were observed. In 20 (86,9%) pts success of the VAC therapy was confirmed. In 1 (4,3%) case in the early period after VAC, a hematoma of the pocket was observed, but during a follow-up visit the success of the procedure was confirmed. In 4 (17,4%) case trans-venous extraction of the system was necessary (Cook Medical). No interactions with devices were found in all. On the figure below VAC therapy is presented. Conclusions: In our group the efficacy of the method was confirmed. The method is not replacement for lead extraction (according to guidelines), but sometimes can be an alternative.
University of Turku, Turku, Finland; 2Kuopio University Hospital, Kuopio, Finland; 3Turku University Hospital, Turku, Finland; and 4Satakunta Central Hospital, Pori, Finland
Purpose: Perioperative anticoagulation is recommended during cardioversion of acute atrial fibrillation (AF) in patients with risk factors for stroke. However, these recommendations are based on a few small retrospective studies. Hence, our aim was to determine the real-life risk related to electrical cardioversion of acute AF. We also assessed if CHA2DS2VASc score predicts embolic complications in this setting. Methods: During 2003-2010 3143 patients underwent 7660 cardioversions to acute (, 48 hours) AF in three hospitals. Embolic and bleeding complications were evaluated after 6508 successful electrical cardioversions. There were 2020 cases with and 4488 without periprocedural anticoagulation. Results: The success rate of electrical cardioversions was 94.2 %. A total of 38 definite thromboembolic complications were noted within 30 days (mean 5 days) after successful electrical cardioversion and 32 of those were strokes. In addition, 5 transient ischemic attacks and two pulmonary embolisms occurred. Incidence of definite embolic events was significantly higher in cardioversions without perioperative anticoagulation (0.8 % vs. 0.1 %, p = 0.001). No major bleeding events were registered. CHA2DS2VASc score predicted (p , 0.0001) embolic events in patients without anticoagulation (Figure). Conclusions: High CHA2DS2VASc is a strong predictor of embolic events when no anticoagulation is used. Periprocedural anticoagulation is important also in cardioversions of acute AF in patients with risk factors for stroke
Upper-Silesian Cardiology Center, Katowice, Poland; and 2Medical University of Silesia, Katowice, Poland
ii139
P994
Very-long-term monitored atrial tachyarrhythmia and time-dependent risk of ischemic stroke in patients with cardiac implanted electronic devices in the real world
Catheter ablation/except atrial
P995
Nonfluoroscopic mapping for supraventricular arrhythmia ablation in pediatric patients. Initial results in a prospective study S. Melo, C. Pisani, F. Darrieux, T. Barbosa, D. Hachul, A. Tanaka, C. Hardy, N. Miura, E. Sosa, and M. Scanavacca
S. Wang, Y.C. Kang, and T.S. Cheng
Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
Chang Gung Memorial Hospital, Taoyuan, Taiwan Objectives: This study evaluates the risk of non-fatal ischemic stroke associated with increased atrial tachycardia (AT) duration, independent of known risk factors, in patients with cardiovascular electronic implantable devices (CIED). Background: Whether long-term cumulative duration of AT increases the risk of stroke remains a contentious issue. Methods: This retrospective review examined 274 patients implanted with CIEDswith the function of monitoring AT. AT burdens (defined as the total AT duration in any of the sixmonth or twelve month follow-ups), collected from implantation to replacement of CIEDs. Patients were separated into high, low, and zero AT burden groups. Primary outcome was nonfatal ischemic stroke. Results: Over an average follow-up of 6.91 years, 10 patients (3.65%) developednon-fatal ischemic stroke. Log-rank test results indicated that the high AT burden group (AT cumulative duration A18 days), low AT burden group (, 18 days) and the group that was free from AT ( p = 0.001) significantly differed in stroke risk. In an alternative Cox model where AT burden was treated as a continuous variable, an increase in daily AT burden was significantly associated with an elevated risk of astroke (HR = 1.01, 95% CI: 1.004 to 1.014, p = 0.001). Multivariate Cox regression analysis revealed that hypertension (HR = 7.73, 95% CI: 1.12 to 53.19, p = 0.038), paroxysmal atrial fibrillation (HR = 18.68, 95% CI: 2.38 to 146.32, p = 0.005) and chronic atrial fibrillation (HR = 128.70, 95% CI: 8.53 to 1941.01, p , 0.001) wereindependently associated with a stroke. Conclusions: Patients during the lifetime of their device who had accumulated an AT duration exceeding 5%(18 days) of the total time in any of the one year periodswere more likely to have an ischemic stroke than those who had a low or zero AT burden.
Background: The current standard of care for imaging during supraventricular tachycardia (SVT) ablation uses fluoroscopy, which exposes otherwise healthy children to the potential harmful effects of radiation. Objective: The purpose of this study was to determine whether the adjunct use of nonfluoroscopic imaging systems reduces radiation exposure during SVT ablation among children. Methods: This was a prospective, single-center study that included consecutive patients aged with less than 18 years-old with SVT and normal cardiac anatomy referred to catheter ablation. Patients were randomized to control (fluoroscopy only) or study group (fluoroscopy þ NavX electroanatomic mapping). The same operator performed all procedures. Fluoroscopic and procedure times (minutes) and X-ray dose delivered (mGy) were registered, and radiation doses (mSv) were measured by two dosimeters positioned on the anterior and posterior chest wall. Results: Twenty nine patients were enrolled (14 control group, 15 study group). Median age was 12.5 years-old (Q1: 8.4, Q3: 15.1), weight was 49.2(Q1: 38.3 Q3: 65.1); 24(82.8%) had accessory pathways, 4(13.8)% had AVNRT and 1 (3.4%) Atrial Tachycardia. There was no difference on fluoroscopic time (Median: 117.5 vs 110 seconds, p=0.16), x-ray dose delivered (14.2 vs 9.3mGy; P=0.10) and x-ray exposure measured on anterior [Study: 0.35mSv (Q1:0, Q3: 0.775) vs Control: 0mSv (Q1: 0, Q3: 0.7); P=0.35] and posterior [Study: 0.5mSv (Q1: 0 Q3 2.07) vs Control: 0.9mSv (Q1: 0.3 Q3: 2); P=0.6] dosimeters. Procedure time was longer on the study group (Median: Study: 95 Control: 52.5, P=0.01). Acute success was obtained in 13 (92.8%) procedures on control group and in 13(86.7%) in the study group (P=1), with no adverse events. Conclusion: Electroanatomic nonfluoroscopic imaging systems during SVT ablation in children resulted no reduction of fluoroscopic time and in radiation. Conversely, an increase in the procedure time was observed.
P996
P997
Prospective characterization of catheter-tissue contact force at the cavotricuspid isthmus in an experimental model in pigs Panoramic body surface electrocardiographic mapping of tachyarrhythmias in adult patients with congenital heart disease
R. Matia, A.H. Madrid, L. Carrizo, A. Delgado, H. Del Castillo-Carnevali, S. FernandezSantos, C. Lazaro, C. Pindado, C. Moro, and J. Zamorano University Hospital Ramon y Cajal, Department of Cardiology, Madrid, Spain
I. Suman Horduna, L. Mantziari, and S. Ernst Royal Brompton and Harefield NHS Trust, London, United Kingdom Introduction: In adult patients with complex congenital heart disease extensive invasive intracardiac mapping is usually necessary during a single EP procedure. We assessed the clinical utility of a novel noninvasive, single beat simultaneous electrocardiographic mapping system (ECVUETM , CardioInsight USA) in diagnosing multiple tachycardias in this population. Methods: Consecutive patients with complex congenital heart disease and documented arrhythmias were selected. Noninvasive ECVUETM simultaneous spatial mapping was performed both pre- and intra-procedurally to localize the arrhythmia origin and to guide ablation. All patients underwent non-gated, native CT scans to provide geometrical information and generate electroanatomic maps of the epicardial activation. Results: Five patients (4 female) with a median age of 37 years were studied. Non-invasive ECVUETM evaluated 12 arrhythmias across the 5 patients (2.4 arrhythmias/patient) and correctly diagnosed the region of interest in 11 of 12 (92%) arrhythmias. Median procedure duration and fluoroscopy time were 270 min and 11 min, respectively. Remote magnetic navigation was used in 2 procedures. Acute ablation success was achieved in 4 of 5 patients, and in 10 of 12 arrhythmias. In one patient the accuracy of the system in localizing the origin of the tachycardia was mitigated by the significant intraatrial delay secondary to post-surgical scarring. Conclusions: Non-invasive panoramic mapping, via ECVUETM , is a novel tool for evaluating complex arrhythmias, particularly helpful in patients with congenital anomalies. It can be used in conjunction with other technologies such as remote magnetic navigation, facilitates ablation of multiple arrhythmias in single procedure, with no longer than expected procedure length or fluoroscopy time.
Objectives: The main objective of this study was to determine in an experimental model in pigs the pathological effects of performing cavotricuspid isthmus catheter ablation with a new contact system that provides continuous pressure monitoring during radiofrequency ablation procedures. Methodology: We performed the procedure in 8 pigs in an experimental electrophysiology laboratory. The animals were sedated with 10 mg/kg intramuscular ketamine and 20 mg/kg of sodium thiopental. After groin dissection were implanted 12 Fr introducer in the right femoral vein. We programmed a maximum pressure of ,10 grs. (axial or lateral), 10-20 grs., 20-30 grs. and . 30 grs. in 2 pigs each. The power set was 40 Watts with a maximum target temperature of 458C. We performed a RF line dragging from the tricuspid valve to the inferior vena cava in the 8 pigs. Euthanasia of the animals was performed a week after the procedure. The heart was sectioned and fixed in 10% formalin and a pathological exam of the lesions was performed. External surface was examined searching for transmural lesions and injury of extracardiac adjacent organs. The endocardial macroscopic analysis and the extent of lesions, the presence of thrombus, transmurality and endothelial rupture was assesed. Results: With , 10 grs. force the lesions were never transmural and the mean depth was very low (, 1mm) (table). Conclusions: When ablating the cavotricuspid isthmus is necessary to achieve contact pressure higher than 20 grs. to produce transmural and deep lesions.
Force
n
Depth
Transmural
Cratering
, 10 grs 10-20 grs 20-30 grs .30 grs
2 2 2 2
0.75 3 6 5
0% 50% 100% 100%
0% 0% 100% 100%
ii140
P998
A novel approach for the successful radiofrequency ablation of noninducible atrial tachycardias using bump induction D.H.J. 1
Elder1,
N.
Grubb2,
and C.
First human use of a novel epicardial access needle embedded with a real time pressure/frequency monitoring of thoracic structures to facilitate epicardial access
Lang2
Ninewells Hospital, Dundee, United Kingdom; and Department of Cardiology, Edinburgh, United Kingdom
2
P999
Royal Infirmary of Edinburgh,
Introduction: Radiofrequency ablation is a well-established treatment for a wide range of cardiac arrhythmias. One of the challenges faced by electrophysiologists in the laboratory is non-inducibility of a previously documented tachycardia. We describe a novel approach for mapping previously documented atrial tachycardia (AT) which could not to be induced by conventional stimulation nor pharmacological provocation. Methods: Patients with a previously documented supraventricular tachycardia and a normal diagnostic electrophysiological study (EPS), in whom no substrate for tachycardia could be identified by programmed stimulation or pharmacological means were included. Isoproteronol was titrated to achieve a heart rate of 100 b.p.m. and a map catheter was placed in the right atrium(RA). The catheter was moved in the RA paying specific attention to the common sites for AT. If no arrhythmias were induced in the RA, the same procedure was undertaken in the LA. Localized mechanical irritability resulting in a reproducible tachycardia of stable cycle length lasting more than 5 seconds was considered significant. RF energy was then delivered to the candidate site. The end-point was non-inducibility at that site. Results: between 2009 and 2012, 522 patients were referred for EPS with a view to ablation of narrow complex tachycardia. 20 patients had both documented supraventricular arrhythmias and a negative EPS and entered the protocol. 18 patients (80%) had 19 atrial arrhythmias induced by ‘bump mapping’ which met criteria, and underwent RF ablation. RF application at successful sites was associated with abrupt onset of tachycardia with RF application, and termination usually within 20 seconds. Mean tachycardia CL was 234 + 43 ms. Over a mean follow-up of 18 months, 14 patients had no recurrence of their symptoms, whilst 4 required a repeat procedure of whom 2 are now symptom free. Candidate sites for ablation were identified in or around the left sided PVs (8), right upper PV (1), crista terminalis (4), tricuspid annulus (1), LA roof (1), mitral annulus (1) and inter-atrial septum (3) Conclusions: In patients with a documented tachycardia and a negative EPS, "bump induction" offers the electrophysiologist a therapeutic possibility with a high medium to long term success rate
L. Di Biase1, Z. Csanadi2, G. Sandorfi2, E. Nagy-Balo2, P. Santangeli1, C. Trivedi1, A. Leny2, A. Kiss2, A. Natale1, and J.D. Burkhardt1 1 Texas Cardiac Arrhythmia Institute at St David Medical Center, Un. of Texas and University of Foggia, Austin, United States of America; and 2University of Debrecen, MHSC-Faculty of Medicine, Institute of Cardiology, Debrecen, Hungary
Introduction: Epicardial (epi) ablation represents an adjunctive strategy for the treatment of challenging arrhythmias. Major complications may occur during epi access since the needle may inadvertently puncture the right ventricle (RV), the pleural space or the lung. We sought to evaluate if a new access epi needle reduce the risk for RV puncture and complications. Methods: 7 consecutive pts with epi arrhythmias (6 ventricular, 1 supraventricular) were enrolled. Epi access with a “novel needle” embedded with a tip sensor able to record beat-to-beat pressure waveform was utilized. Successful epi access was confirmed by fluoroscopy, contrast injection and visualization of the guidewire looping around the epi border of the heart. In 4 cases the epi access was obtained by an expert operator, while in 3 cases the access was obtained by a less experienced operator. Results: Successful epi access was obtained in all cases. No acute and delayed complications occurred. Mean Pericardial pressure/pulsation was 3.5 +1.3 mmHg while mean RV pressure was 15+4 mmHg ( p=0.001). Pressure monitoring identified pericardial wire access position in 75% of the attempts and was able to identify RV puncture in 100% of the cases. 3 false negative readings were recorded, where the guidewire was within the pericardial space while the needle tip pressure was indicating differently. Unintended RV puncture occurred in 50% of the cases(always detected). Unintended RV puncture occurred more often in the less experienced operator (6 times vs 2 times, P, 0.05). Conclusion: Real time pressure monitoring identifies successful pericardial access and RV perforation. This information would be important to facilitate epi access to less experienced operators.
P1000
P1001
Accuracy of electrocardiographic algorithms in patients with Wolff-Parkinson-White syndrome and left ventricular hypertrophy
Common atrial flutter ablation with duty-cycled radiofrequency energy
D. Novikov1, M. Kandinsky1, S. Popov2, A. Samoilov1, and M. Latkin1
A. Avella, P. De Girolamo, F. Laurenzi, and A. Pappalardo
1
Regional Clinical Hospital No1, Krasnodar, Russian Federation; and 2Research Institute of Cardiology SB of RAMS, Tomsk, Russian Federation Purpose: Accessory pathway (AP) location may be determined before ablation procedure by many electrocardiographic (ECG) algorithms. But there is lack of data about electrocardiographic features in patients with Wolff-Parkinson-White (WPW) syndrome and concomitant heart diseases. The purpose of the study was to evaluate the accuracy of Arruda, Iwa and Gallagher algorithms in patients with WPW syndrome and left ventricular hypertrophy. Methods: 508 patients ( pts) with manifest WPW syndrome were included in the study (317 men, mean age 34.6 + 16.3 years old). ECGs of 486 pts had clearly visible delta-wave in all standart and precordial leads and were analyzed with Arruda, Iwa and Gallagher algorithms before radiofrequency ablation. 47 pts had left ventricular hypertrophy or thickness of the interventricular septum or posterior left ventricular wall more than 10 mm measured by two-dimensional echocardiography (first group). Other 439 pts were included in second group. Radiofrequency catheter ablation of AP was performed in all pts in 2007-2011. Ablation catheter position during successful ablation considered final location of AP. The accuracy of algorithm was defined as ratio between pts with accurately determined AP position and all pts where the algorithms were used. Statistical analyses were performed using chi-square test. Results: Accuracy of Gallagher algorithm in pts from the first group does not differ significantly from accuracy in the second group (27.7 % and 16.2 %, p = 0.109). Accuracy of Arruda algorithm in pts from the first group does not differ significantly from accuracy in the second group (44.7 % and 41.9 %, p = 0.817). Accuracy of Iwa algorithm in pts from the first group does not differ significantly from accuracy in second group (10.6 % and 19.4 %, p = 0.210). Accuracy of Arruda algorithm in pts from the first group does not differ significantly from accuracy of Gallagher algorithm in the first group ( p = 0.238) but is higher than accuracy of Iwa algorithm in this group ( p = 0.005). Conclusions: Left ventricular hypertrophy and thickness of the interventricular septum or posterior left ventricular wall more than 10 mm do not reduce the accuracy of Arruda, Iwa and Gallagher algorithms in pts with WPW syndrome. It is preferable to use Arruda or Gallagher algorithms in these cases.
San Camillo-Forlanini Hospital, Research Institute of Cardiac Arrhythmia & Heart Failure, Cardiology, Rome, Italy Purpose: an innovative hexapolar ablation catheter (T-VAC, Medtronic-Ablation Frontiers) has been recently developed to create continuous linear lesions. Using duty-cycled RF (DCRF) energy, T-VAC catheter should simplify the ablation of macroreentrant atrial arrhythmias such as typical right atrial flutter (AFL). Aim of our study was to assess the learning curve with TVAC catheter during cavotricuspid isthmus (CTI) ablation. Methods: we enrolled 22 consecutive patients ( pts) (18 men, 65 + 8 years) with typical AFL. Conventional mapping was performed with multipolar diagnostic catheters placed at the lowlateral tricuspid annulus (TA) and within the coronary sinus (CS). Before ablation 14 pts (64 %) showed isthmus-dependent AFL. In 8 pts (36 %), presenting in sinus rhythm, pacing maneuvers confirmed conduction capability of the CTI. DCRF energy was delivered, in a temperature-controlled power-limited manner, at the T-VAC catheter positioned on CTI, until local activity was no longer observed (target temperature: 60 8C; maximum duration: 90 seconds). Bidirectional CTI block was confirmed by: a) craniocaudal activation sequence along the low-lateral TA while pacing from the proximal CS; b) analysis of activation time at proximal CS with differential pacing from lateral vs low TA. Results: CTI block was obtained with the T-VAC catheter in 18 pts (82 %), (RF time: 597 + 250 seconds; RF applications: 8.3 + 2.8, 84% with 1:1 and 16% with 2:1 bipolar/unipolar ratio setting). In 4 pts (18 %) CTI block was completed with a conventional 8 mm tip ablation catheter. All failures occurred during the first 8 procedures (learning phase). A 93 % success rate (14/15 pts) was obtained supporting T-VAC catheter positioning with a steerable introducer, against a 57% success rate (4/7 pts) obtained with T-VAC only. No major complications were observed. Conclusions: CTI ablation may be safely performed using T-VAC catheter and duty-cycled RF energy. Anyhow a short learning phase and the support of a steerable introducer may be necessary to obtain the best therapeutic efficacy.
ii141
P1002
P1003
Escaping from the window of interest phenomenon during electroanatomical mapping of atrial tachycardias E. Lyan1, A. Klukvin2, G. Gromyko1, F. Tursunova2, A. Kazakov1, A. Merkureva1, A. Morozov2, P. Krasnoperov2, and S. Yashin1 1 Pavlov State Medical University, Saint Petersburg, Russian Federation; and 2State Medical Academy named after I. I. Mechnikov (SPSMA), Saint Petersburg, Russian Federation
Purpose: "Window of interest" (WOI) is the time frame tool, which is applied during electroanatomical mapping (EAM). It usually corresponds to 90% of the cycle length (CL) and helps to define local activation time (LAT) of the point. Despite of "early meets late" activation pattern suggests reentry, in some cases this mechanism cannot be proved by entrainment maneuvers. One of the causes of such discrepancy is the "escaping from the window of interest" phenomenon, when LAT of point with very late timing shifts beyond the WOI to the next cycle and becomes "early". This takes place in some cases of atrial tachycardia (AT) in presence of area with very delayed conduction, when total chamber activation time exceeds CL. The purpose of this study was to evaluate the incidence and substrate for this phenomenon. Methods: Study included 183 patients, who had undergone catheter ablation of atrial tachycardia. In each case both EAM and entrainment mapping had been performed. WOI had been set as 90% of AT CL and its borders had been adjusted to mid-diastolic interval relatively ECG. Results: During EAM 87 cases had showed “early meets late” activation pattern. Amid 9 cases with very long postpacing interval (PPI-CL .40 ms) at the "early meets late" site, four had demonstrated "escaping from the window of interest" phenomenon. Characteristics of substrate for this phenomenon is displayed in the table1. In each case previous lesions had created passively activated delayed conduction area. Total chamber activation time had exceed AT CL. LAT of points inside delayed area had shifted beyond WOI to the next cycle ( pseudo-early). After adjustment of AT mechanism interpretation all patients had been successfully ablated and hadn’t any relapse of arrhythmia during follow up. Conclusion: “Escaping from the window of interest” is the rare phenomenon (2%) and should be considered during interpretation of EAM. Entrainment mapping is essential for validation of AT mechanism.
Patient#
AT mechanism
CL, ms
Total activation time, ms
PPI in delayed area, ms
Delayed conduction area
Previous operations
1
RA upper loop
200
210
570
MAZE IV
2
RA upper loop
210
220
410
3
Perimitral AFL Perimitral AFL
220
240
370
RA lateroinferior wall RA lateroinferior wall right PV antrum
260
270
390
left PV antrum
4
MAZE IV þ mitral valvuloplastic
The stepwise algorithm using clinical features after ECG differentiation could localize the origins of focal atrial tachycardias from the adjacent structures J.-S. Uhm, J. Shim, J. Wi, H.S. Mun, H.N. Pak, M.H. Lee, and B. Joung Yonsei University, Severance Hospital, Seoul, Korea, Republic of Background: It is difficult to differentiate the origins of focal atrial tachycardias (AT) from the adjacent structures by only ECG. This study evaluated whether the different clinical features of these AT might help to differentiate the origins of AT. Methods: We included 194 patients (age, 43.5 + 17.9 years; male, 53.8%) who underwent electrophysiologic study due to focal AT. We evaluated the accuracy in differentiating the origin of AT by using ECG alone and by adding clinical features. Results: The ECG between AT from LSPV (n=24) and LAA (n=6) using ECG features (V1þ, II/III/aVFþ, I-, aVL-), and between RSPV (n=14) and SVC (n=8) (V1þ, II/III/aVFþ, Iþ, aVR-) showed same patterns. However, while all AT from LAA showed, 22 (92%) out of 24, AT from LSPV was related with atrial fibrillation. After localizing AT foci with ECG, the incessant clinical feature could be differentiated AT from LSPV and LAA with accuracy rate of 93%. Moreover, on-and-off pattern was observed in 4 (50%) out of 8 AT from SVC and 13 (93%) out of 14 AT from RSPV. After localizing origins of AT with ECG, on-and-off clinical feature differentiated AT from RSPV and SVC with accuracy rate of 77%. Conclusions: The differentiations of AT from the adjacent structures including LSPV and LAA, and RSPV and SVC were difficult because of similar ECG patterns. The stepwise algorithm using clinical features after ECG differentiation was useful to differentiate the focal AT from adjacent structures.
Catheter PVIþ LA linear abl Catheter PVIþ LA linear abl
AFL = atrial flutter, RA= right atrium, PV = pulmonary vein
P1004
P1005
More than 50% of atrial flutter cycle length - a simple algorithm to evaluate isthmus block during ablation of atrial flutter Prognostic value of incremental pacing maneuver for long term recurrences after typical flutter ablation
P. Insulander, H. Bastani, F. Braunschweig, N. Drca, K. Gudmundsson, G. Kenneback, B. Sadigh, J. Schwieler, J. Tapanainen, and M. Jensen-Urstad Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
E. Valles Gras, V. Bazan, B. Benito, M.E. Jauregui, J. Bruguera, and J. Marti Hospital del Mar, Barcelona, Spain Background: Achievement of complete conduction block across the cavotricuspid isthmus (CTI) is associated with a reduction in typical atrial flutter recurrences after ablative therapy. A ,20 ms increase in the distance between the 2 CTI potentials during the Incremental Pacing (IP) maneuver has been proved as a highly specific marker to differentiate functional from complete CTI block during ablation. Methods: One hundred and thirty-four patients (78% males; 67 + 13 years) undergoing successful CTI ablation were included and separated into 2 groups as follows: Group 1 (n = 68), in whom ablation was performed before the incorporation of the IP maneuver; and Group 2 (n = 66), undergoing IP during ablation to corroborate complete CTI block. The completion of the CTI block was also assessed through other previously reported maneuvers in both groups. Results: No differences between Group 1 and Group 2 were observed in relation to fluoroscopy or radiofrequency times (18 + 2 vs. 17 + 7 min and 873 + 380 vs. 825 + 426 sec, respectively, p . 0,05). As expected, the follow-up period was longer in Group 1 (1366 + 571 vs 588 + 228 days, p , 0,01). Flutter recurrences were observed in 12 patients (9%), essentially occurred during the first year after ablation (in 9/12 patients, 75%), and were more common among Group 1 patients (10/68 patients (15%) vs. 2/66 patients (3%); p = 0,039). Conclusion: Utilization of the IP maneuver for the diagnosis of complete CTI block is accompanied by a reduction in atrial flutter recurrences after ablation.
Background: Isthmus ablation in patients with common atrial flutter (AFL, cavotricuspid dependent) is recommended first line therapy and successful ablation is evaluated by bidirectional isthmus block, i.e. recording of double potentials (DP) in isthmus during stimulation septally and laterally of the ablation line and by cranial-to-caudal activation sequence in the right atrial lateral wall. Usually a DP . 100-110 ms is considered consistent with a block, although it has been shown that DP duration depends on AFL cycle length (CL). We wanted to evaluate DP in relation to AFL CL in patients with recurrent AFL after acutely successful isthmus ablation. Materials and methods: 80 patients (11 women) with persistent AFL undergoing acutely successful isthmus ablation with no recurrence and 23 patients (3 women) with acutely successful isthmus ablation but with recurrence were included. AFL cycle length and double potential duration in the isthmus line after ablation and during septal and lateral pacing were measured as well as confirmation of cranial-to-caudal activation. Correlation between AFL CL and DP was done in successful procedures and compared with procedures where recurrences had occurred. Results: Follow-up was 52 (range 12-67) months. There was a linear relationship between AFL CL and DP duration in patients with successful isthmus ablation ( p , 0.0001), which was absent in non-successful cases. Depending on AFL CL, an expected minimum DP duration could be estimated as ~50% of the AFL CL in successful procedures. In procedures with a DP duration ,50% of the AFL CL, the recurrence rate was 88% (15/17 cases) and in procedures with DP duration 50% of the AFL CL the recurrence rate was 9% (8/86 cases). In 13 cases successful redo ablation was done, in 11/13 cases DP increased to .50% of AFL CL. Conclusion: Duration of double potential for successful isthmus ablation should be evaluated in respect to atrial flutter cycle length. A double potential duration less than 50% of the atrial flutter cycle length is usually not consistent with de facto bidirectional block, and ablation should be continued with an aim of double potential duration more than 50% of the atrial flutter cycle length.
ii142
P1006
P1007
Influence of radiofrequency catheter ablation of idiopathic ventricular tachycardia / premature ventricular ectopics form the outflow tracts on quality of life D. Goncharik, A. Mrochek, A. Chasnoits, O. Kovalenko, V. Golenischa, and T. Burmistrova
The relationship of congenital diverticulum in right outflow tract (RVOT) and ventricular arrhythmia
Republican Scientific and Practical Centre of Cardiology, Minsk, Belarus Purpose: Most idiopathic ventricular tachycardia (VT) / premature ventricular ectopics (PVC) from outflow tract (OT) are not life threatening. The goal of treatment is usually to improve the quality of life. The effects of ablation on health-related quality of life have not been systematically studied in this group. So the purpose was to assess influence of catheter ablation on quality of life in patients referred with idiopathic (VT) /frequent PVC from the OTs. Methods: Quality of Life was measured with The Short Form Health Survey (SF-36) before and after catheter ablation (6 month) of idiopathic VT/PVC from OTs. Overall 94 patients (18 years of age or older) had idiopathic arrhythmiogenic focus in regions of OT and referred for radiofrequency catheter ablation of symptomatic idiopathic ventricular arrhythmias in last 3 years. In all patients with ablation success (81 patients [34 males, 47 females]; success rate = 86.1%) the following parameters were measured: individual’s sense of vitality and of mental, physical functioning, physical role function, emotional, and social role functions, bodily pain, and general health. Scores were normalized to a scale ranging from 0 to 100, with lower scores representing a lower quality of life. Results: Catheter ablation was associated with significant improvement in quality of life measured 6 months after ablation. Women as compared to men express more improvement in SF-36 Vitality, SF-36 Physical Functioning, SF-36 Emotional Role Function. Conclusions: RF catheter ablation improves the health-related quality of life for patients with idiopathic VT/PVC from OT.
Before ablation 6 month after ablation P SF-36 Mental Health SF-36 Vitality SF-36 Physical Functioning SF-36 Physical Role Function SF-36 Emotional Role Function SF-36 Social Role Function SF-36 Bodily Pain SF-36 General Health
64.67 42.56 60.72 44.29 56.94 67.37 64.04 63.15
71.12 61.22 78.15 68.44 79.82 78.69 75.12 71.02
,0.05 ,0.05 ,0.05 ,0.05 ,0.05 ,0.05 ,0.05 ,0.05
P1008
K. Cui, J. Jiang, H. Fu, Q. Yang, and H. Hu West China Hospital, Sichuan University, Department of Cardiology, Chengdu, China, People’s Republic of Introduction: Congenital ventricular diverticulum (CVD) in right ventricular outflow tract ( RVOT ) is a rare cardiac malformation, which can produce ventricular tachycardia or premature ventricular contraction (PVC).CVD in RVOT is often clinically asymptomatic and shows no abnormality in the chest X-ray or echocardiogram. Method: This study investigated clinical characteristics of patients with CVD presenting with VT or PVC. We retrospectively analyzed 91 cases with VT/PVC originating from RVOT in our single center from 2010 to 2012. The ventricular diverticula of RVOT were diagnosed by ventriculography of the right ventricle , reconstruction cardiac CT or cardiac MRI in five cases. The coronary artery disease, systemic inflammatory diseases, traumatic causes, or cardiomyopathies was excluded. Result: Eight VTs or PVCs were found in the five cases. The resting ECG and echocardiogram of the five patients were normal. The ECG of VT/PVC indicated the origination located in ROVT. The electro-anatomical mapping (CARTO 3 or CARTO XP) indicated that the earliest activation region during VT was localized in the septal aspect of the right outflow tract (RVOT) in the five cases. Repeated radiofrequency catheter ablation was performed at this region but failed to terminate the VT or PVC. Ventriculography of the right ventricle , reconstruction cardiac CT or cardiac MRI indicated diverticula. Ablation was performed at the margin of diverticula terminated the VT/PVC successfully in three cases. In the other two cases the diverticula were vessel-like. Ablations were performed in the vessel-like diverticula terminated the VTs. Conclusion: Ventriculography of the right ventricle , reconstruction cardiac CT or cardiac MRI will be considered to perform to reveal the congenital diverticulum especially for the difficult cases by routing mapping.
P1009
Epicardial ablation of a focal atrial tachycardia from the right atrial appendagge mimicking innaproppriate sinus tachycardia
Concomitant atrial fibrillation ablation and percutaneous closure of the left atrial appendage: a pivotal experience
S. Castrejon Castrejon1, D.D. David Doiny2, A.E.M. Alejandro Estrada Mucci1, J.F. Jorge Figueroa1, M.O.M. Marta Ortega Molina1, D.F.R. David Filgueiras Rama1, J.L.S. Jose Luis Lopez Sendon1, and J.L.M.L. Jose Luis Merino Llorens1
G.M. Fassini, O. Al-Nono, A. Dello Russo, M. Casella, S. Riva, M. Moltrasio, F. Tundo, M. Zucchetti, E. Russo, and C. Tondo
1
Robotic Cardiac Electrophysiology Unit, University Hospital La Paz, Madrid, Spain; and 2University Hospital La Paz, Department of Cardiology, Madrid, Spain Introduction: A 47-years old female patient with permanent supraventricular tachycardia with heart rate between 110 bpm during sleep up to 170 bpm with minimal daily activity and very limitating symptons was referred to our center after two unsuccessful attempts to modify the sinus node with radiofrequency catheter. The morfology of the P wave was identical independently of the heart rate and was compatible with sinus rhythm. Material and methods: A 24-poles circumferential catheter was placed around the tricuspid annulus and an steerable 4 mm tip irrigated ablation catheter was used to perform an activation map with an electroanatomic navigation system. Results: The tachycardia manifested overdrive suppresion and transitory slowing with adenosine boluses with inmediate resumption. The earliest atrial activity was mapped to an acute cul-de-sac in the right atrial appendage. Several RF applications terminated the arrhythmia but it reappeared after a few minutes. A subxifoideal pericardial access was then performed and a virtual anatomy of the whole pericardial cavity was reconstructed with the support of a navigatiom system. The earliest atrial acctivity was mapped 140 ms before the onsed of the P wave and 30 ms before the best endocardial precocity. The epicardial catheter was placed at the top of the right atrial appendage. A single RF lesion terminated the arrhytmia and rendered it noninducible. Only minimal changes of the P-wave morfology were appreciable on lead V1. The patient has remained asymptomatic after six months follow-up. Conclusion: Focal atrial tachycardias arising from the right atrial appendage may mimic innaproppriate sinus tachycardia and require epicardial ablation as is the case with focal tachycardias arising from the left atrial appendage.
Cardiology Center Monzino (IRCCS), Arrhythmology Unit, University of Milan, Milan, Italy Purpose: Percutaneous closure of the left atrial appendage (LAA) is a novel alternative for the treatment of patients with atrial fibrillation (AF) and a high risk of stroke in whom anticoagulation therapy is contraindicated. Pts selected for this procedure share an indication for catheter ablation too, and the presence of a closure device may complicate a subsequent ablation procedure. We report our experience of a combined AF ablation and LAA closure approach with the aim of assessing its safety, feasibility and mid-term efficacy. Methods: 14 patients (mean age 67.5 + 11 years) with AF, a high risk for stroke (CHADS2 score . 2), and contraindications to oral anticoagulation underwent, in the same session, AF ablation (12 pts with standard radiofrequency, 2 pts with cryoballoon) aimed at obtaining pulmonary veins isolation (PVI) alone for paroxysmal AF (3 pts) and PVI plus posterior box lesion for persistent AF (11 pts), and percutaneous LAA closure (Amplatzer Cardiac Plug, St Jude Medical, in 11 pts and Watchman, Boston Scientific, in 3 pts). All the procedures were performed under fluoroscopy and 3D transesophageal echocardiography (TEE) guidance. The patients were evaluated at 1,3,6 months. Patients were discharged on double antiplatelet therapy for 3 months until a TEE was performed to confirm LAA exclusion and then kept with aspirin alone. Results: The LAA was successfully occluded in all the patients. The mean fluoroscopy time was 35.6 + 10 minutes. The mean device size was 24+4 mm. Follow-up TEE showed complete exclusion of LAA without device-related thrombus formation and without peri-device leaks in all patients. None of the patients experienced recurrence of AF or major adverse events during the follow-up following the previous antiarrhythmic drug therapy. Conclusion: Our preliminary data suggest a one-session AF ablation and LAA closure as safe and feasible approach, with favorable mid-term clinical outcome.
ii143
P1010
P1011
Peripartum focal atrial tachycardia originating from right atrial appendage with cardiogenic shock requiring circulatory support refractory to catheter ablation
Safety and efficacy of open irrigated-tip catheter ablation of Wolff-Parkinson-White syndrome in children and adolescents
R. Nakamura, A. Mizukami, M. Suzuki, A. Matsumura, and Y. Hashimoto
S. Gulletta, D. Tsiachris, A. Radinovic, P. Mazzone, C. Bisceglia, N. Trevisi, G. Paglino, B. Bellini, S. Sala, and P. Della Bella San Raffaele Hospital (IRCCS), Arrhythmology, Electrophysiology and Cardiac Pacing Unit, Milan, Italy Purpose: Irrigated tip-catheter technology has been used for the elimination of resistant accessory pathways (AP) in adults with Wolff-Parkinson-White (WPW) syndrome. However, there are persistent concerns regarding the safety of irrigated catheters in the pediatric population. In this report we present our experience, in terms of effectiveness and safety, of irrigated catheter technology in children and adolescents who underwent ablation of WPW. Methods: We prospectively followed up all patients less than 18 years old (n=41, mean age of 12.8 years old) who were referred to our center for radiofrequency (RF) catheter ablation of WPW between January 2010 and July 2011. Catheter ablation was performed in all patients using an open-irrigated tip catheter (Biosense, Celsius Thermocool 3.5 mm, 7F, B-type). Power was started from 15 W up to 30 W in right-sided AP; RF pulses in left-sided APs were delivered at 40 W while 20 W was delivered inside the coronary sinus. Results: Mean procedure time was 26.4 min and mean fluoroscopy time was 12.2 min. Overall procedural success was obtained in 39/41 (95.1%) patients after the first procedure. No complications were observed after the procedure. All patients attended their scheduled follow up visit at 3, 6 and 12 months and no recurrences were observed based on 12-lead ECG and 24hour Holter monitoring. Conclusions: RF ablation of APs using open irrigated-tip catheters can be performed in children and adolescents with a high acute and long term success rate, very short procedure times and acceptable fluoroscopy times.
Kameda Medical Center, Kamogawa, Japan A 28-year-old woman in 19th week of her first pregnancy presented with chief compliant of palpitation. ECG showed atrial tachycardia (AT) with HR of 180 bpm. The AT was resistant to medications and direct current shocks. Due to occurrence of exertional dyspnea, we performed radiation-free catheter ablation with electroanatomical mapping system (CARTO) at 26th week of pregnancy. Activation map of AT showed the apex of right atrial appendage (RAA) as the focus of the tachycardia. Repeated ablation around this area with 4mm tip ablation catheter and open irrigated tip ablation catheter failed to terminate the tachycardia, but the cycle length of the AT prolonged from 300ms to 400ms. After the ablation, AT with heart rate of 140-150 bpm continued, but she was free from heart failure symptoms, and delivered a healthy baby in 39th week of pregnancy. Two months after delivery, she developed heart failure and transported to our hospital. AT was over 200 bpm and severe systolic dysfunction was observed by echocardiogram. Amiodarone and randiolol had started carefully which slowed the heart rate 150/min, but she got into cardiogenic shock which did not respond to cathecolamines. We immediately inserted percutaneous cardiopulmonary bypass (PCPB) and intraaortic balloon pumping (IABP), and performed electrophysiological study. The origin of AT was the apex of RAA, unchanged from the first session. Repeated attempts of cauterization failed again, and surgical RAA resection was performed. After that, no arrhythmia has appeared. We succeed in withdrawal of PCPB and IABP support. She has administered bisoprolol and enarapril, and was discharged without notable after-effects. Her cardiac function estimated by echocardiography recovered normality by 3 months. We experienced a very rare case of refractory peripartum AT requiring circulatory support. In peripartum period, many hormonal and hemodynamic factors effect the cardiovascular system, which is suspected to induce peripartum cardiomyopathy is some cases. In this case, pregnancy triggered the arrhythmia, and resulted in tachycardia induced cardiomyopathy. The effect of peripartum condition may have led to the hemodynamic collapse.
P1012
Factors of failure or recurrence of AV nodal reentrant tachycardia after ablation
P1013
Groin hematoma after electrophysiological procedures - incidence and predisposing factors
B. Brembilla-Perrot, J.M. Sellal, J. Schwartz, A. Olivier, P.Y. Zinzius, C. De Chillou, E. Aliot, M. Andronache, and D. Beurrier
A. Dalsgaard, C. Jakobsen, S. Riahi, and S. Hjortshoj
University Hospital of Nancy - Hospital Brabois, Vandoeuvre les Nancy, France
Center for Cardiovascular Research, Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
Purpose: the aim of study was to evaluate the factors explaining the failure or recurrence of atrioventricular nodal re-entrant tachycardia (AVNRT) after radiofrequency ablation of the slow pathway. This last technique is now frequently used to treat the patients with AVNRT. Methods: 768 patients were admitted for the radiofrequency ablation of typical (n=689) or atypical AVNRT (n=79). They were 244 males and 524 females, aging from 12 to 90 years (mean 53 + 18). AVNRT was induced in control sate or only after ioproterenol. Then, slow pathway ablation was performed by conventional methods using radiofrequency energy, 658, 40 w max, delivered on a potential of slow pathway, until that AVNRT was not induced after 20 minutes following the application. The patients were followed from 3 months up to 20 years (mean 3+2 years). Results: AVNRT remained inducible in 89 patients (11.5%) (failure) (group I) and was not inducible after slow pathway ablation in 679 patients (apparent success; group II). Group I and II differed by the mechanism of AVNRT. Failure were more frequent in atypical AVNRT (43%) than in typical AVNRT (8%)(p , 0.0000). Age and sex did not differ. Surprisingly, ablation was more frequently successful in AVNRT induced only after isoproterenol infusion before ablation (94% vs 6%) than in patients with AVNRT induced in control state (86% vs 14%)( p , 0.003). During follow-up, 46 patients (6%) had new symptoms of tachycardia; in 5 of them, symptoms were due to another tachycardia (group IIA); in 14 of them no tachycardia was induced at the second study (group IIB); in 27 patients (4%), initial AVNRT was still induced (true recurrence)(group IIC); 633 patients had no symptoms (group IID. There was only one statistical significant difference between group IIB and IID: patients were younger (39 + 19 vs 53 + 17.5 years)( p , 0.001). Sex, mechanism of AVNRT and need of isoproterenol to induce AVNRT did not differ between each group. Conclusion: the rate of initial success of AVNRT ablation is dependent on the mechanism of tachycardia with a higher success in typical AVNRT than in atypical AVNRT. The recurrence of symptoms without new inducible AVNRT is correlated with a younger age. The true recurrence has no identifiable causes.
Purpose: The most common complication after electrophysiological (EP) procedures is groin hematoma. While often a cause of anxiety and discomfort, hematoma may also occasionally be dangerous. Predisposing factors are not well described, and initiatives to prevent groin bleeds are often based on tradition rather than knowledge of actually predisposing factors. We performed an extensive evaluation of hematoma in a population of patients undergoing a variety of EP procedures with femoral access. Methods: We evaluated the incidence of hematoma after EP procedures in 253 patients (males 62 %) undergoing EP procedures (AF ablation: n= 151; SVT ablation/Diagnostic EP: n= 82;VT ablation=18). Procedural data and the incidence of hematoma were recorded during the first 24 hours. Further, a telephone follow up was performed after 2 weeks and self-reported hematoma were recorded. Regression analysis was performed to identify predisposing factors for hematoma. All patients underwent a standard regimen with 3 hours post procedural bed rest. AF ablations were performed during ongoing warfarin treatment with INR 2-3 and activated clotting time (ACT) . 300. Adhesive pressure dressings (APD) were applied if: sheath size . 10F; long procedural times; BMI . 30. Manual compression was performed for 5-10 minutes. Results: Regression analysis on sex, age, BMI , or . 25, ACT , or . 300, use of APD, complicated venous access were not statistically significantly associated with hematoma after 2 weeks. However, a hematoma that had already developed at the end of the EP procedure was associated with patient reported hematoma after 2 weeks with odds ratio 18.7 (CI 95 %: 5.0069.8; P , 0.001). Conclusions: Patients with a hematoma detected at the end of the EP procedure had a significantly increased 18-fold risk of developing hematoma. All other recorded variables were not associated with the occurrence of hematoma after 2 weeks. The results suggest that initiatives to prevent groin hematomas should be aimed at the procedure itself and not post procedural care.
ii144
P1014
Sudden cardiac death and implantable defibrillators
P1015
Implantable cardioverter-cefibrillators in arrhythmogenic right ventricular cariomyopathy :A Single Center Experience
Electrophysiology interventions without the used of femoral via G. Rodriguez-Diez, M. Ortiz, M. Cortes, M. Alcantara, and R. Robledo-Nolasco
E.H. Hatzinikolaou-Kotsakou, M. Kotsakou, P. Latsios, G. Moschos, T.H. Beleveslis, E. Reppas, and K. Tsakiridis
National Medical Centre 20 de Noviembre.ISSSTE, Mexico City, Mexico Introduction: The actual tendency for invasive procedures in cardiology is the patient comfort, without compromising the safety of the patient and the efficacy of the procedure. In some interventional centres the radial artery puncture is the preferred approach for a coronary angiogram.However In Electrophysiology (EP) this trend has not been extended in part due to the used of several catethers that makes difficult to think in another approach than femoral. We belived that we can diminish the catheters used in the vast majority of basic EP studies and ablations (up to three) allowing us to explore another approaches instead of the traditional femoral via, for a better postprocedural recovery for the patient . Patients and Methods: In a 4 months period we prospectively and systematically included all patients underwent a basic EP procedure; excluding typical atrial flutter (other tachycardias like AF or VT were considered complex tachycardias). For an artery via we used a radial artery puncture and 7 Fr sheat, for a vein via we used two subclavian vein puncture at the same site with 6 and 7 Fr sheat. One up to three catheters was used for a single procedure. Results: We completed 20 patients; 5 for an EP study and 15 for ablations. The diagnostic studies were for ventricular stimulation after a coronary angiography and we used 1 catheter and the artery approach used for the angiogram. The ablations were performed in 15 patients; 7 due to WPW syndrome, 4 due to a concealed accessory pathway, 2 due to nodal reentry tachycardia and 2 for AV node ablation. We used 3 catheters in 9 patients 2 catheters in 4 patients and 1 catheter in 2 patient (the later,for AV nodal ablation). In the ablation procedures we have 7 left side and 4 right side accessory pathways. The mean time of fluoroscopy was 24 + 20 min. All cases were successfully done without any complications. Conclusion: This is a brief report and as far as we known is the first study that systematically uses other approach instead of the traditional femoral pathway for electrophysiology procedures that includes ablations, with satisfactory results and outcomes.
Saint Lukas Hospital, Electrophysiology Department, Thessaloniki, Greece Introduction: Arrhythmogenic Righr Ventricular Cardiomyopathy ( ARVC) is associated with potential life-threating ventricular tachyarrhymias and an increased risk of sudden death. Our purpose was to study the outcome of ARVC patients treated with an implantable cardioverterdefibrillator (ICD). Methods and Results: We included 28 ARVC patients with ICD ( 60% male, ages 15-58 , median 36). The mean follow-up was 35 +18 months. Complications associated with ICD implantation included need for lead repositioning (n=1). During follow-up, one patient underwent heart transplantation. The ICD implantation was for secondary prevention in 24 patients and for primary prevention in4 patients. During this period 20/28 (70%) patients received a mean of 4.7 (range 2-68) appropriate ICD therapies. The median period between ICD implantation and the first shock was 6-months. ICD electrical storms were observed in 3 patients. Inappropriate shocks were seen in 9 patients. Predictors of appropriate therapy were fulfilment of the ARVC criteria ( 82% vs 25% respectively, p , 0.001) , the frequency of the daily PVCs . 3.500 ( 72% vs 29% respectively, p , 0.001) induction of VT during EPS (70% vs 35% respectively, p , 0.001), syncope ( 82% vs 31% respectively, p , 0.001) severe RV dysfunction in echocardiography ( 69% vs 14% respectively, p , 0.02) and impairment of left ventricle function ( 70% vs 25% respectively, p,0.001). The inappropriate shocks were seen in patients with very frequent atrial tachyarrythmias. Conclusions: Patients with ARVC have a high arrhythmia rate requiring appropriate ICD therapies. ICD treatment appears to be well tolerated and effective in the management of patients with ARVC.
P1016
P1017
Incidence and risk factors for the development of fast ventricular tachycardia in recipients of implantable cardioverter defibrillators R. Cozar-Leon1, E. Diaz-Infante1, R. Peinado2, B. Prado1, M. Gonzalez-Vasserot2, E. Macias2, D. Garofalo2, and J.M. Cruz1 1
University Hospital of Virgen Macarena, Department of Cardiology, Seville, Spain; and 2University Hospital La Paz, Department of Cardiology, Madrid, Spain Purpose: Few studies have analysed the incidence and predictors of fast ventricular tachycardias (FVT). These arrhythmias have been associated with a certain anatomic substrate and a lower response to antitachycardia pacing. The main objective was to analyse the incidence of FVT in patients with an implantable cardioverter defibrillator (ICD) and to identify predictors for its development during follow-up. Methods: This observational, multicentre study analysed the incidence of FVT (defined as VT with a cycle length between 240-300 ms) in a prospective cohort of 238 ICD recipients. The median age was 67 years (IQR 58-74), 89% were men, 66% had ischemic cardiomyopathy, the median left ventricular ejection fraction (LVEF) was 30% (IQR 25-40), and 73.5% were secondary prevention implants. We analysed the usefulness of key clinical, electrocardiographic and echocardiographic variables to predict the development of FVT. Results: During a mean follow-up period of 26 + 11 months, 51 patients developed 269 episodes of FVT (incidence of FVT: 21.4%). On univariate analysis, only LVEF (29 + 9% vs. 34 + 13%; p=0.009) and secondary prevention (24.6% vs 12.7%; p=0.04) were significantly associated with the development of FVT(Table). On multivariate analysis, a higher LVEF (OR 0.37, CI 95%: 0.16-0.87; p=0.022) and a primary prevention indication (OR 0.96, CI 95%: 0.93-0.99; p=0.014) were independent factors that protected against the development of FVT during follow-up. Conclusions: In our cohort the incidence of FVT was 21.4%. The LVEF and the type of indication for ICD implantation were the only independent factors associated with the development of FVT.
N LVEF PRIMARY PREVENTION (%) ISCHEMIC CARDIOMYOPATHY (%)
FVT YES
NO
p
51 29 + 9 16 71 I: 30 II: 59
187 34 + 13 29 65 I: 39 II: 55
III: 10 IV: 2 33 92 35
III: 6 IV: 0 29 89 30
NYHA FUNCTIONAL CLASS (%)
LBBB (%) BETA-BLOCKER (%) ANTIARRHYTHMIC DRUGS (%)
0,009 0,04 0,4
0,12
0.5 0.5 0.5
Longterm primary preventive ICD treatment, a single center experience F. Gadler1, and T. Malmkvist2 1 Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden; and 2Orebro University Hospital, Department of Cardiology, Orebro, Sweden
Background: Treatment with primary preventive internal defibrillator (ICD) have become an established therapy to prevent sudden death in patients with advanced heart failure. In many hospitals in is the major part of ICD implantations. Long-term studies of effects, complications and cost efficacy are not many. We present a single center follow up from the Karolinska Hospital. Material and methods: We studied 337 consecutive patients implanted with a primary preventive ICD at Karolinska Hospital from 2007 to 2009. Patient records including ICD interrogations and stored IEGMs were scrutinized. Results: The most common ethiology to underlying heartt failure was ischemic disease (60%) followed by non ischemic dilated cardiomyopathy (28%). Median follow up was 26 + 11 months. During the follow up 14% of the patients died, with a one year mortality of 6.5%. Adequate therapy was delivered in 16% of the patients within 10 + 8,7 months after implantation. The most common complication to ICD treatment was inadequate chock in 7% of the patients. A total of 15% of the patients had to undergo surgical reintervention. The most common cause to malfunction of the ICD system was lead dislodgement or inadequate pace/ sense function including technical failure of leads. Conclusion: Primary preventive ICD treatment gave adequate therapy in the event of life threatening arrythmias in 49 of 306 (16%) patients.This can be transformed toa NNT of 6,25,The negative effects of ICD treatment are perioperative complications requiring re-intervention in 12% during the follow up period. Inadequate chocks, 7% during follow up, were much less common tha previously published. Primary preventive ICD implantation in patients with advanced heart failure is a cost effective life saving treatment.
ii145
P1018
P1019
Suppression of ventricular arrhythmias with flecainide in patients with Andersen-Tawil syndrome with KCNJ2 mutation K. Miyamoto1, H. Kimura2, H. Hayashi2, M. Ishihara1, T. Anzai1, S. Yasuda1, H. Ogawa1, S. Kamakura1, M. Horie2, and W. Shimizu1
Prognostic value of electrophysiology studies among ICD recipients in the israeli ICD registry
1 National Cerebral and Cardiovascular Center Hospital, Department of Cardiovascular Medicine, Suita, Osaka, Japan; and 2Shiga University of Medical Science, Department of Cardiovascular and Respiratory Medicine, Otsu, Japan
J.E. Schliamser1, G. Amit2, M. Haim3, M. Suleiman4, A. Militianu1, A. Glick5, V. Khalameizer6, N. Gavrielov-Yusim7, I. Goldenberg7, and M. Glikson7, Israeli working group on pacing and electrophysiology
Background: Andersen-Tawil syndrome (ATS) is an autosomal dominant genetic or sporadic disorder characterized by ventricular arrhythmias (VA), periodic paralyses, and dysmorphic features. The pharmacologic treatment of VA in patients with ATS remains unknown. Aims: We evaluated efficacy and safety of flecainide for VA in patients with ATS with KCNJ2 mutation. Methods: The efficacy of drugs was compared by 24-hour Holter recording and treadmill exercise testing between on conventional therapy and on combination therapy of flecainide with conventional drugs. Results: The study population consisted of 6 ATS probands. Four patients were female and 2 patients were male. Their averaged age was 29 + 7 (23 - 41) years old. No evidence of structural heart diseases was demonstrated by echocardiogram in any patients. Bidirectional VA had been documented in all 6 patients. Four patients were symptomatic: syncope (n = 3), palpitations (n = 1), and dizziness (n = 1). There were neither cases of aborted cardiac arrest nor family histories of sudden cardiac death. Five of 6 patients were treated with b-blockers, 1 also received Ca2 þ -channel blockers and the other also received disopyramide before flecainide was started. Flecainide dose was 100 mg in 5 patients and 200 mg in 1 patient. Table shows the efficacy of flecainide in each patient. VA was suppressed with flecainide in all 6 patients. During a mean follow-up of 315 + 242 days, no patients developed syncope or cardiac arrest and no side effect was observed in any patients. Conclusion: This study shows that flecainide is a safe and effective therapy to suppress VA in patients with ATS.
24-hour Holter recording Number of VPBs
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
#
1
Lady Davis Carmel Medical Center, Haifa, Israel; 2Soroka University Medical Center, Beer-Sheva, Israel; 3Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; 4Rambam Health Care Campus, Haifa, Israel; 5Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 6Barzilai Medical Center, Ashkelon, Israel; and 7Sheba Medical Center, Ramat Gan, Israel
Introduction: There are conflicting data regarding the prognostic implications of electrophysiology studies (EPS) among patients with reduced left ventricular ejection fraction (LVEF) who receive an implantable cardiac defibrillator (ICD). Methods: We compared the clinical characteristics and the risk of ventricular tachyarrhythmic events (VTE) of patients who had ventricular tachyarrhythmia induced at EPS with those of patients implanted on the basis of LVEF alone in the Israeli ICD Registry. Results: Of 2971 patients undergoing ICD implantation in the Israeli ICD Registry, 504 (17%) patients (age 66 + 11, 89% male) had an EPS prior to ICD implantation, of whom, 91% yielded positive results. Patients who underwent EPS had a higher LVEF, a lower frequency of advanced heart failure symptoms, less atrial fibrillation, narrower QRS, and were less likely to be treated with diuretics, anticoagulation, and anti-arrhythmic drugs. Among 1188 registry patients with available follow-up, the rate of appropriate ICD therapy for VTE was similar between those with a positive EPS and patients who underwent ICD implantation on the basis of LVEF alone ( p=0.92; Figure). Consistently, multivariate analysis showed similar VTE risk between the 2 groups (HR=1.97; p=0.49) after adjustment for age, gender, type of prevention, NYHA, and LVEF. Conclusions: Our findings indicate that EPS inducibility testing prior to ICD implantation performed in a selected group of lower risk patients has limited prognostic implications.
Treadmill exercise test Longest ventricular salvo, VPBs
Longest ventricular salvo, VPBs
10-s VPB/SB†
Baseline
Flecainide
Baseline
Flecainide
Baseline
Flecainide
Baseline
Flecainide
35380 72073 10767 65355 19389 30792
4003 45933 3201 22518 10854 10232
25 24 35 18 14 11
3 12 15 6 4 3
5 22 6 2 4 2
0 6 0 1 1 0
16/4 32/1 15/5 11/9 13/8 13/13
0/28 16/5 0/24 1/19 2/12 0/29
# VPB: ventricular premature beat† 10-s VPB/SB: Ratio of VPBs to sinus beats during the 10-s period with the maximum number of VPBs
P1020
P1021
Results of implantable cardioverter defibrillator in very elderly population Programmed ventricular stimulation can accurately predict appropriate ICD therapy in patients with idiopathic dilated cardiomyopathy A.-I. Vouliotis, K. Gatzoulis, D. Tsiachris, S. Archontakis, P. Dilaveris, T. Gialernios, P. Arsenos, G. Karystinos, S. Sideris, and C. Stefanadis Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece Background: We considered the role of programmed ventricular stimulation (PVS) in primary prevention of sudden cardiac death (SCD) in an idiopathic dilated cardiomyopathy (IDCM) population. Methods and Results: 158 IDCM patients underwent PVS. Ventricular tachycardia/ventricular fibrillation (VT/VF) was triggered in 44 patients (group I, 27.8%) versus 114 patients (group II) where VT/VF was not induced. Sixty-nine IDCM patients underwent ICD implantation: 41/44 in Group I and 28/114 in Group II. The major end-points of the study were overall mortality and appropriate ICD activation. Overall mortality during the 46.9 months of mean follow-up was not significantly different between the two groups. Patients with LVEF 35% (n=119) demonstrated a higher overall mortality rate compared to the patients with LVEF . 35% (n=39), (16.8% vs. 10.3%, log rank p=0.025). Advanced NYHA class (III-IV vs I-II) was the single independent and strongest prognostic factor of overall mortality (HR 11.909, p , 0.001, CI: 3.106-45.65), as well as of cardiac mortality (HR 14.787, p=0.001, CI: 2.958-73.922). Among ICD recipients, ICD activation rate was significantly higher in group I compared to group II (30/41 patients-73.2% vs. 5/28 patients-17.9%, log-rank p=0.001), either in the form of antitachycardia pacing (68.3% vs. 17.9%, log-rank p=0.001) or in the shock delivery form (51.2% vs. 17.9%, log-rank p=0.05). Induction of VT/VF during PVS in contrast to left ventricular ejection fraction was the single independent prognostic factor for future ICD activation (HR 4.195, p=0.007, CI: 1.467-11.994). Conclusions: Inducibility of VT/VF was associated with an increased likelihood of subsequent ICD activation and SCD surrogate.
M. Cortes Garcia, P. Avila, E. De La Cruz, I. Hernandez, J.A. Palfy, A.M. Romero, J.J. Hernandez, J. Benezet, J.M. Rubio, and J. Farre Foundation Jimenez Diaz, Madrid, Spain Introduction: The implantable cardioverter defibrillator (ICD) reduces mortality in selected patients with heart disease. Its role in the very elderly population is not adequately established. There are few studies in patients aged .75 years to estimate the ICD benefit reliably. In this study we describe the results after ICD implantation in a population over 75 years, observing the prognostic role and clinical benefit. Methods: We have selected patients over 75 years old receiving an ICD with and without resynchronization function at our centre between January 2008 and March 2011. We have recorded the baseline characteristics of the patients as well as the events and complications related to the implant and during follow-up. Results: We have included 59 patients (36 ICD, 23 CRT-D) aged 79.44 + 3.05 years, 86.4% males, 66.1% of them with at least one significant comorbidity. 67.8% had ischemic heart disease, 25.4% nonischemic dilated cardiomyopathy, one ARVC, one hypertrophic cardiomyopathy and another one idiopathic VT. Devices were implanted for a primary prevention indication in 66.1% of the patients. In 10.1% of the patients we observed an implant-related complication (usually a significant hematoma). After an average follow-up of 23.6 + 11.7 months, we observed a total mortality of 32.3%, of cardiac origin in 11.9% and non-cardiac or unknown in the remaining 20.4%. Significant clinical events (mortality or hospital admission due to heart failure or arrhythmia) occurred in 55.9% of our population. During follow-up, 10 patients (16.9%) had an appropriate therapy of the device (6 patients with a primary prevention indication of the ICD). At the end of follow-up, 6 of these 10 patients were alive (10% of the total population). Two patients (3,4%) had inappropriate shocks. Conclusion: The net clinical benefit of an ICD or a CRT-D implant in people over 75 years of age is counterbalanced by the reduced life expectancy of this patient population and the comorbidities imposed by the underlying cardiac and extracardiac diseases. After a mean followup of 2 years mortality was 32%, but in some 10% of our study population the ICD contributed to maintaining the patient alive through appropriate effective device therapies.
ii146
P1022
Implantable cardioverter-defibrillator guidelines application in Argentine patients with heart failure. A registry from 64 cardiology residencies A.G. Carrizo1, E. Fairman1, N. Gonzalez2, L. Corradi3, E. Zaidel4, G. Perez5, A. Alfie1, and O. Oseroff1, CONAREC 1
Clinica Bazterrica, Ciudad de Buenos Aires, Argentina; 2Hospital Italiano, Ciudad De Buenos Aires, Argentina; 3 Clinica Velez Sarsfield, Cordoba (Argentina), Argentina; 4Hospital Argerich, Ciudad De Buenos Aires, Argentina; and 5Sanatorio Mitre, Ciudad De Buenos Aires, Argentina Guidelines (GL) establish as Class I indication for primary prevention ( pp) Implantable Cardioverter Defibrillator (ICD) in symptomatic patients (p) with left ventricular ejection fraction (LVEF) 35% or asymptomatic with LVEF ,30% due to myocardial infarction (MI).The purpose of present study was to evaluate the real daily application of GL for pp in p with heart failure (HF) and factors related for the implant. Methods: The CONAREC XVIII registry included 1310 consecutively HF p during June and July 2011 in Argentina from 64 centers with Cardiology Residency. Audit excluded 33 p. We looked for p with Class I ICD indication and compared those who got the ICD (Y-ICD) versus (vs) those who did not get the ICD (N-ICD). We used the MADIT-II Risk Score (ICD benefit using five factors), those with 3 factors do not benefit from ICD therapy. Results: Of 1277 p enrolled, 263 p (20.6%) had Class I indication and only 39 p (14.8%) with indication were prescribed an ICD. Y-ICD subgroup, compared with N-ICD subgroup, had a significant higher incidence of MI, syncope and CRT, lower LVEF (mean 23 vs 27 p= , 0.001) and wider QRS (mean 0.14s vs 0.12s p= , 0.01). We observed a higher prescription in p treated at private centers (19% vs 8% p=0.01) located in Buenos Aires City (20% vs 10% p=0.04) and those with 8 cardiology residents (20% vs 7% p= , 0.01). Table 1 shows distribution of population according to Risk Score and the independent predictors of ICD implant. Conclusion: The ICD rate prescription for primary prevention in Argentina is low according to GL and an important proportion of patients who received ICD belong to the group with less benefit. GL indications are better followed by centers with more residents.
Low/Intermediate Risk (0-2 RF) High Risk (3 RF) LVEF QRS .0.12s CRT 8 Residents
Y-ICD (n 39)
N-ICD (n 224)
p
66.7 33.3 23 (20-26) 64.1 79 79.5
76 24 27 (25-30) 31.3 21 54.5
ns ns ,0.001 ,0.001 ,0.001 ,0.01
Multivariate Analysis OR (95% IC)
1.6 (1.3-1.9) 7.9 (1.1-20.7) 109 (14.8-815) 4.8 (1.1-20.7)
Values are % or median (intercuartile range). Risk factors(RF): CF .II, age .70 years, blood urea nitrogen .26mg/dl, atrial fibrillation and QRS .0.12s.
P1023
Prevalence of externalized conductors in Riata and Riata ST silicone ICD leads: results from a prospective, multicenter study D. Hayes1, R. Freedman2, A. Curtis3, M. Niebauer4, G. Neal Kay5, J. Dinerman6, S. Beau7, and W. Wong7 1 Mayo Clinic, Rochester, United States of America; 2University of Utah Hospitals, Salt Lake City, United States of America; 3University at Buffalo, Buffalo, United States of America; 4 Cleveland Clinic, Cleveland, United States of America; 5University of Alabama at Birmingham, Birmingham, United States of America; 6Huntsville Hospital, Huntsville, United States of America; and 7Arkansas Heart Hospital, Little Rock, United States of America
Introduction: The prevalence of externalized conductors (EC) in Riata/Riata ST silicone leads has been reported to be between 12 - 33%. Many of the reports have been single-center analyses, some of which relied on retrospective reviews and have not used consistent adjudication methodology. The objective of the prospective Riata Lead Evaluation study was to determine the prevalence of EC in Riata (8F) and Riata ST (7F) silicone leads across multiple centers based on prospective fluoroscopic evaluation using pre-specified criteria for determining the presence of ECs. Methods: Patients implanted with Riata or Riata ST silicone leads and a St. Jude Medical ICD/CRT-D were enrolled in this study. Fluoroscopy was performed at enrollment using a standardized protocol and three views (AP, LAO, RAO). EC was present if any conductor did not fit within the shock electrode shadow width and/or if the radius of curvature of the suspected EC was significantly different from the remainder of the lead body. All images were adjudicated by a panel of experienced electrophysiologists. Results: A total of 776 patients with Riata/Riata ST silicone leads (8F/7F = 66.6%/33.4%; Single/Dual coil = 12.9%/87.1%) across 23 centers were analyzed. A total of six leads (1 with EC; 5 without EC) have been replaced or extracted for electrical abnormalities. The prevalence of EC was significantly lower in 7F Riata ST leads compared to 8F Riata leads (9.3% vs. 24.2%, p , 0.001). Implant duration of 7F leads was significantly less than 8F Riata leads (4.8 + 0.9 vs. 6.5 + 1.6 years, p , 0.001). The prevalence of EC remained significantly lower in 7F leads compared to 8F leads (9.4% vs. 18.8%, p = 0.006) after adjusting for lead implant duration of 6 years (4.8 + 0.9 vs. 4.8 + 0.9 years, p = ns). Conclusions: Larger diameter Riata silicone leads (8F) were more prone to EC than smaller diameter Riata ST silicone leads (7F) even after adjusting for implant duration. Additional data regarding the time course of EC, along with the incidence of electrical abnormalities present in leads with and without EC, may help guide patient management considerations.
P1024
P1025
Pulse width optimisation of ICD defibrillation waveform is both a safe and effective programming strategy at time of implant Longevity of implantable cardioverter defibrillators in a large multicenter experience
P. Nolan, C. Mcfadden, B.D. Macneill, J. Crowley, P.J. Nash, and K. Daly University Hospital Galway, Galway, Ireland
M. Gasparini1, G. Boriani2, A. Proclemer3, M. Santini4, M. Landolina5, M. Biffi2, G. Zanotto6, A. Gentili7, S. Bisetti7, and M. Lunati8, ClinicalService cardiological centres 1
Clinical Institute Humanitas IRCCS, Rozzano, Italy; 2Sant’Orsola-Malpighi Polyclinic, Department of Cardiology, Bologna, Italy; 3University Hospital "Santa Maria della Misericordia", Department of Cardiology, Udine, Italy; 4San Filippo Neri Hospital, Department of Cardiology, Rome, Italy; 5Foundation IRCCS Polyclinic San Matteo, Department of Cardiology, Pavia, Italy; 6Mater Salutis Hospital, cardiology department, Legnago, Italy; 7Medtronic Italia, Milano, Italy; and 8Niguarda Ca’ Granda hospital, cardiology department, Milano, Italy Purpose: Implantable cardioverter-defibrillators (ICD) are a milestone in the prevention of sudden cardiac death in patients at high risk for ventricular tachycardia/fibrillation. Device replacements impact health care costs and may affect patient due to re-operation discomfort and possible complications during implantation. We aimed to estimate ICD longevity in a large cohort of patients involved in an observational research and medical care project within a network of 136 Italian cardiological centers. Methods: A total of 6124 patients implanted with ICD were followed between January 2003 and June 2011. Device longevity was estimated by the Cutler-Ederer survival analysis method. Results: In a median follow-up of 24 months, 927 (15%) patients had 1071 device replacements. Overall 7146 ICDs were followed, in particular 1014 single-chamber ICD, 1106 dualchamber ICD and 5026 cardiac resynchronization therapy ICD (CRT-D). Median longevity was 7 years and 4 months for single-chamber ICD, 6 years and 4 months for dual-chamber ICD and 4 years and 7 months for CRT-D. Our estimations of ICD longevity, based on real-life ICD use, were compared, finding a good agreement, with longevity data published in the Medtronic product performance reports, which are based on the numbers of devices which are explanted and returned to the manufacturer. Conclusions: Data from our large multicenter observational research supply a detailed and reliable estimation of ICD longevity which may represent the benchmark for future evaluations on ICD longevity and cost-effectiveness.
Introduction: Pulse width optimisation of ICD defibrillation waveforms, as opposed to traditional fixed tilt waveforms, has been proposed as a means of reducing defibrillation thresholds. Some implanters are unwilling to utilise this strategy as optimised pulse width waveforms deliver less energy, as measured in joules, compared to fixed tilt waveforms. The aim of this study was to assess whether pulse width optimisation based on the high voltage lead integrity (HVLI) measurement is a safe and effective strategy. The HVLI measurement can also vary from the shock lead impedance (SLI) measured during shock delivery. The study also aimed to investigate whether programming based on the HVLI would be significantly different from that based on the SLI. Methods: Consecutive patients implanted with St Jude Medical ICD’s, who underwent DFT testing, were enrolled. At time of implant the HVLI was checked and the defibrillation waveform pulse width was optimised to Block 1 based on this measurement and the company supplied table of values. DFT was performed and if an adequate safety margin was not achieved DFT was reperformed with waveform optimised to Block 2 and subsequently Block 3 if an adequate safety margin was still not achieved. SLI associated with shock delivery was noted. Results: 102 patients were enrolled (m=81.4%,f=18.6%) with a mean age at implant of 60.5yrs (27.2-80.0yrs). 73.5% were implanted for primary prevention with 26.5% implanted for secondary prevention. Amongst primary prevention patients, with DCM, the mean EF was 22.8% (range 10-35%). Secondary prevention patients had a mean EF of 32.8% (range 10-55%). 95.1% of patients achieved an adequate DFT safety margin when optimised to block 1 with a mean safety margin of 12.24J, 1.96% needed to optimised to Block 2 with a mean safety margin of 10.2J. The remaining 2.94% needed to be optimised to Block 3 with a mean safety margin of 9.33J. All patients achieved an adequate safety margin using an optimised pulse width defibrillation waveform. When comparing the HVLI measurement and the SLI during shock delivery there was no significant difference (62.2 vs 65.19V, p=0.113). Programming of the waveform based on the HVLI and the SLI also demonstrated no significant difference either in Phase I (4.63 vs 4.75ms, p=0.09) or in Phase II (3.01 vs 2.97ms, p=0.13). During a mean follow-up of 2.97yrs (0.04-7.05yrs), 13 patients had at least one episode of VF, all of which demonstrated first shock success. Conclusion: Pulse width optimisation of ICD defibrillation waveforms based on the HVLI measurement is a safe and effective strategy at time of implant.
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P1027
The remote monitoring systems in management of children with Brugada Syndrome: single center experience D. Ricciardi, C. De Asmundis, M. Namdar, J. Rao, M. Rodriguez Manero, F. Bayrak, R. Casado, K. Wauters, G.B. Chierchia, and A. Sarkozy Free University of Brussels (ULB), Cardiovascular Centre, Heart Rhythm Management Centre, Brussels, Belgium Background: Implementation of remote home monitoring systems (HM) in clinical practice has become undoubtedly an added value for all patients with implantable cardiac devices. The aim of this observational single center study was to investigate the impact of HM in a population of children with Brugada Syndrome (BS) who received an implantable cardioverter defibrillator (ICD) as there are little data about the long term follow-up of children with BS implanted with ICD and no literature is showing the role of HM in managing these patients. Methods: Eleven children (age between 6 months and 18 years) implanted with an ICD were followed either by means of HM and with conventional in-hospital visits in our centre. Alerts received by the HM and/or device related clinical events were recorded, analysed and subsequent clinical decisions were made if needed. Results: During an average observation time of 26 months a total of 16 relevant alerts were recorded in 7 patient of our population (repeated alerts received in three children because of supraventricular tachycardias were excluded from recounting). Only one patient experienced appropriate therapies for life threatening ventricular arrhythmias. Three patients experienced inappropriate therapies due to supraventricular tachycardia and lead dislodgement, importantly the patient were mainly asymptomatic because. By means of HM two patients were discovered to have lead problems because of dislodgement or lead fracture. And one patient was recalled to verify some noises on the ventricular leads that turned out to be external electrical noises. Calculating the anticipation of treatment based on the HM alerts an average anticipation of 76 + 59 days was showed. Conclusion: Children with an ICD need careful and continuous evaluation because of the high probability for system and arrhythmia-related inappropriate therapies and failures. Remote monitoring systems substantially improve the proper management of children with BS, mainly because in a very young population is also difficult to discriminate the symptomaticity in case of arrhythmias.
Defibrillation efficacy of the single coil screw-in lead Sprint Quattro Secure S 6935 - Evaluation during intraoperative testing L. Binner1, S. Stiller2, G. Grossmann3, W. Rottbauer1, and D. Walcher1 1 University of Ulm, Ulm, Germany; and 3Stiftsklinik, Weissenhorn, Germany
2
Elisabethenklinik,
Ravensburg,
Germany;
The ICD-lead Sprint Quattro Secure S 6935 (single coil, true bipolar active fixation ,Medtronic Inc. Minneapolis, MN, USA) was implanted in 385 patients (295 male). Single chamber devices were implanted in 181 pats., 75 pats. had dual chamber systems and CRT-D systems were implanted in 120 pats. In the remaining 9 pats. lead exchange was performed connecting the the lead to the previously implanted device. In all pats. ICD-devices delivering a maximum energy of 35 Joule (J) were implanted. Methods: In 312 (81%) out of the 385 pats. intraoperative defibrillation testing was performed. Reasons for non-testing were e.g. insufficient anticoagulation in pats. with atrial fibrillation (7), intracavitary thrombus formation (3), difficult subclavian puncture (9), potassium imbalance (4), persistent high grade coronary artery stenosis (4), physicians decision (32). At least two intraoperative tests were performed. Device programming: 1.test: 12J-18J-35J-external defibrillation, 2. test: 9J-15J-35J-external or higher energy setting if necessary due to the result of the first test.Ventricular fibrillation was induced by means of a 1 Joule T-wave shock. Results:In 170 pats. (54,5%) VF could be terminated by means of a 9 J Shock, in addition, in 65 pats. (20,8%) VF could be terminated with 12 J . However, 22 pats. (7,1%) needed 25 J to terminate VF, in 10 patients (3,2%) an additional SVC-lead had to be placed to maintain a safety margin of 10 J. Conclusion:The Sprint Quattro Secure S 6935 single coil screw-in defibrillation lead allows safe implantation maintaining a 10 Joule safety margin during intraoperative testing in 95,5% of the patients. In 75,3% of the pats. the lowest tested energy to successfullydefibrillate induced VF was 12 J. In 3,2% of the pats. an additional SVC-lead had to be placed.
P1028
P1029
Beta-blockers reduce cardiac mortality among ICD patients presenting with shocks: a long-term prospective study J. Jimenez-Candil, C. Ledesma, J. Morinigo, J.C. Rama, A. Martin, and C. Martin-Luengo University Hospital of Salamanca, Salamanca, Spain Shocks (SH) are associated with an increase in cardiac mortality (CM) among ICD patients with left ventricular dysfunction (LVD). This negative effect could be secondary to myocardial damage, in part due to the activation of the sympathetic nervous system following the discharge, which produces tachycardia, ischemia and endothelial dysfunction. Were this the case, the beta-blocker treatment (BB-t) may have positive prognostic effects in ICD patients presenting with SH. Methods: In this prospective study we followed-up 416 ICD patients with LVD (age: 65 + 12; LVEF: 30 + 8; functional class II-III: 63%; primary prevention: 63%; ischemic etiology: 62%; BB-t: 79%; no cardiac resynchronization therapy) and without changes in the BB-t after the implant. ICD programming was standardized, including antitachycardia pacing for slow and fast VT. We determined the BB-t at each ICD intervention. Patients were classified into three groups: no SH (64%, group A), SH taking beta-blockers (25%, group B) and SH without BB-t (11%, group C). Results: During the follow- up, 1597 events were recorded, 1511 (89%) of them were appropriate therapies. A total of 473 (30%) events produced SH (18% were inappropriate). The cumulative CM was 73/416 (18%), the mean survival from ICD implant being 85+3 months. Heart failure was the cause of death in 90%. CM was higher in P with SH: 28% vs. 12% ( p , 0.001, log-rank test), but after adjusting for the BB-t, CM was: 12% (group A) vs. 17% (group B) vs. 55% (group C); p , 0.001 for C vs. A-B; p=ns for A vs. B. Among patients presenting with SH, the cumulative survival free of CM after the first SH was higher in those under BB-t (mean [95% confidence interval]): 80 months (70-91) vs. 40 months (29-51); p , 0.001 (log-rank test). By multivariate analysis (Cox-regression) - which included LVEF(%), indication, etiology, functional class (NYHA), medical treatment, number of SH and shock-related arrhythmia- the functional class (OR=2.9; p=0.001) and the BB-t (OR=0.3 ; p , 0.001) remained as independent predictors of CM after the first SH. Conclusions: Among ICD patients with LVD presenting with SH, the BB-t is independently associated with a decrease in CM. Therefore, the sympathetic nervous system could play a central role in the shock-related myocardial damage.
Fractal property of self-similarity distinguishes ventricular tachycardia from atrial fibrillation M. Mollerus St. Mary’s Duluth Clinic, Duluth, United States of America Introduction: Inappropriate implantable cardioverter-defibrillator (ICD) shocks are a significant clinical problem. The most common etiology is supraventricular tachycardia such as atrial fibrillation (AF). Prior work has shown that spectral techniques can distinguish AF from ventricular tachycardia (VT), but limited work has been done using nonlinear dynamics. Methods: A retrospective analysis was performed on 9 clinical VT and 17 clinical AF events from 23 patients that were detected by an implanted ICD. All events were retrieved from the storage diskette and analyzed off-line using Matlab software. The scaling exponent (SE) and fractal dimension (FD) were estimated from 2 sec. of signal obtained at a sampling rate of 200 samples/sec. Each 2 sec. event was upsampled to 1601 samples using splines. The fractal dimension was estimated from the Hurst exponent. The data are normally distributed and are expressed as mean + standard deviation. Findings: AF had a SE of 1.037 + 0.015 while VT had a SE of 1.020 + 0.008 (P = 0.001). AF had a FD of 1.059 + 0.024 while VT had a FD of 1.033 + 0.015 (P = 0.003). The SE and FD during VT had values closer to 1 than AF, and were significantly lower during VT than AF. Conclusions: Both SE and FD are able to distinguish VT from AF. A value closer to 1 suggests that VT has a smoother curve than AF.
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P1030
Impact of cable externalization in feasibility of Riata lead extraction in a tertiary referral G. Zucchelli1, L. Segreti1, D. Levorato1, E. Soldati1, A. Di Cori1, S. Viani1, L. Paperini1, B. Valente2, R. De Lucia1, and M.G. Bongiorni1 1 Azienda Ospedaliero - Universitaria Pisana, Pisa, Italy; and 2Hospital Santa Marta, CHLC, Lisbon, Portugal
Purpose: RIATA leads are associated with an increased rate of failure related with cable externalization (CE), but the scientific community is still uncertain about the best way to manage these patients. We aimed to evaluate the feasibility of RIATA leads extraction, focusing on leads with CE. Methods: We enrolled all patients referred to our hospital for defibrillating leads removal from January 1997 through June 2012. Mechanical dilation (MD) was the technique used with polypropylene sheaths. The Internal Trans-Jugular Approach (ITA) was applied in case of difficult leads. Results: In 566 patients ( pts) undergoing ICD lead extraction, 94 had a RIATA lead (16%). Population had 78 male pts (83%), the mean age was 64 + 14 years and the left ventricle ejection fraction was 36 + 10%. The RIATA dimensions were 8 French in 82 patients, 7 French in 12 patients (ST series). Double coil (91%) and passive fixation (79%) leads were the most represented. Cardiac device infection was the main indication to removal (78%). In the available pre-operative chest x-rays (79/94 patients), cable abnormalities were present in 20 leads (25.3%), including a CE in 8 leads. The radiological success rate was 98.9%, without major complications. The manual traction was effective in 2 patients (2%), the MD through venous entry site was effective in 85 patients (90%), while the ITA was necessary in 7 patients (8%). In patients with CE, the extraction was more difficult, as demonstrated by longer extraction time (27.3 + 22.1 vs 16.4 + 21.1 min; p , 0.001), higher use of ITA (20% vs 3%; p , 0.001) and bigger dimensions of sheaths (11.9 + 1.6 vs 11.1 + 1.2 French; p , 0.05). Moreover, longer pacing period (64 + 13 vs 25 + 18 months; p , 0.0001) and incomplete insertion of the stylet (50% vs 22%; p , 0.001) was also associated with CE. Conclusions: The extraction of RIATA leads is feasible and effective in our study. However, the presence of CE and probably the lack of backfilling of the space between the coils in 8 French leads, can make the extraction more difficult, requiring larger sheaths, longer procedural time and skilled operators.
P1031
Cardiac device-related endocarditis- safety and effectiveness of transvenous leads extraction procedures A. Polewczyk1, A. Kutarski2, A. Tomaszewski2, K. Boczar2, and M. Janion3 1 Swietokrzyskie Cardiology Center II - Cardiology Department, Kielce, Poland; 2Medical University of Lublin, Department of Cardiology, Lublin, Poland; and 3Swietokrzyskie Cardiology Center II - Cardiology Dept; The Jan Kochanowski University, Dept Sciences, Kielce, Poland
Background: Transvenous leads extraction (TLE) consists the key-procedure in management of cardiac device– related endocarditis (CRDIE). The assessment of TLE safety and effectiveness in this particular group of patients seems to be very important. Methods: Data of 320 consecutive CDRIE patients (mean age 66,3 +15,0 years; 98 women) admitted to Reference TLE Center in years 2007-2012 were analyzed. The number and leads, dwelling time, complexity of pacing systems, procedure duration and additional factors causing potential TLE technical difficulties were in the study group assessed. The complete procedural success and clinical success of TLE procedures in CDRIE patients were evaluated. Results: The total number of the leads removed in study group was 666. The mean dwelling time of the leads was 89 + 63,7 months (the oldest: 386 months). The most often CRDIE patients represented two-leads pacing system (60,0%), in 23,6 % the number of the leads was no less than three. The mean time of TLE whole procedure was 112,3 + 52,9 min. Complete clinical success was achieved in 93,4%, clinical success in 99,1% CDRIE patients. The major complications (1,8%): cardiac tamponade with cardiosurgical intervention –2 paracenthesis -2, and cerebral stroke in 2 cases. Minor complications (1,9%) were: pulmonary embolism -2, haemopericardium -2 and increase of tricuspid regurgitation in 2 patients were affirmed. Technical problems during TLE occurred in 55 (17,2%) patients; most often it were lead rupture or necessity to change of the approach and tolls. CRDIE patients had probably originally another pacing complications: in 74 (22,6%) too long loops of the lead were observed, in 8 (0,01%) the dry perforation phenomenon was affirmed; furthermore-the 77(11,6%) abandoned leads were removed. The periprocedural mortality was 0,6% (2 deaths in the 2 & 9 day after TLE). Conclusions: The present study demonstrated a very high safety and effectiveness of TLE procedure in the large CDRIE group of patients. This observation confirms that TLE should be the basic of the treatment this very serious disease.
P1032
First clinical experience with the new four-pole standard connector for high-voltage ICD leads. Results from a multicentric prospective comparative study G.B. Forleo1, L.P. Papavasileiou2, M. Mantica3, L. Di Biase4, G. Panattoni1, M. Santamaria5, D. Sergi1, L. Santini1, A. Natale4, and F. Romeo1 1
University of Rome, Polyclinic "Tor Vergata", Department of Cardiology, Rome, Italy; Hygeia Hospital, Athens, Greece; 3Sant’Ambrogio Clinical Institute, Department of Cardiology, Milan, Italy; 4Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, United States of America; and 5Catholic University of the Sacred Heart, Campobasso, Italy 2
Purpose: A new four-pole connector system (DF-4) for transvenous high-voltage implantable cardioverter defibrillators (ICD) has been designed and pre-clinically tested. However, no clinical experience demonstrated the safety and effectiveness of this complex electromechanical design. This study aims to verify the safety and effectiveness of this newly designed system compared to conventional DF-1 defibrillation leads implant outcomes. Methods: During a 3-year period, 331 consecutive patients were implanted with DF-4 leads as part of an ICD or ICD-cardiac resynchronization therapy (CRT-D) system. They were matched for age, sex, and follow-up duration with 145 patients implanted with a standard DF-1 lead. Patients were followed for at least 6 months. The primary outcome of the study was defibrillation lead failure, defined as the need for lead removal or capping. Operative, electrical and safety data were obtained at implant, pre-discharge, and every 6 months post-implant. Results: Implantation success rate in both groups was 100%. Baseline characteristics, and operative data did not differ significantly between groups. The total follow-up time was 480 patient-years, with an overall average of 12.1 + 6.7 months of follow-up per patient. There were 4 system erosion/infection and 4 ICD-lead failures. Clinical outcomes, electrical performance and implant conversion testing did not significantly differ between the 2 groups. Conclusions: This prospective, controlled study provides strong evidence that the feasibility and safety of this novel technology compare favorably with those of the conventional DF-1 leads.
P1033
Pacemakers patients perception of daily life activities and medical follow-up: a French survey W. Amara1, S. Cheggour2, H. Salih1, A. Elhraiech1, P. Sagnol3, J. Taieb4, F. Ghanem5, B. Lahitton6, K. Gacem1, and A. Dompinier7 1
GHI Le Raincy-Montfermeil, Montfermeil, France; 2Avignon Hospital Center, Avignon, France; 3General Hospital, Department of Cardiology, Chalon-sur-Saone, France; 4General Hospital of Aix en Provence, Aix en Provence, France; 5General Hospital, Chateauroux, France; 6Hospital of Dax, Dax, France; and 7Hospital of Annecy, Annecy, France Introduction: The aim of our study was to assess patients’ knowledge about pacemakers after the implantation. Material and methods: We performed a multicenter survey in 13 French centers from January 2011 to July 2012. In each center, patients received usual informations about pacemaker implantation, functioning, and about their habits after the implantation. They signed a consent for implantation. One to 10 days after implantation, all patients received a questionnaire. The questionnaire evaluates patients’ perceptions of information and consent, risks of implantation, follow up, and about performing various routine activities (daily life activities, use of electrical devices, ability to undergo medical imaging tests). Results: We included 258 patients. The mean age was 75.6 þ 10.6 years 34-102 yrs) and 61% were men. The intervention was a primary implantation in 89 % of patients. We noted that 78% on the patients remember that they have signed a consent and 73% of patients remember that they received counselling in the peri-operative period. A considerable proportion of patients considered many routine activities unsafe including driving automobiles (30%), swimming (39%), passing through metal detectors (47%), sleeping on the side of the pacemaker (42%). Also, 28% of patients think they can use induction hobs and 18% think they can use arc welding equipment. Regarding medical imaging, 45%; 29% and 33% of patients considered unsafe making scanners, radiography and echography respectively; and 41 % ignored if they can have MRI. Finally, regarding the medical follow up, 11% of patients think they don’t need heart medications and 17% of patients think they are exempt from monitoring by a cardiologist. Conclusion: The results of our study highlight on patients’ misperceptions on pacemaker functioning and the need in improving practices to better inform patients. Thus, the quality of life of implanted patients may be improved.
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P1035
Pulmonary hypertension in advanced atrioventricular block is related to the duration of atrioventricular block and is reversed after pacing A.D. Margulescu1, B.M.C. Suran2, C. Siliste1, and D. Vinereanu2 University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; and 2University Emergency Hospital, Bucharest, Romania
The incidence of cardiac device infections in the modern era. Experience from a single UK tertiary centre
Purpose: The prevalence of pulmonary hypertension (PHT) in advanced atrioventricular (AV) block has not been adequately described. Our aim was to assess the prevalence, severity, and reversibility of PHT after permanent pacing in such patients. Methods: Conventional Doppler echocardiography was performed in 30 patients (77+7 years, 13 men) with high degree Mobitz II (n=9) or complete (n=21) AV block, before and within 7 days after permanent pacemaker implantation (VVI(R)=23, DDD(R)=7). Mean pulmonary pressure (PAPm) was estimated using transtricuspid peak gradient and the maximal and minimal inferior vena cava diameter (maxIVC and minIVC, respectively); a PAPm 25 mmHg defined PHT. End-diastolic left ventricular (LV) and right ventricular (RV) diameters, and maximal left atrial (LA) and right atrial (RA) diameters were measured as markers of preload. We also measured LV ejection fraction (EF), tricuspid annular peak systolic excursion (TAPSE), and qualitative estimation of severity of mitral (MR) and tricuspid (TR) regurgitation (MR) (grade 1 = mild to grade 4 = severe). Results: Mean heart rate during AV block was 40+8 bpm. Estimated onset of AV block was 12+9 days before admission. The duration of AV block correlated with PAPm (r=0.60, p=0.003), severity of MR and TR (r=0.47, p=0.03; r=0.78, p , 0.001, respectively), and RA diameter (r=0.46, p=0.036). Heart rate did not correlate with PAPm, MR and TR severity or chamber dimensions (all r , 0.20, p . 0.50). Seventeen pts (57%) had PHT during AV block. PAPm decreased after pacing by .5 mmHg in 10 of these pts (59%) while in the reminders varied by ,5mmHg (range of change in PAPm before vs. after pacing: -35 to þ3 mmHg). In pts with PHT during AV block, PAPm correlated with LV end-diastolic diameter (r=0.67; p=0.003) and RA maximal diameter (r=0.56; p=0.02). Central venous pressure (estimated by maxIVC: 22+4 vs. 17 + 7, p=0.01; and minIVC 15+5 vs. 10+7 mm; p=0.02) decreased after pacing. Regardless of the presence of PHT, significant reduction of EF (0.58 + 0.11 vs. 0.53 + 0.10; p=0.04) and TAPSE (23+4 vs. 20+4 mm; p=0.012) were noted after pacing, but is uncertain what proportion is attributable to true reduction of systolic function vs. decrease in loading. Conclusion: PHT appears in a significant number of patients with advanced AV block in relation to the duration of AV block and subsequently increased preload. In these patients, PHT is rapidly reversible after pacing. Documentation of PHT in patients with advanced AV block should be regarded as physiologic, and reassessed after pacing.
D. Monnery, R. Beadle, and A. Patwala
1
University Hospital of North Staffordshire, Stoke On Trent, United Kingdom Aim: Cardiac device infection is a serious complication of cardiac device implantation. The ESC has published guidelines for the diagnosis and treatment of cardiac device infection. We sought to audit the diagnosis and management of device infection at our institution. Furthermore, we have examined the incidence of cardiac device infection in the era of modern antibiotic prophylaxis. Methods: Data was collected retrospectively for all patients with a device infection between the 1st April 2009 and 30th November 2011. Patients’ notes and clinical letters were examined to audit diagnosis and management. Furthermore, we also examined all patients with a new device implant of the same time period and looked to see how many of these developed a cardiac device infection up until the 1st February 2012. Results: 1687 patients had device procedures performed. There were 27 new infections with a mean follow up period of 16 months (1.6%). In this group, 91% were culture positive, and most commonly following device generator changes (41%). All patients were managed with intravenous antibiotics and 83% were extracted in compliance with ESC guidance. In the remaining 8 patients (17%) 6 were treated with long term antibiotics because they were too frail to undergo a procedure and 2 died before any intervention could be undertaken. Conclusion: Cardiac device infection is a serious complication of device implantation. This study has shown that cardiac device infection at our institution is comparable to other published work with an incidence of 1.6%. Infection was generally managed in concordance with ESC guidance. This incidence rate is important when consenting patients, this is especially relevant for patients following generator replacement. This study also highlights the realties of modern clinical medicine when a small minority of patients are not suitable for extraction despite confirmed infection.
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P1037
Reduction in right ventricular pacing with a new reverse mode switch algorithm: results from the IVORY trial
Cardiac device infections are more frequent in male patients with cardiac resynchronization therapy devices
J.M. Tolosana1, D. Gras2, J.B. Le Polain De Waroux3, P. Le Franc4, J. Goetzke5, P. Jones6, N. Wold6, and R.S. Gardner7, The IVORY Study Investigators
S. Yuksel, S. Demircan, A. Erbay, K. Soylu, O. Gulel, and M. Sahin
1
University of Barcelona, Hosp. Clinic, Thorax Institute, Barcelona, Spain; 2Nouvelles Cliniques Nantaises (NCN), Nantes, France; 3Saint-Luc University Clinics, Brussels, Belgium; 4Clinic Saint-Hilaire, Rouen, France; 5 Boston Scientific, Brussels, Belgium; 6Boston Scientific, Saint Paul, United States of America; and 7Golden Jubilee National Hospital, Clydebank, United Kingdom Purpose: Unnecessary right ventricular pacing (RVP) has been associated with increased risk of heart failure. Device algorithms such as Reverse Mode Switch (RMS) have been developed to minimize unnecessary RVP. Prolongation of the intrinsic PR interval due to the increased atrial rate with rate response pacing can lead to additional RVP. Little data are available on effectiveness of RMS in the presence of rate response programming. RYTHMIQ is an enhanced version of the RMS feature and provides AAI/R pacing with VVI back-up pacing. Methods: IVORY is a prospective multi-center approval study for features in INGENIO devices. Pacemaker patients (n=100) were randomized to receive RYTHMIQ programmed ON followed by OFF in a crossover design. AV Search was programmed OFF with RYTHMIQ OFF. All other settings were programmed at physician discretion. Effectiveness was assessed by a median relative reduction of RVP percent within patient. Results: Mean age was 74 years and 60% were male. The median RVP with RYTHMIQ ON was 4% compared to 98% with RYTHMIQ OFF. The median of the within-patient relative reduction of RVP was 80% (p , 0.001 compared to no reduction). The median absolute reduction in RVP was 50% overall and 76% for patients programmed to rate response mode (figure). Two patients with intermittent 3rd degree AV block had an increase in RVP with RYTHMIQ ON. No patients with permanent 3rd degree AV block experienced a reduction in RVP with RYTHMIQ ON. Conclusions: Despite ICD and pacemaker trial results demonstrating deleterious effects of unnecessary RVP, a high degree of pacing was observed in pacemaker patients with conventional programming. RVP was significantly reduced with RYTHMIQ programmed ON compared to OFF. RYTHMIQ was also effective in the presence of rate response pacing mode.
Ondokuz Mayis University, Faculty of Medicine, Department of Cardiology, KurupelitSamsun, Turkey Purpose: Use of permanent cardiac pacemaker (PPM), implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) devices has been increasing and infection is a significant problem. The presentation, consequences, and treatment of cardiac device infections (CDI) vary according to the location and extent of infection and the clinical characteristics of the patient. In this report; we presented an analysis of the clinical findings and results of CDI’s. Methods: We identified the 39 (32 male, mean age 67,9 + 15,2) patients from the database. The demographic and clinical characteristics, device type, laboratory, microbiologic, treatment and outcome data of all patients were analyzed. Results: All of the CDIs were related to pacemaker pocket. The median time from implantation to clinical diagnosis of CDI was 12 months. The devices were CRT-P or CRT-D in 16 (41%), ICD in 4 (10,2%), single chamber PPM in 14 (36%) and dual chamber PPM in 5 (12,8%) patients. The patients with CRT devices had significantly higher C-reactive protein levels and white blood cell counts (8 + 8,9 mg/l vs. 3,5 + 3,2 mg/l and 8212 + 2072 /ml vs.6214 + 2524 /ml). Congestive heart failure was present in 21 (53,8%), coronary artery disease in 12/39 (30,7%) and diabetes mellitus in 10 (25,6%) patients. Microbiological examination and cultures were negative in 31 (79,4%). The most common microorganism isolated from the cultures was the coagulase negative Staphylococci (6 patients, 15,4%). Pocket interventions including revision of pocket and debridement were needed in 21 (54%) patients. In 10 (26%) patients, whole system was removed and new systems were implanted to opposite site. Antimicrobial treatment alone was sufficient in control of infection in 8 (20%) patients. Two patients died during follow up. Conclusions: The incidence of CDIs have been rising, likely due to both the increasing comorbidities of patients with cardiac devices and the increasing number of indications for their usage. In our patients, most of the patients were male and more than 50% of the infections are involved CRT devices. Congestive heart failure was the most common comorbidity. Diagnosis of CDIs is still difficult because of the relative lack of sensitive and specific clinical markers. Management requires proper antimicrobial treatment and complete system removal.
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P1039
Effects of AV-delay optimization on hemodynamic parameters and quality of life in patients with VDD-pacemakers
Complete heart block: audit of potential safety and cost effectiveness of direct transfer of patients needing pacing to a pacing center J.M. Mccomb, and M. Dewhurst
K.A. Krychtiuk1, N. Nuernberg2, R. Volker2, L. Pachinger2, R. Jarai2, M.K. Freynhofer2, J. Wojta1, K. Huber2, and T.W. Weiss2
Freeman Hospital, Newcastle upon Tyne, United Kingdom
1
Introduction: There are significant delays from onset of symptoms to permanet pacemaker (PPM) implantation. Direct transferto a heart attack centre for patients with acute ST elevation myocardial infarction is established practice.We investigated the potential safety and cost savings of using a similar process to expedite permanent pacing for the 50% of patients who present as emergensies wirth symptomatic bradycardia. Methods: We undertook a retrospectiveobservational survey in a pacing centre and one referring centre with an emergency department in the same city. Hospital records were reviewed in 45 consecutive patients over a 2 year period with complete heart blcok (CHB) referred for urgent pacing. We examined potential hospital bed days savings, and in hospital complications that might have been avoided if patients had been sdmitted directly to a pacing centre, with prompt pacing. Results: Mean age was 76.8y ( range 41-93). Mean length of stay in the pacing centre was 2 (18) days and in the referring centre 6 (0-27) days. Mean ttotal hospital stay was 8.6 (2-29) days. 37 (82%) patients were potentially suitable for direct admission to the pacing centre. Reasons for lack of suitability included delayed recognition of pacing indication, injuries requiring treatment, and concurrent sepsis, 3 patients were treated with temporary pacing: 1 wire was repositioned, then removed because of sepsis, 1 was inserted after a cardiac arrest with ensuing pneumonia. An additional patient had a collapse with a head laceration while waiting transfer. Conclusions: Direct transfer from the ambulance service to a pacing centre is feasible and potentially cost effective in the majority of patients who present as an emergency with CHB. Average potential saving is equivalent to 900euros for every suitable patient. This study has implications for patient safety in avoiding complications related to their pacing indication, temporary wire placement and prolonged hospital stay
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Medical University of Vienna, Department of Internal Medicine II, Division of Cardiology, Vienna, Austria; and 2Wilhelminen Hospital, 3rd Department of Internal Medicine, Cardiology and Emergency Medicine, Vienna, Austria Aims: Atrioventricular (AV)-delay optimization improves hemodynamics and clinical parameters in patients treated with cardiac resynchronization therapy and DDD-pacemakers (PM). However, data on optimizing AV-delay in patients treated with VDD-PMs are scarce. We therefore investigated the acute and chronic effects of AV-delay optimization on hemodynamics and quality of life (QOL) in patients treated with VDD-PMs due to AV-conduction disturbances. Methods In this prospective, single-center interventional trial we included 64 patients (38 men, 26 women, median age 77 (70 ; 82) years) with implanted VDD-PM. AV-delay optimization was performed using a formula based on the surface electrocardiogram (ECG). Hemodynamic parameters (stroke volume (SV), cardiac output (CO), heart rate (HR) and blood pressure (BP)) were measured at baseline and follow-up after three months using impedance cardiography. QOL was assessed by a questionnaire. Results: Using an ECG formula for AV-delay optimization, the AV-interval was decreased from 180 (180; 180) to 75 (75; 100) ms. At baseline, AV-delay optimization lead to a significant increase of both SV (71.3 + 15.8 vs. 55.3 + 12.7 ml, p , 0.001 for optimized AV-delay versus nominal AV-interval, respectively) and CO (5.1 + 1.4 vs. 3.9 + 1.0 l/min; p , 0.001), while HR and BP remained unchanged. At follow-up, the improvement in CO remained stable (4.9 + 1.3 l/min, p=0.09), while SV slightly, but significantly, decreased to 65.1 + 17.6, p , 0.01). QOL increased in one third of patients, more than two thirds of patients preferred the optimized pacing method. Conclusion: AV-delay optimization in patients treated with VDD-PMs exhibits immediate beneficial effects on hemodynamic parameters that are sustained for three months.
P1041 Evolution of the acute effect of ventricular activation sequence change induced by right ventricular apical pacing on the function of ventricles by echocardiography and radionuclide ventriculography S. Topal1, M. Basara2, S.K. Acikgoz1, A. Akyel1, Y. Alsancak1, M. Unlu2, and H.M. Ozdemir1
Abnormal autocapture algorithm phenomenon after pacemaker implant J. Benezet Mazuecos, J.A. Iglesias, J.M. Rubio, M.A. Quinones, P. Sanchez-Borque, E. Macia, and J. Farre Foundation Jimenez Diaz, Madrid, Spain Background: The AutoCapture (St. Jude Medical, USA) is an algorithm designed to confirm the pacing capture and to automatically adjust the energy output. Methods:We analyzed prospectively the pacemaker interrogations performed routinely the day after the implantation in our Institution during 2012. Results:We present 6 patients (50% men, aged 78+8 year-old) in whom the AutoCapture showed an abnormal response. All of them showed an excellent manual stimulation threshold ,0.25 V. Surprisingly the automatic AutoCapture test showed captured beats when the energy delivered was 0.0 V (theoretically "no energy"). Therefore the algorithm was automatically disabled and an automatic output of 5 V programmed compromising the long-term duration of the battery. When the algorithm is performed in this kind of patients after a loss of capture a high-output back-up pulse of 5 V is delivered. When the threshold is ,0.125 V the algorithm decrease the energy delivered to 0.0 V. Then a loss of capture happens and a back-up pulse of 5 V is delivered. The next stimulation is not really 0.0 V because after a high energy pulse there is an amount of residual energy charge in the condenser that can produce captured beats when the stimulation threshold is low enough. Figure. A week after the implant the stimulation threshold lightly increased and the algorithm was performed normally. Conclusions:We report a reproducible and non-previously described phenomenon showing an abnormal behavior of the pacemaker AutoCapture algorithm.
1 Gazi University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey; and 2Gazi University, Faculty of Medicine, Department of Nuclear Medicine, Ankara, Turkey
The aim of this study was to evaluate the acute effect of ventricular activation sequence change induced by right ventricular apical pacing on the systolic and diastolic functions of the right and the Left Ventricle (LV) by echocardiography and Radionuclide Ventriculography (RNV) in patients without structural heart disease. Methods: Seventeen patients with dual chamber pacemakers implanted for Sick Sinus Syndrome(SSS) were studied. All had intact Atrioventricular (AV) nodal conduction and narrow intrinsic QRS complexes and an apically placed ventricular lead in the right ventricle. They were evaluated by echocardiography and RNV in two pacing modes; first in Mode 1: AAI with intrinsic AV conduction and 5 minutes later in Mode 2 (DDD with the longest possible AV interval that resulted in 100 % ventricular pacing). Left and right ventricular volumes, ejection fractions (EF), myocardial performance index, inter- and intraventricular dyssynchrony indexes were calculated in the two pacing modes. Findings: The left atrial diameter was larger in mode 2 as compared to mode 1 (37,1 + 3,9 vs 35,5 + 2,4; p=0,014). The LV end-diastolic volume was lower in mode 2 as compared to mode 1 both by echocardiography and RNV (96,3 + 10,9 vs 110,8 + 18,6; p=0,017, 94 + 11 vs 104,3 + 11,6; p=0,02, respectively). The LV stroke volume and EF was likewise lower with mode 2 as compared to mode 1 by echocardiography and RNV (53,2 + 9,4 vs 64,2 + 11,3; p=0,008, 43,8 + 6,3 vs 54,9 + 7,2; p=0,004 and % 55,1 + 5,1 vs % 59,1 + 4,5; p=0,003 and % 46,8 + 7,4 vs % 52,9 + 7,3; p=0,008, respectively). MPI was similar when measured at the lateral tricuspid annulus (0,46 + 0,14 vs 0,47 + 0,12; p=0,71) but was higher when measured at the lateral mitral annulus in mode 2 as compared to mode 1 (0,51 + 0,06 vs 0,42 + 0,05; p=0,001). The LV electromechanical delay, interventricular electromechanical delay and interventricular dyssynchrony values were higher in mode 2 as compared to mode 1 (73,4 + 28,5 vs 23,4 + 12; p , 0,001, 49,4 + 20,3 vs 7,1 + 12,7; p , 0,001, 38,8 + 12,1 vs 1,8 + 3,7; p , 0,001, respectively). All the studied systolic and diastolic function parameters regarding the right ventricle were similar in the 2 pacing modes by both echocardiography and RNV. Conclusion: In patients with structurally normal hearts and dual chamber pacemakers implanted for SSS, a switch from intrinsic AV conduction to right ventricular apical pacing acutely resulted in a decrease in LV enddiastolic and stroke volumes and EF, an increase in the left atrial diameter and the MPI and led to a higher level of intra- and interventricular dyssynchrony.
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Evolution of cardiac conduction system abnormalities in paced patients
Limitations of the pacemaker autocapture algorithm: when save energy turns to waste energy
E. Simantirakis1, E. Foukarakis2, S. Chrysostomakis1, E. Arkolaki1, S. Petousis1, A. Dermitzakis2, and P. Vardas1 1 University Hospital, Crete, Cardiology Department, Heraklion, Greece; and 2Venizelion General Hospital, Iraklion Crete, Greece
J. Benezet Mazuecos, J.A. Iglesias, J.M. Rubio, J.J. De La Vieja, A. Espejo, S. Calle, E. Aguado, and J. Farre Foundation Jimenez Diaz, Madrid, Spain Background: AutoCapture (St. Jude Medical, USA) is an algorithm designed to assure capture and adjust the output to decrease energy consumption. Methods: Pacemaker programmer reports of 100 consecutive patients undergoing routinely check-up were analyzed to evaluate the long term AutoCapture efficiency. Results: AutoCapture appeared as an accurate system in keeping the stimulation output slightly above the threshold in the historical data reporting. On the other hand, 2 abnormal situations were identified. First, in patients with permanent atrial fibrillation and low percentage of ventricular pacing, the historical data showed a great variability in the threshold value calculated along time. Second, in patients with very low output threshold (,0,25V 0,4ms), the historical AutoCapture data showed alternating normal and out of range measures. Figure. Both abnormal situations implied an automatic high energy chronic stimulation (5V) that compromises the device longevity. When AutoCapture was deactivated and the output energy programmed 2-folds the stimulation threshold, the estimated longevity of the battery increased significantly in these patients. Conclusions: Although AutoCapture algorithm has shown both efficacy and safety, our findings suggest that some patients may not benefit from it. Patients with atrial fibrillation (especially those showing low percentage of ventricular pacing) and those with very low stimulation threshold showed high energy stimulation in the historical AutoCapture data.
Although many studies have evaluated the natural history of impulse formation and conduction abnormalities in paced patients ( pts), their study population is usually consisted of specific subgroups based on the pacing indication and the follow up period was, in the majority of cases, relatively short. The aim of our study was to evaluate the evolution of the ECG abnormalities, in a mixed cohort of paced pts with various pacing indications for an extended period of follow-up. Methods: Our study population consisted of 187 consecutive pts (97 male, with mean age 74.8 + 12.7 years) who referred to our hospital for pacemaker (PM) replacement 11.25 + 4.66 (6-21) years after first implantation. Pts’ distribution according to ECG indication at initial implantation was: sinus node disease (SND) 58 pts(31%), atrioventricular block (AVB) 96 pts (51.4%), bifascicular block (BFB) 25 pts (13.4%) and SND plus AVB 8 pts (4.3%). Before PM replacement, the underlying rhythm was recorded and evaluated, in each patient. Supraventricular rhythm, QRS duration, AV conduction and intraventricular conduction were compared to the initial implantation data. Results: Atrial fibrillation and flutter was developed in 54 pts (28.87%) who were in sinus rhythm at the time of implantation. Patients with SND developed the arrhythmia more frequently to pts with AVB and BFB (38.09% vs 21.87% and vs 16%, p=0.046 and p=0.036 respectively). QRS duration was extended during reimplantation period from 104.91 + 24.48msec to 112.21 + 28.21msec, p , 0.001. Patients with SND without any conduction disturbances at the time of first implantation developed at the time of reimplantation AVB in 14.28%, and BBB in 17.85% of cases. In 62.5% of the pts with BBB but without any AV conduction disturbances at initial implantation, AVB had developed at the time of PM replacement, whereas most of the pts (85%) with BFB had developed AVB. Based on aforementioned, progression to AVB is significantly more probable in pts paced for BFB than in pts treated for SND (p , 0.001). In pts with BFB without any evidence of SND before implantation eventually 20% developed SND-like ECG changes whilst, these changes were observed in 8.88% of pts with AVB indication and no evidence of SND on initial implantation (p=ns). Conclusions: Our findings confirm previous observations that impulse formation and conduction disturbances that dictate PM implantation are an evolving process and each type of abnormality can progressively transit into another. These changes should be taken under consideration during PM mode selection at the time of first implantation.
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Defibrillators patients perception of daily life activities and medical followup : a French survey W. Amara1, S. Cheggour2, A. Elhraiech1, H. Salih1, J. Taieb3, N. Rabah4, G. Glerici1, F. Ghanem5, A. Dompinier6, and P. Bru7 1
GHI Le Raincy-Montfermeil, Montfermeil, France; 2Avignon Hospital Center, Avignon, France; 3General Hospital of Aix en Provence, Aix en Provence, France; 4Hospital Evreux, Evreux, France; 5General Hospital, Chateauroux, France; 6Hospital of Annecy, Annecy, France; and 7Hospital General La Rochelle, La Rochelle, France Introduction: The aim of our study was to assess patients’ knowledge about defibrillators after the implantation. Material and methods: We performed a multicenter survey in 10 French centers from January 2012 to december 2012. In each center, patients received usual informations about defibrillator’s implantation, functioning, and about their habits after the implantation. They signed a consent for implantation. One to 10 days after implantation, all patients received a questionnaire. The questionnaire evaluated patients’ perceptions of information and consent, risks of implantation; follow up, and about performing various routine activities (daily life activities, use of electrical devices, ability to undergo medical imaging tests). We also evaluated the patients’ anxiety using the Beck Anxiety Inventory Score and the health status of patients considered by themselves by a numerical scale (between 0 and 100) . Results: We included 119 patients. The mean age was 66.5 þ 11.8 years 34- 82 yrs) and 87% were men. The intervention was a primary implantation in 79% of patients. We noted that 89% on the patients remember that they have signed a consent and only 72% of patients remember that they received counseling in the peri-operative period. A considerable proportion of patients considered many routine activities unsafe including driving automobiles (40%), passing through metal detectors (33%), sleeping on the side of the defibrillator (48%). Also, 33% of patients think they can use induction hobs and 72% think they can use mobile phone without any precautions. Regarding medical imaging, 47%; 23% and 29% of patients considered unsafe making scanners, radiography and echography respectively; and 32 % ignored if they can have MRI. Finally, regarding the medical follow up, 18% of patients think they are exempt from monitoring by a cardiologist. Despite an altered perceived health status (the mean of numerical scale was 33.7), the perceived anxiety was low (the mean of Beck anxiety inventory score was 28.5). Conclusion: The results of our study highlight on patients’ misperceptions on defibrillator functioning and the need in improving practices to better inform patients. Thus, the quality of life of implanted patients may be improved.
Endocardial leads extraction - what has changed during last 7 years - based on experience of polish leads registry M. Chudzik1, A. Kutarski2, P. Mitkowski3, A. Maciag4, M. Kempa5, and B. Malecka6 1 Medical University of Lodz, Department of Electrocardiology, Lodz, Poland; 2Medical University of Lublin, Department of Cardiology, Lublin, Poland; 3Poznan University of Medical Sciences, Department of Cardiology, Poznan, Poland; 4Institute of Cardiology, 2nd Department of Coronary Artery Disease, Warsaw, Poland; 5Medical University of Gdansk, Department of Cardiology and Electrotherapy, Gdansk, Poland; and 6John Paul II Hospital, Department of Electrocardiology, Krakow, Poland
Introduction: Over last ten years, there has been an increasing number of patients with a pacemaker (PM) and a cardioverter-defibrillator (ICD) implantation. This study is a retrospective analysis of indications for an trnsvenous lead extraction (TLE) performed between 2006 and 2012 based on the data of five Polish Referral Lead Extraction Centers. Materials and Methods: Since 2006 till 2012, the authors have consecutively collected all cases and entered the information in the database. All cases were classified according to HRS 2009 guidelines on indications for leads extraction. Results: During 7 years 2119 TLE procedures were performed. In the following years, a significant increase in number of lead extraction procedures was observed. In 2012 the main cause of extraction were non infection indications – 64,2 % of cases. Infection as an indication for LE decreased from 74% in 2006 to 35,2% in 2012 Nonfunctioning lead extraction constituted the main group of indications in 2012 for LE in 46,7% patients with 22,8% performed because of defect of an endocardial lead. During the registry period, the percentage of class I indication decreased from 76,7% in 2006 to only 42,5% in 2012. On the other hand, increasingly more leads were removed because of class 2, especially class 2b – 18,6% in 2006 and 54,7% in 2012 respectively. Conclusions: The Polish Registry, 2006-2012, shows an increasing number of lead extraction procedures. The main cause for TLE during 7 years were non-infection indications. An increase in class 2, mailny 2b TLE indication in every center during the study period, indicates, that non-necessary lead abandonment stays less utilised option.
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Transvenous lead extraction: single centre experience of more than 1000 cases O. Al-Razzo, E. Gonzalez, R. Sanchez, A. Hurtado, M. Monteagudo, L. Sartor, J.A. Blazquez, U. Ramirez, J. Silvestre, and J.M. Mesa University Hospital La Paz, Department of Cardiac Surgery, Madrid, Spain Introduction: The growing number of pacemaker and implantable cardioverter defibrillator lead implants has increased the interest in transvenous lead extraction. We present a single centre experience in transvenous lead extraction performed by a variety of techniques. Objectives: To examine the transvenous lead extraction indications, techniques and results in a large series of patients at a single centre. Methods and Results: Between January 1984 and January 2013, 1583 leads were extracted from 1175 consecutive patients. Different types of locking stylets and dissection sheathes were used. Median age was 61 years (range, 22-92 years). Median implant duration was 7,3 years (range, 1-31 years). The indications for lead extraction were, infection in 634 cases (54%), lead malfunction in 294 cases (25%), pulse generator and/or lead erosion in 176 cases (15%), and up grade of device system in 70 cases (6%). Manual traction (with the use of locking stylets) was used to extract 55% of the leads, 20% were extracted using the Evolution dissection sheath, 18% extracted with the use of metallic sheath, 1% with laser technique, and an electrosurgical sheath was used to extract 2% of the leads. A femoral approach was required to extract 2% of the leads, and 1,7% were surgically removed. Minor and major complications rates were 2,6% and 0.8%, respectively. Extraction-related mortality occurred in 2 cases. Complete procedural success was achieved in 90% of cases and overall clinical success was 95%. Conclusions: Transvenous lead extraction has a high success rate and low complication rate. Minor and major complications and procedural failure rates had decreased with the use of new extraction technologies.
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Advanced techniques for chronic lead extraction. Heading from the Laser towards the Evolution system P. Mazzone, D. Tsiachris, A. Marzi, G. Paglino, G. Stavropoulos, N. Sora, F. Guarracini, P. Vergara, S. Gulletta, and P. Della Bella San Raffaele Hospital (IRCCS), Arrhythmology, Electrophysiology and Cardiac Pacing Unit, Milan, Italy Purpose: The most recently developed hand-powered Evolution mechanical dilator sheath (Cook Medical, Grandegrift, PA, USA) has been reported to be an effective extraction tool for chronically implanted leads although studies comparing it with other techniques are lacking. Therefore our purpose was to compare the efficacy and the safety of the Evolution system versus the established Laser system in cases where advanced extraction tools are required. Methods: From 2005 to 2009, all extractions requiring the use of a powered sheath were performed using the excimer laser system (n=73). Since 2009, laser system was no longer available and the Evolution system was introduced as the first-line method for powered extraction (n=48) (Figure 1). All procedures were performed by a single first operator. Success and complications were defined according to the current guidelines. Results: Patients of the Evolution group compared to those of the Laser group had a greater number of extracted leads per patient (2.77 vs. 2.4, p=0.049) and a longer implant duration (101.1 vs. 62.4 months, p=0.001). Additional use of snare was required in 27.1 % of the Evolution group and 8.2% of the Laser group ( p=0.005). Complete procedural success was achieved in 91.7% of the Evolution group and 97.3% of the Laser group ( p=0.16). There was also no difference between Evolution and Laser groups in clinical success (97.9% vs. 98.6%, p=0.76), as well as regarding major (4.2% vs. 2.7%, p=0.66) or minor complications (4.2% vs. 5.5%, p=0.76). Conclusion: Use of the recently introduced Evolution system for lead extraction exhibit acceptably high levels of safety, as well as of procedural and clinical success, although and additional use of snare was required more frequently in the Evolution compared to the Laser group.
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Drug-related atrioventricular block, is it a benign condition? Dry heart wall perforation - the new epidemy or better diagnosed phenomenon?
M.A. Akbarzadeh1, S. Sayah1, Z. Emkanjoo1, A. Azhari1, R. Mollazadeh2, and S. Shahrzad1 1 Rajaei Cardiovascular, Medical and Research Center, Department of Electrophysiology, Tehran, Iran (Islamic Republic of ); and 2Tehran University of Medical Sciences, Imam Khomeini Hospital, Department of Cardiology, Tehran, Iran (Islamic Republic of )
Background and Objectives: Prognosis and natural history of the patients with beta blocker or calcium channel blocker induced AV block are not well known till now. Methods: We prospectively collected all patients with symptomatic second degree or third degree atrioventricular(AV) block who referred to our institution between April 2010 and April 2011 .Patients were classified in two groups according to consumption of drug (beta blocker or calcium channel blocker ) or not. They followed for 6 months and then collected data analyzed. Results: Of 49 patients who entered the study, 28 patients (age 60.1 + 20 years, 19 males) were not using any beta blocker or calcium channel blocker (No-DU group). Other 21 patients (age73.5 + 10.4, 7 males) were receiving beta blocker, calcium channel blocker or both at the time of AV block (DU group). This group was significantly older than No-DU group (P=0.04) and dominantly was female. Sinus rhythm was the most atrial rhythm in both groups and there were no significant difference in QRS widening or ventricular rate , 40 in both groups. AV block regressed in 43% of the DU patients with discontinuation of drug after 5 half life. But, 50% of cases that AV conduction improved, again Mobitz type 2 or complete AV block developed in 6 months despite discontinuation of the culprit drugs.(Table 1) Conclusion: More than two third of the patients who developed AV block on beta blocker and/or calcium channel blocker were needed permanent pacemaker in 6 months of follow up, so we conclude that developing of AV block is not as benign as it seems in these patients.
Age(yrs) Male Level of Block QRS Duration . 120 Vantricular Rhythm
Wenckebach Mobitz type 2 Complete AV block
AV block regressed after discontinuation of drugs (9 patients)
AV Block remained after discontinuation Drugs (12patients)
P Value
69.7þ/-10.4 4(44.4%) 0(0%) 4(44.4%) 5(55.6%) 4(44.4%) 4(44.4%)
76.4 þ/- 20 3(25%) 1(8.3%) 3(25%) 8(66.7%) 8(66.7%) 4(33.3%)
0.14 0.4 0.76 0.4 0.67
Table 1- Characteristic of the patients with AV block on medication after discontinuation of drugfor 5 half life.
A. Kutarski, A. Tomaszewski, W. Brzozowski, K. Oleszczak, and K. Boczar Medical University of Lublin, Department of Cardiology, Lublin, Poland Theoretically increased risk of perforating lead extraction inclined us for attempt to localise tip of lead in relation to epicardium and the commonness of the phenomenon was surprising. The goal: retrospective analysis computer data-base referential centre of transvenous lead extraction (TLE) in our country. TEE & TTE and other preoperative findings were analyzed. We have extracted 1815 ingrown leads from 1082 patients; 138 leads presented signs of perforation (12,7%). Results: ECHO: dry perforation (tip in epicardial space, no fluid) – 88 (63,8%), small ldquo;lens” of dense fluid round the lead tip – 11 (8,0%), wet perforation (thin layer of fluid – 13 (9,4%), deep subepicardial tip penetration – 15 (10,9%) but in last 13 pts diagnosis was based on other symptoms (9,4%). Indications for TLE: “lead dysfunction” ( pacing / sensing impedance abnormalities) - 71 (51,4%), diagnosed perforation 32 (23,2%), infection – 20 (14,5%), other – 15 (10,9%). In 20 pts all parameters of pacing/sensing/impedance were normal (14,5%) but in other drop of sensing (49) or sizzles (9) were noted (42,0%) rise of Pth in 65 or loss of pacing (16) were observed (58,7%) and rise in 45 or drop in 12 of impedance (41,4%) were noted in different combinations. In 18 of PM pts Pth was lower in BP than UP configuration. In most of pts with ICD leads – transient increase and after gradual drop of potential amplitude, accompanied with increase of pacing threshold; changes of impedance were less characteristic (especially in BP pacing configuration) – but finally rise up to . 2000 Ohm were noted usually. Subjective symptoms (in 32/138 only): 22 atypical chest pain, “pacing intolerance” 6, extracardiac pacing 4. Perforating lead location: RVA 105, RVOT 26 and RAA 6. Perforating lead’s model: PM BP72, ICD HV 56, PM UP 9. Active fixation 63, passive – 75. Time implantation – diagnosis: aver.67,5 (21-316) mth, ,3 mth – 12, 3m-2year -21, . 2y – 105. 105/138 (76,1%) perforations were diagnosed . 2 y after implantation. Dry perforation was rarely visible in standard chest X-ray (6/138), standard ECHO showed very low sensitivity; the tip of lead must to be search using additional projections. Pacing / sensing / impedance parameters abnormalities may to lead to proper diagnose. Its’ gradual deterioration seems to be the most frequent but non-specific symptoms. Conclusion: 1. “Dry” perforation (without cardiac tamponade or marked volume of fluid in pericardial space) consists relatively frequent finding in pts referred fort TLE (13%). It demonstrates usually as “lead dysfunction” mask but in remaining pts is asymptomatic.
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Resynchronisation therapy
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CRT-defibrillator long-term survival compared with CRT-pacemaker in patients meeting class Ia indication for CRT: data from CONTAK Italian Registry F. Zanon1, G. Morani2, M. Gasparini3, A. Spotti4, A. Reggiani5, F. Solimene6, G. Molon7, M. Accogli8, C. Ciardiello9, and L. Padeletti10, CONTAK Italian Registry Investigators 1
Santa Maria della Misericordia Hospital, Rovigo, Italy; 2Civil Hospital Maggiore at Borgo Trento, Verona, Italy; 3Clinical Institute Humanitas IRCCS, Rozzano, Italy; 4Hospital of Cremona, Cremona, Italy; 5Hospital Carlo Poma, Mantova, Italy; 6Montevergine Cardiology Clinic, Mercogliano, Italy; 7"Sacred Heart Don Calabria" Hospital of Negrar, Negrar-Verona, Italy; 8Cardinale G. Panico Hospital, Department of Cardiology, Tricase, Italy; 9Boston Scientific Italy, Milan, Italy; and 10Careggi Hospital, Florence, Italy Purpose: In candidates for cardiac resynchronization therapy (CRT), the choice between pacemaker (CRT-P) and defibrillator (CRT-D) implantation is still debated. We compared the longterm prognosis of patients who received CRT-D or CRT-P according to class IA recommendations of the European Society of Cardiology (ESC) and who were enrolled in a multicenter prospective registry. Methods: A total of 620 heart failure patients underwent successful implantation of a CRT device and were enrolled in the Contak Italian Registry. The present analysis included 266 patients who received a CRT-D and 108 who received a CRT-P according to class IA ESC indications. Their survival status was verified after a median follow-up of 55 months. Results: During follow-up, 73 CRT-D and 44 CRT-P patients died (rate 6.6 versus 10.4%/y; Log-rank test, p=0.020). Patients receiving CRT-P were predominantly older, female, had no history of life-threatening ventricular arrhythmias, and more frequently presented non-ischemic etiology of heart failure, longer QRS durations and worse renal function. However, the only independent predictor of death from any cause was the use of CRT-P (hazard ratio, 1.97; 95% confidence interval, 1.21 to 3.16; p=0.007). Conclusions: The implantation of CRT-D, rather than CRT-P, may be preferable in patients presenting with current class IA ESC indications for CRT. Indeed, CRT-D resulted in greater long-term survival and was independently associated with a better prognosis.
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VISTA clinical study: rationale, objectives, and design D. Lebedev, V. Lebedeva, E. Zubarev, T. Lubimceva, and E. Shlyakhto Almazov Federal Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation This study is a prospective randomized pilot study in patients with permanent or long-standing persistent atrial fibrillation (AF) who are candidates for catheter atrioventricular (AV) node ablation, as treatment for the symptoms of the underlying disease, and a pacemaker (PM) implant procedure. Study objective: to identify ways to improve treatment outcomes in patients with coexistent AF and moderate Chronic Heart Failure (CHF) with less preserved (less than 45%) ejection fraction (EF). Study Purposes: To determine whether cardiac resynchronization therapy (CRT) is superior to right ventricular (RV) septal pacing in terms of reverse remodeling and progression of CHF in patients who have undergone successful AV node ablation and a PM implant procedure. Materials and methods: According to the design, sixty patients will be randomized in two groups in a 1:1 ratio: CRT group and RV pacing group. The inclusion criteria are age between 18 and 75; AF requiring AV node ablation; NYHA class II or III CHF; and LV ejection fraction of 30–45%. In both groups, the RV electrode will be implanted into the interventricular septum (IVT). In the CRT group, isolated right ventricular septal pacing mode will be used for 3 months after AV node ablation and PM implanting, and biventricular pacing will be used thereafter. The follow-up visits are scheduled for months 3 and 6 after the start of biventricular pacing mode. The study methods include ECG, 24-hour ECG monitoring, Doppler echocardiography, the 6 minute walk test, the cardiorespiratory test, and quality-of-life assessment using the Minnesota Living with Heart Failure Questionnaire. The primary endpoint is left ventricle (LV) end-systolic volume. The secondary endpoints are the rate of cardiovascular events, quality of life, class of CHF, and parameters of LV remodeling. Conclusion: The VISTA study is being conducted to help doctors improve treatment outcomes and quality of life in patients with AF by choosing an optimal pacing mode in patients who have undergone successful AV node ablation and a PM implant procedure. The study is registered at the database of scientific studies. Its ClinicalTrials identifier is NCT01512381.
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Relationship between tapse and both renal and left ventricular function in patients undergoing cardiac resynchronization therapy P. Pieragnoli, G. Ricciardi, E. Sticchi, F. Ristalli, P. Attana, L. Checchi, C. Fatini, L. Padeletti, R. Abbate, and A. Michelucci
Delayed ECG-based left ventricular activation time and outcome in patients after cardiac resynchronization therapy
Careggi University Hospital, Department of Critical Care Medicine and Surgery, Florence, Italy Purpose: Right ventricular function (RVF), in particular tricuspid annular plane systolic excursion (TAPSE), is useful to identify responders to cardiac resynchronization therapy (CRT). RVF has been also associated with renal impairment, possibly representing a mechanistic link between heart failure (HF) and renal dysfunction. We investigated the relationship between TAPSE and both renal markers and echocardiographic parameters in HF patients scheduled for CRT with defibrillator (CRT-D). Methods: Eighty-eight HF patients in sinus rhythm on optimal medical therapy [median age 67(29-89), M/F 75/ 13, ischemic etiology:47%, NYHA class II-IV, left ventricular (LV) ejection fraction (EF) ,40%], undergoing CRT-D were studied. Forty-five (51%) patients showed narrow QRS (,120 ms) with systolic dyssynchrony. All subjects underwent echocardiography to assess TAPSE. Baseline renal function was evaluated using usually adopted [creatinine, glomerular filtration rate, estimated by the abbreviated Modification of Diet in Renal Disease equation (MDRD), and blood urea nitrogen (BUN)] and emerging parameters [cystatin C (CysC) and neutrophil gelatinase-associated lipocalin (NGAL)]. Results: By evaluating the relationship between TAPSE and both traditional and emergent renal parameters, a significant positive correlation with eGFR (MDRD) (p=0.04), and a significant negative correlation with CysC ( p=0.02) and NGAL ( p=0.02) was found. TAPSE significantly correlated with NT-proBNP levels (p=0.02), indexed LV end-diastolic and end-systolic volume (EDV: p=0.005; ESV:p=0.03) and LV mass (p=0.03), and with inter-ventricular delay (IVD: p=0.006) (Figure). Conclusions: Our results suggest that RVF is linked to both renal function and LV remodeling, thus being taken into account in evaluating patients undergoing CRT.
B. Urbanek, M. Chudzik, I. Cygankiewicz, E. Nowacka, and JK. Wranicz Medical University of Lodz, Department of Electrocardiology, Lodz, Poland Purpose: Optimal election of “responders” among patients qualified for cardiac resynchronization therapy (CRT) is a great challenge in clinical practice. Recent data indicates that delayed left ventricular activation time (LVAT) calculated from surface electrocardiography (ECG) may play a crucial role in selection of CRT responders. The purpose of the study was to assess the relationship between baseline LVAT and ECG/ echocardiography (ECHO)/ hemodynamic changes as well as clinical outcome in patients after CRT. Methods: Data were analyzed from 37 end-stage HF patients (Male 33, mean age 68 +10) who underwent CRT implantation (indications class I according ESC) between January 2010 and November 2011. In all patients ECG, ECHO and impedance cardiography were recorded pre- and 1- year post CRT implantation (1-year FU) in order to assess, intrinsic QRS duration, ejection fraction (EF) and cardiac output (CO), respectively. The LVAT was measured preCRT. “Responders” were defined by 10% increasing EF (EF 10%). Results: During 1- year FU 11 (29%) patients died. Those who survived were divided based on ECHO changes into group A “responders” (18 patients - 69%) and group B non-responders (8 patients - 31%). Baseline LVAT did not correlate with pre CRT implantation EF and CO, nor with delta changes in these parameters ( pre -1-year FU). Baseline LVAT did not differ significantly between patients who died and survived ( 98 + 22 vs 105+ 33 ms, p=NS). Furthermore LVAT was not significantly different between group A and B (99.4 + 21 vs 95 + 21 ms, p=NS) Conclusions: Baseline LVAT did not predict responders in patients with CRT.
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Trying to predict the unpredictable:device-based daily monitored parameters can predict malignant arrhythmic events in patients undergoing cardiac resynchronization R. Lenarczyk1, E. Jedrzejczyk-Patej2, O. Kowalski2, B. Sredniawa2, P. Pruszkowska2, A. Sokal2, M. Szulik2, M. Mazurek2, J. Kowalczyk2, and Z. Kalarus2, for the Triple-Site Versus Standard Cardiac Resynchronization Trial (TRUST CRT) Investigators 1 Silesian Medical University, Silesian Center for Heart Disease, Zabrze, Poland; and 2Medical University of Silesia, SCHD, Dpt. of Cardiology, Congenital Heart Disease & Electrotherapy, Zabrze, Poland
Purpose: The aim of this substudy was to evaluate the prognostic values of device-based diagnostic parameters as predictors of malignant ventricular arrhythmias in patients undergoing cardiac resynchronization therapy (CRT). Methods: Study population consisted of 96 CRT-D recipients participating in the TRUST CRT Trial. Inclusion criteria included heart failure (HF) in NYHA3 class, QRS 120msec, left ventricular ejection fraction (EF) 35% and significant mechanical dyssynchrony. Patients were divided into those with (n=31, 92 arrhythmias) and without (n=65) appropriate ICD interventions within the median follow-up of 12.03 + 6.7 months. Daily monitored device-based diagnostic parameters - day and night heart rate (HR), thoracic impedance (TI), heart rate variability and physical activity were screened for significant changes within 4 time windows: within 10, 7, 3 days and 1 day prior to the first and to all appropriate ICD interventions. Results: Only 6 arrhythmias (6.5%) in 4 patients (13%) showed temporal relationship to HF exacerbation. There was a consistent pattern of changes in three out of five monitored factors prior to arrhythmia: a gradual increase of daily HR (103.43% of reference within 10-day window, 103.6% in 7-days, 104.6% in 3 days and 105.55% one day before, all P , 0.05 vs. reference). Similarly varied night HR (104.75% in 3 days, 107.65% one day, all P , 0.05). On the contrary, intrathoracic impedance was decreasing significantly (97.8% in 10 days, 97.7% in 7days, 97.34% in 3 days and 96.81% in 1 day, all P , 0.05). Changes in device-monitored parameters showed only moderate sensitivity, but high specificity, the combination of three parameters had better predictive performance (sensitivity 42%, specificity 86%), which improved further after excluding patients with atrial fibrillation. The predictive model combining changes in HR and TI together with EF and NTproBNP (AUC 0.7, 95%CI 0.63-0.77; P , 0.05) was more prognostic in forecasting day-by-day risk than model involving EF and NTproBNP alone (difference in AUC 0.05, 95% CI 0.0005-0.09; P=0.04). Conclusions: Daily device-measured parameters show reproducibly significant variations prior to ventricular arrhythmia. Combination of multiple parameters improves their predictive performance, whereas presence of atrial fibrillation diminishes it. Predictive value of these variables is additive to baseline risk factors.
Prognosis after implantable cardioverter defibrillator / cardiac resynchronization therapy defibrillator implantation in cardiac sarcoidosis patients T. Kabutoya1, T. Mitsuhashi1, H. Watanabe1, T. Watanabe1, R. Nakagami2, Y. Hata1, and K. Kario1 1 Jichi Medical University, Department of Cardiology, Tochigi, Japan; and 2New Tokyo Hospital, Chiba, Japan
Background: Mortality and appropriate therapy following implantable cardioverter defibrillator (ICD)/ cardiac resynchronization therapy defibrillator (CRT-D) implantation in cardiac sarcoidosis (CS) patients remains unclear. Methods: We enrolled 28 consecutive CS patients and 106 ischemic heart disease (IHD) patients who underwent ICD/CRT-D implantation from January 2006 through December 2010. We evaluated fatal events and appropriate ICD therapy for ventricular tachycardia/ventricular fibrillation (VT/VF) and compared these events between the two disease groups. Results: During the follow-up period (30 + 17 months), two deaths and appropriate ICD therapy in nine patients were recorded in the CS patient group. One fatal case had prior inappropriate ICD therapy, but both fatal cases had not had prior appropriate ICD therapy. Mortality (log rank 0.86, p=0.36) and achievement of appropriate ICD therapy for VT/VF (log rank 0.01, p=0.95) were similar between CS patients and IHD patients, although the CS patients was more likely to be of younger age (58 + 13 vs. 64 + 12 years, p=0.035), to have higher left ventricular ejection fraction (42 + 16 vs. 35 + 13%, p=0.023), and to have a primary indication for ICD implantation (40 vs. 18%, p=0.003). There were similar numbers of appropriate ICD therapy cases between primary prevention cases (N=12) and secondary prevention cases (N=16) in the CS patient group (log rank 0.68, p=0.41). Conclusions: The prognoses of CS and IHD patients treated with ICD therapy were similar. Appropriate ICD therapy did not predict fatal events in CS patients.
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Impact factor of beta1-gly-389-arg adrenergic receptor polymorphism on left ventricular remodelling after crt A. Fundaliotis1, P. Marino1, A. Cuko2, E. Cassetti1, E. Occhetta1, M. Moscatiello2, C. Pappone2, and G. De Luca1 University of Eastern Piedmont, Department of Cardiology, Novara, Italy; and 2Department of Arrhythmology, VMC Hospital, GVM Care&Research, Cotignola, Italy
Biventricular pacing in patients with hypertrophic obstructive cardiomyopathy: long term follow-up
1
Purpose: A very high variability has been found in response to cardiac resynchronization therapy (CRT) in patients with dilated cardiomyopathy (DCM). However, except of QRS duration on surface ECG and functional NYHA Class, are still unclear so far which other factors may predict better response to CRT. In heart failure (HF) patients, the down-regulation of beta-1 adrenergic receptors (b1 AR) has been described. Genetic variant (Gly389-Arg) has been found to increase up to four times the response to adrenergic agonists. Therefore, the aim of our study was to evaluate the influence of b1 AR gene polymorphism (b1-Gly-389-Arg) on CRT induced reverse remodeling in patients affected by DCM. Methods: From January 2010 to December 2011, we evaluated 95 patients with DCM undergoing CRT-D according to current guidelines. All patients underwent to coronary angiography, CRT-D implantation and genetic evaluation of B1-Gly-389-Arg. Echocardiographic and clinical assessment was performed at 6 months follow-up (FU). Statistical analysis was measured with SPSS 13.0. Results: The polymorphism was observed in 87 patients (46 of them in heterozygosis). No differences in baseline clinical characteristics were observed between the groups. However, we found that the patients carrying the polymorphism type, compared to wild type patients, had a more favourable left ventricular (LV) remodeling (improved in LV ejection fraction and reduction of LV volumes) after CRT response (see Table) and an improved in global survival. Conclusions: This is the first study showing that the polymorphism of B1-Gly-389-Arg is associated with improved LV remodeling and a better outcome in CRT patients. This genetic pattern may be potentially useful to identify the CRT responders.
EF Bl NT(8) 23.5 (7.3) TNT 25.7 (46) (6.8) TT 25.9 (41) (6.1)
EDV P
Bl
ESV
6m
D
6m
D
P
Bl
6m
D
P
28.9 (9.2) 34.9 (11.6) 35 (9.9)
5.4 0.19 182.2 182.6 0.4 0.9 138.1 133 (74.5) -5.1 (45.5) 0.76 (10.5) (51.7) (83.6) (43.2) (35.1) 9.2 ,0.001 172 158 -14 0.03 128.4 106.2 (46.7) -22.2 (33.2) ,0.001 (9.2) (44.8) (48.7) (38.6) (40.4) 9.1 ,0.001 178.2 155.8 -22.3 ,0.001 130.2 103.1 (39.5) -27 (29.3) ,0.001 (6.9) (49.4) (44.7) (36.4) (44)
Analysis of Echocardiographic Follow-Up in CRT patients according B1 AR polymorphism. NT = Wild Type patients; TNT = Heterozygotic patients; TT Homozygotic patients.
D. Penela, A. Berruezo, R. Evertz, J. Fernandez-Armenta, E. Arbelo, J.M. Tolosana, M. Sitges, X. Alsina, L. Mont, and J. Brugada Arrhythmia section, Cardiology Dep. Thorax Institute. Hospital Clinic, Universitat de Barcelona, Barcelona, Spain Introduction: Few data with short term follow-up is available on biventricular pacing in patients with hypertrophic obstructive cardiomyopathy (HOCM). These studies show that there might be a benificial effect. The objective of this study was to assess the long-term benefit. Methods: Severely symptomatic HOCM patients with a resting left ventricle outflow tract (LVOT) gradient 50 mmHg were eligible. After informed consent a biventricular pacemaker, with or without backup defibrillator was implanted. The primary endpoint was improvement of symptoms, defined as a decrease of 1 point in NYHA class plus an increase in exercise capacity . 10% on a 6-minute walk test (6MWT) plus a decrease of . 10 points on the Minnesota living with Heart Failure Questionnaire (MLWHFQ), as marker of an improvement in the quality of life. The secondary endpoint was a persistent reduction 40% of the LVOT gradient. Results: Fifteen HOCM patients were included in the study and were programmed for implantation of an atrial synchronous biventricular pacing device. Twelve patients (51 + 19 years, NYHA class 3.1 + 0.5, LVEF 68 + 9%) were successfully implanted. The optimal pacing mode was biventricular in 9, LV only in 1 and RV only in 2 patients. After a mean follow-up of 55 + 24 months, 7 patients (58%) reached the primary endpoint and were considered responders. In the responders the NYHA class improved from 3,3 (+ 0,5) to 1,6 (+ 0,8), p = 0.016, patients walked a longer distance on the 6MWT: 498 (+ 101) vs 355 (+ 90) meters, p = 0.018 and the MLWHFQ improved from 61 (+ 13) at baseline to 42 (+ 18) points at follow-up, p = 0.028. The LVOT resting gradient in the responders decreased from 74 (+ 26) to 45 (+ 38) mmHg, p = 0,046. Explanation for clinical non-responding was fusion of intrinsic conduction with ventricular pacing partially nullifying the desired effect in 3 patients, the development of AF in 1 patient and severe diastolic dysfunction in the last patient. A total of 8 patients (67%) met the secondary endpoint of persistent reduction of the LVOT resting gradient 40%. Conclusion: Biventricular pacing is the optimal pacing mode in most of the patients with HOCM, providing a long-term persistent clinical and echocardiographic improvement in the majority of them.
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Change of intrinsic AV intervals with increased heart rate associated with exercise and atrial pacing: Results of the RAVE Study Narrowing the QRS complex: a new pacing mode in cardiac resynchronization therapy
M.R. Gold1, Y. Yu2, J.L. Sturdivant1, J. Everidge2, P. Kaveney2, and C. Athill3, RAVE study group 1
Medical University of South Carolina, Charleston, United States of America; 2Boston Scientific Corporation, St. Paul, United States of America; and 3San Diego Cardiac Center, San Diego, United States of America
Purpose: One of the frequent concerns of AV delay optimization (AVO) for cardiac resynchronization therapy (CRT) is that it is performed when the patient is in the supine and resting state. Several electrogram based AVO algorithms calculate AV delay based on the intrinsic AV intervals. To evaluate the effect of posture and exercise on such AVO, we prospectively measured intrinsic AV intervals in patients following CRT implant. Methods: RAVE was a multicenter study of 36 patients in sinus rhythm following CRT implantation. Atrial to right ventricular (ARV) and atrial to left ventricular (ALV) time intervals were measured in supine, sitting and standing positions. Heart rate was then increased with incremental atrial pacing (AP) up to 130 beats/min (bpm) to assess the change in AV timing with heart rate. Finally, treadmill exercise was performed in the absence of pacing. Results: The patient population was 72% male with a mean age of 65 + 10 years old. The mean EF was 29 + 12 and 52% had mild HF (NYHA I/II) at the time of testing. ARV and ALV intervals increased with incremental atrial pacing with posture having little effect (Figure). In addition, interventricular conduction times changed , 2ms/10 bpm atrial paced heart rate change in any posture. Changes in AV intervals were much smaller with exercise (Figure). Conclusions: The primary results of RAVE demonstrate that posture and exercise had little effect on AV timing in CRT patients. In contrast, atrial pacing significantly increased AV but not VV intervals. Accordingly, performing AVO in a supine and resting condition may be adequate for sensed AV delay. However, AV delays and paced AV offset may need to be adjusted at higher atrial pacing rates for CRT patients requiring such pacing.
T. Guo, L.M. Zhang, and R.J. Li 1st affiliated hospital of kunming medical university, Kunming, China, People’s Republic of Objective: To evaluate the impact of biventricular pacing with AV node intrinsic conduction (Biv-intrinsic) on width of QRS complex in patients with cardiac resynchronization therapy (CRT). Method: All patients with congestive heart failure who met IA recommendation for CRT were enrolled from Jan-Dec 2009.Among 44 patients enrolled, 34 (77.3%) were male,25 (56.8%) were diagnosed as dilated cardiomyopathy (DCM) and 19 (43.2%) with ischemic heart disease (IHD); the mean age was 62.11 + 9.03.All patients underwent CRT insertion successfully. Patients were programmed as traditional pacing mode first, which required the ventricles totally captured by CRT with echo optimization for 1 month, and then switched to Biv-intrinsic mode which showed in the ECG as ventricular fusion with narrowest QRS width for another 1 month. QRS duration, AVd/VVd and time consuming were compared between two modes. Results: The mean QRS width was shorter in Biv-intrinsic mode compared to traditional mode in both immediate after programming (117.00 + 19.47ms vs.140.75 + 18.75ms, P , 0.001) and 1 month follow-up (118.35 + 21.59ms vs.146.35 + 5.31ms, P , 0.001).In traditional mode, QRS width increased at 1 month compared to baseline (146.35 + 5.31ms vs.140.75 + 18.75ms, P=0.024). Conclusion: The biventricular pacing with AV node intrinsic conduction mode shortened QRS duration in patients with CRT compared to traditional biventricular pacing. This mode may benefit those CRT patients with sinus rhythm, short PR duration and not respond well to CRT including those whose QRS complex remained unchanged or even wider after CRT.
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Echo-guided upgrading from biventricular to triple site cardiac resynchronization therapy
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Transvenous retrieval of foreign objects lost during cardiac device implantation or revision: a 10-year experience GM. Calvagna1, P. Romeo1, F. Ceresa2, and S. Valsecchi3 1
G. Moubarak1, P. Ritter2, G. Vedrenne1, and S. Cazeau1 1
Groupe Hospitalier Paris Saint Joseph, Paris, France; and 2University Hospital of Bordeaux - Hospital Haut Leveque, Bordeaux-Pessac, France Purpose: Limited data suggest that non-responders to standard biventricular cardiac resynchronization therapy (CRT) may benefit from upgrading to triple site ventricular stimulation by addition of a second right ventricular (RV) lead. We evaluated a strategy of intraoperative guidance of RV lead positioning using online measurement of the left preejection interval (LPEI). Methods: Patients with persistent symptomatic heart failure despite a first CRT system and at least one echocardiographic criteria of mechanical dyssynchrony (left ventricular filling time [LVFT]/RR interval ratio , 40%, interventricular mechanical delay [IVMD] . 40 ms, LPEI . 140 ms, or "diastolic" contraction of the left ventricular [LV] lateral wall or septum) were selected. A second RV lead was implanted at a site distant from the original RV lead and moved until obtaining the best optimized biventricular or triple site ventricular stimulation, defined by the greatest LPEI shortening. Results: Fourteen patients (9 men, mean age 72 + 10 years, ischemic heart disease In 8 patients) were included. Final stimulation configuration was triple site ventricular in all patients. At the end of the procedure, LV ejection fraction improved from to 25 + 9% to 32 + 12% ( p = 0.03), QRS width shortened from 184 + 30ms to 169 + 20 ms ( p = 0.07), and QRS axis shifted rightward from -11 + 1048 to þ69 + 918 ( p= 0.06). LPEI decreased from 186 + 25 ms to 155 + 22 ms ( p, 0.001), with an absolute reduction 10 ms in 13 patients. LPEI/ LV ejection time improved from 0.63 + 0.13 to 0.51 + 0.14 ( p, 0.001). The effect on LV filling (final LVFT/RR 49 + 8% vs. 45 + 8% at baseline, p=0.25) or interventricular synchrony (final IVMD 15 + 22ms vs. 48 + 33ms at baseline, p=0.26) was not statistically significant. Conclusions: Upgrading from biventricular to triple site ventricular stimulation with echocardiographic intraoperative guidance of RV lead position resulted in acute improvement of ejection fraction, global intraventricular synchrony, and LV systolic efficiency.
San Vincenzo Hospital, Taormina, Italy; 2Ospedale Papardo, Messina, Italy; and 3Boston Scientific Italy, Milano, Italy Purpose: Many techniques for the endovascular retrieval of lost or misplaced foreign objects have been developed, and the removal of almost every foreign object has become possible. We report our experience in retrieving foreign objects lost during cardiac device implantations or previous extraction procedures. Methods: The present study was a retrospective analysis of the case records of all patients referred to our institution for transvenous retrieval of intravascular foreign objects. Results: Over 10 years, 45 consecutive patients underwent procedures for the retrieval of intravascular foreign objects. Details of foreign objects and their locations are reported in table. The majority of fragments were located in the right ventricle and subclavian and caval veins. Some had migrated to the pulmonary artery or more distally. The median dwell time of the fragments was 3 months. Retrieval was most frequently achieved through the femoral veins, and was successful in 42 (93%) procedures. No procedure-related complications occurred in this series. Conclusions: In the present single-center experience, the endovascular approach to retrieving intravascular objects lost during cardiac device implantation or previous extraction procedures seemed effective with currently available tools and was associated with no complications.
Foreign object (n)
Location of foreign object (n)
Details
Fragment of pacing lead (16 ventricular; 2 atrial) Fragment of introducer sheath (25)
All pacing leads fractured during previous removal attempts
Guidewire (1)
Right ventricle (14); Right atrium (2); Renal vein (1); Pulmonary artery (1) Subclavian and caval vein (21); Jugular vein (2); Right ventricle (2) Jugular vein (1)
Anchoring sleeve (1)
Pulmonary artery (1)
17 sheaths fractured during implantation procedures and 8 during removal procedures Accidentally inserted completely into the vessel during implantation The sleeve was not secured on implantation and entered into the vein. During lead extraction, the use of dilators caused its distal migration and embolization
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The Jurdham procedure for left ventricular endocardial CRT: absence of complications at medium term follow up S. Worley1, N. Lopez Cabanillas2, J. Trainini2, A. Fischer3, L. Cardinali2, J.L. Barisani2, J. Jazbik4, J. De Paz2, F. Verbal5, and B. Elencwajg2 Lancaster Heart Group, Lancaster, United States of America; 2Presidente Peron Hospital, Buenos Aires, Argentina; 3Mount Sinai Medical Center, New York, United States of America; 4 Hospital Universitario Pedro Ernesto, Rio de Janeiro, Brazil; and 5Hopital Las Higueras, Talcahuano, Chile
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Differences in mode of death in super responders as compared to negative responders to cardiac resynchronization therapy A.C. Van Derh Heijden, U. Hoke, C.J.W. Borleffs, J. Thijssen, J.B. Van Rees, E.T. Van Der Velde, M.J. Schalij, and L. Van Erven
1
Purpose: In spite of the advantages of endocardial left ventricular (LV) pacing over traditional CS lead implantation for CRT, concerns remain about potential complications – systemic thromboembolism, mitral regurgitation and LV lead extraction. Data about the very low actual incidence of these events in anticoagulated patients are being published by several groups, utilizing diverse implantation techniques. We present our medium term follow up of patients who underwent the Jurdham procedure for LV endocardial implantation. Methods: Implantation was performed in all the patients utilizing a femoral transeptal approach, the Jurdham procedure, We included patients with standard indication for CRT, able and willing to take optimal vitamin K antagonist therapy (target INR of 2-3[AF1] ) who had previous failed attempts at CS lead placement or – for the last 4 patients - that preferred this approach as the first option. Results: Twenty one patients, (57,9 + 11.3 y.o., 13 males, EF 23.1 + 3.8%, LBBB, QRS 157 + 21.8 ms, NYHA 3.1 + 0.43) were implanted and followed for 15.6 + 7.3 months (range 1 – 20 months). LV leads were implanted in lateral or posterolateral regions in all patients. No surgical, thromboembolic or hemorrhagic complications occurred during the follow up period. All patients maintained adequate levels of INR. No new or increased mitral regurgitation was seen. No reoperations were required. The first 4 patients died: 3 from progressive CHF and one from septicemia after 2 previous failed CS attempts. Conclusions: In endocardial CRT patients under adequate chronic anticoagulation with vitamin K antagonist therapy, there were no thromboembolic or lead related complications. These results remain sustained over a medium term follow up period.
Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands Background: Cardiac resynchronization therapy-defibrillator [CRT-D] implantation has demonstrated to reduce mortality in selected heart failure patients. Small studies report patients with major improvement in left ventricular ejection fraction. Data of prognosis in these CRT-D super responders is scarce. Methods: All patients who underwent CRT-D implantation at Leiden University Medical Center are divided in subgroups according reduction of left ventricular end-systolic volume [LVESV], 6 months after implantation. Subgroups are: negative responders (increased LVESV) and super responders (decreased LVESV . 30%), remaining patients are excluded. For deceased, mode of death is retrieved from hospital or general practitioner records. Results: This study includes 318 CRT-D recipients (135 negative; 183 super responders). During a median follow up of 51 + 43 months, 58 (43%) negative and 45 (25%) super responders died ( p= , 0.001). Cardiac death occurred in 35 (60%) negative and 15 (33%) super responders (p=0.007), from which 28 (48%) negative and 12 (27%) super responders died of heart failure ( p=0.02). Non cardiac death occurred 12 (21%) negative and 21 (47%) super responders ( p=0.09), respectively 5 (9%) and 9 (20%) died due to malignant neoplasm ( p=0.23). Conclusion: In clinical practice CRT-D super responders have lower mortality compared to negative responders. Super responders die significantly less of cardiac deaths (heart failure), but tend to die more of non-cardiac death (malignant neoplasm).
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Patient-specific computer modeling for analysis of ventricular conduction disorders
Vectorcardiography for optimizing cardiac resynchronization therapy in dyssynchronous canine hearts
M. Potse1, W. Kroon1, D. Krause1, M. Acena2, F. Regoli2, R. Murzilli2, E. Caiani3, F.W. Prinzen4, R. Krause1, and A. Auricchio2
M. Strik1, P. Houthuizen1, L.B. Van Middendorp1, S. Ploux1, E. Evers1, A. Van Hunnik1, M. Kuipers1, A. Auricchio2, and F.W. Prinzen1
1
2
Institute of Computational Science, University of Lugano, Lugano, Switzerland; Foundation "Cardiocentro Ticino", Department of Cardiology, Lugano, Switzerland; 3Politecnico di Milano, Milano, Italy; and 4Maastricht University, CARIM, Department of Physiology, Maastricht, Netherlands Purpose: Characterization of the ventricular activation sequence (VAS) in heart failure patients is key to individualizing the delivery of cardiac resynchronization therapy (CRT). Our purpose was to use computer modeling to exactly define VAS. Methods: Chest magnetic resonance imaging (MRI), endocardial contact mapping, and electrocardiography were performed prior to CRT in five patients (left-ventricular mass 171 to 290 g, QRS duration 127 to 225 ms). Accurate three-dimensional models of the heart and torso were built from MRI data. The 3-dimensional electroanatomical mapping was registered to the MRI-based heart model. Twelve-lead electrocardiograms (ECG) were obtained with a high-fidelity ECG system. Depolarization and repolarization of the ventricles were simulated using a bidomain reaction-diffusion model running on 4096 processors of a Cray XE6 supercomputer. Earliest right-ventricular activation sites, tissue conductivity, and dispersion of repolarizing ionic currents were adapted to match predicted endocardial activation times and morphology of ECGs and local unipolar electrograms with measured data. Results: Twelve-lead ECGs, activation times, and electrograms could be accurately simulated by assuming a variable degree of fiber disarray and tuning the right-ventricular early activation areas. Assuming a higher conductivity along the subendocardium led to a poorer match, suggesting that retrograde Purkinje activation did not play a role in these patients. Conclusions: This is the first study confronting predictions from a physiologically realistic computer model with endocardial mapping and ECG in heart-failure patients. Our results may help in precisely characterizing the ventricular activation times using a standard 12-lead ECG and improving patient selection for device therapies.
1
Maastricht University, CARIM, Department of Physiology, Maastricht, Netherlands; and "Cardiocentro Ticino", Department of Cardiology, Lugano, Switzerland
2
Foundation
Introduction: A parameter to adequately optimize Cardiac Resynchronization Therapy (CRT) programming is currently lacking. We compared epicardial cardiac mapping with surface ECG and investigated their potential to predict acute CRT response using a vectorcardiography approach. Methods: CRT was performed in dogs with chronic left bundle branch block (LBBB, n=8) by sequential atrial (A), right ventricular (RV) apex and left ventricular (LV) basolateral pacing. 100 randomized A-LV/A-RV delay combinations were tested interspersed with 25 baseline measurements. Acute CRT response was assessed as percent change in LV dP/dtmax, settings providing 90% of peak LV dP/dtmax being defined as optimal. Maximal vector amplitudes were calculated from the activation times at 100 epicardial cardiac mapping electrodes (VA-CM) and from the surface ECG (VA-QRS). VA halfway between LV-pacing at short A-LV and intrinsic LBBB were defined as predictive for optimal response. (The arrays of data were subjected to quadratic fitting to account for measurement variability and plotted for comparison.) Results: VA-QRS behavior was highly comparable with VA-CM as evidenced by high surface plot correlation (mean of R=0.94). The mean surface correlation coefficient between VA-QRS ( proximity to the halfway value) and percent change in LV dP/dtmax was 0.73 (see figure). Optimal LV dP/dtmax increase was found at multiple A-LV/A-RV settings, which were accurately identified by VA-QRS (area under the receiver-operating characteristic = 0.89). Conclusion: During CRT optimization, the vector amplitude behavior from the ECG matches epicardial cardiac mapping and accurately predicts optimal settings for acute CRT response.
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Long term outcomes of cardiac triventricular pacing in patients with a high risk of non response to cardiac resynchronization therapy A. Duparc, C. Cardin, A. Rollin, E. Thomson, R. Noblemaire, M. Rezai, P. Maury, M. Delay, D. Carrie, and P. Mondoly University Hospital of Toulouse - Rangueil Hospital, Toulouse, France
P1068
Benefit of additional pacing leads in CRT patients with heart failure and short QRS I. Kosmidou1, D. Dan1, A. Wickliffe1, T. Deering1, F. Zanoni2, and S. Cazeau3, ACCESS study investigators 1
Piedmont Heart Institute, Piedmont, United States of America; 2Sorin CRM SAS, Clamart, France; and 3AP-HP - Hospital Saint-Joseph, Paris, France
Background: Some recent studies suggest that triventricular pacing could be more effective than conventional biventricular pacing in heart failure non selected patients. In our study, we chose to select patients with an important left ventricular dilatation which is a predictive factor of non response. Moreover, our experience of triventricular pacing allows a follow up of 24 month, up to all previous studies. Methods: We included patients with symptomatic heart failure despite optimal drug therapy, with complete bundle branch block, EF under 35% and an EDLVD up to 70mm. A triventricular device was implanted with a transvenous way. One of the two ventricular lead had to be positioned on the lateral wall. The two left ventricular leads were connected with an Y-adaptator. A positive response was defined as an NYHA class improvement, without hospitalization for heart failure. Device- related adverse events and electrical parameters of the left ventricular leads were also collected during the follow up. Results: 25 patients were included, 50% in NYHA class 3, 50% in NYHA class 4. 40% had an ischemic cardiomyopathy, QRS duration was 164ms þ/-28, EF was 21% þ/-6, and EDLVD was 80mm þ/-8.4. 19 patients were successfully implanted with a triventricular device. The 6 others were implanted with a biventricular device. No complication was related to the procedure. During the follow up, 3 patients presented an infection leading to device extraction. 4 patients had a reintervention because of a lead dysfunction or dislocation (right ventricular lead and defibrillator lead in all these cases). No triventricular interruption was related to a phrenic stimulation. At 12 months of follow up, 74% of the patients were responders. At 24 months of follow up, triventricular pacing was lost in only one patient, because of his atrial lead dysfunction and 62% of the patients were responders. Impedance of the left ventricular circuit is stable during the follow up (441 ohms þ/- 153 vs 371 ohmsþ/-78). Left ventricular pacing thresholds significatively increased during the follow up (1.31V þ/-1.2 vs 1.76V þ/-1.49, p , 0.05), but no impact on triventricular effectiveness. Conclusion: Triventricular pacing is a feasible and safe technique, with stable stimulation performances during two years follow up, except maybe a higher risk of infection that have to be confirmed by larger studies. Effectiveness is acceptable, but there are not enough date to assess his superiority on biventricular pacing.
P1069
Prediction of the anatomy of coronary sinus branches through angiographical characteristics of obtus marginalis branches of left circumflex coronary artery
Introduction: Acute mechanical response to cardiac resynchronization therapy (CRT) predicts long-term clinical response and reverse remodeling. However, the rate of response remains low, particularly in patients (pts) with short QRS. This study assessed the impact of multisite pacing on the acute mechanical response in pts with heart failure (HF) and short QRS. Methods: The ACCESS trial evaluates 29 pts with 120-170ms QRS duration (mean QRS=138 + 14ms) and standard CRT-D indications. During implantation standard lead positioning (S-CRT; RV apical and LV lateral positions) vs. optimized (O-CRT; best lead configuration guided by Echo, including BiV, TriV and .TriV pacing) was tested. O-CRT was defined as the configuration showing the largest reduction of Left Pre-Ejection Interval (LPEI) vs. S-CRT. The benefit of each additional pacing site in O-CRT configuration was assessed towards LPEI reduction. Results: Among the 29 enrolled pts, CRT acute mechanical response (defined when LPEI was reduced by more than 10ms vs. intrinsic) was demonstrated in 17 (59%) pts. 5 (17%) did not derive any significant benefit from OCRT (LPEI changes ,10ms) and 7 (24%) experienced deleterious effect of O-CRT (LPEI increase 10ms). Among the 17 pts presenting acute response in O-CRT, TriV and .TriV pacing configurations provided additional benefit vs. BiV in 15 pts (cf. table). Conclusions: 1) CRT in any configuration worsened the acute mechanical response in a quarter of patients with baseline QRS duration 120-170 ms. Acute optimization should be performed at the time of implantation to avoid deleterious configurations. 2) TriV and .TriV pacing allows further acute optimization compared to optimized BiV pacing.
O-CRT
Additional LPEI decrease, ms (mean + SD) p-value
BiV optimized vs. S-CRT
TriV & .TriV vs. BiV optimized
12.7 + 13.7 ,0.001
12.7 + 9.1 ,0.001
P1070
Right-to-left ventricular pacing-lead distance and reverse remodelling in cardiac resynchronization therapy F. Zoppo1, A. Berton1, F. Zerbo1, N. Frigato1, M. Michieletto1, A. Zanocco1, A. Lupo1, E. Bacchiega1, G. Brandolino1, and E. Bertaglia2
B. Candemir, M. Kilickap, O. Akyurek, A.T. Altin, M. Gerede, M. Guldal, and C. Erol Ankara University School of Medicine, Ankara, Turkey Aim/Background: Proper lead implantation to a suitable coronary sinus main branch is the mainstay of cardiac resynchronization therapy (CRT). As the circumflex artery (Cx) lies side by side with coronary sinus, this study aimed to determine whether angiographical characteristics of obtus marginal (OM) branches are correlated with those of coronary sinus. Materials and Methods: Coronary angiography and coronary sinus venographies of 39 patients who were scheduled to have CRT implantation were retrospectively analyzed and compared. Patients were grouped into 2 according to diameter of the largest OM 2.5mm (Group A) or above (Group B). Results: Findings of the study are being shown in Table 1. There were no significant differences between groups regarding the basal characteristics. Larger OM diameter was significantly associated with large major coronary arteries. While diameters of OM ve CS branches and CS tortuosity were not found to be correlated, OM diameter . 2.5mm was significantly associated with take off angle of CS branch. Conclusion: Anatomical characteristics of coronary sinus main tributaries showed no correlation with their arterial counterparts, obtus marginal branches of circumflex artery.
Age Male sex HT DM LAD diameter RCA diameter Cx diameter Sinus rhythm Main CS diameter Diameter of the largest side branch of CS CS tortuosity Low Medium High Take off angle of CS branch ,90 .90
Group A (n=14)
Group B (n=25)
p
59.2 + 3.8 11 (78.6%) 10 (71.4%) 6 (42.9%) 3.2 + 0.1 2.8 + 0.2 2.8 + 0.1 11 (78.6%) 8.8 + 0.6 2.8 + 0.4 3 (21.4%) 6 (42.9%) 5 (35.7%) 13 (92.9%) 1 (7.1%)
61.5 + 2.9 18 (72%) 16 (64.0%) 8 (32.0%) 3.7 + 0.3 3.3 + 0.2 3.3 + 0.1 20 (80%) 9.3 + 0.5 3.2 + 0.3 7 (28%) 9 (36%) 9 (36%) 16 (64.0%) 9 (36.0%)
0.36 0.689 0.46 0.37 0.01 0.03 0.006 0.61 0.62 0.23 0.81
0.05
1 Dept of Cardiology, Mirano, Italy; and 2University of Padua, Department of Cardiology, Padua, Italy
Introduction: The inter-lead distance (ILD) between the right and left ventricular (RV and LV) pacing leads may play a role in CRT response. We measured the ILD during the CRT procedure in the left and right anterior oblique (LAO and RAO) fluoroscopy projections and correlated these measurements with transthoracic echocardiographic (TTE) reverse remodelling. Methods and results: Between January and December 2010, 48 consecutive CRT patients were enrolled (16/48, 33.3% with upgrading indications). The ILD was measured in the LAO and RAO projections to obtain 2 direct (LAO ILD and RAO ILD) and 1 merged bi-dimensional (LAO ILD x RAO ILD Index) body surface-normalized indexes. Fourtyfive patients (mean age 72.6+9 years, 28 males) completed the TTE follow up at mean of 12.3 + 7.8 months. They were divided into CRT "responders" and "non-responders" according to the 4 following endpoints: LV ejection fraction (LVEF), LV end-systolic volumes and diameters (EVS, ESD) and end-diastolic diameter (EDD). These groups were compared: 1) LVEF improvement - responders: 29 patients - non-responders: 16 patients (35%) 2) LV ESV reduction - responders: 26 patients - non-responders: 19 patients (42%) 3) LV ESD reduction - responders: 12 patients - non-responders: 33 patients (73%) 4) LV EDD reduction - responders: 11 patients - non-responders: 34 patients (88%) No difference in the 3 ILD indexes was found between responders and non-responders. Conclusions: In our study, the mono and bi-dimensional ILD failed to predict a reverse remodeling in CRT patients.
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P1071
P1072
Prediction of functional recovery after resynchronization by contractile and coronary flow reserve analysis A. Djordjevic-Dikic1, and G. Milasinovic2
Device monitoring of heart failure in CRT-D recipients. A single-center experience with a novel multi-vector impedance monitoring system G.B. Forleo, L.P. Papavasileiou, G. Panattoni, V. Schirripa, D.G. Della Rocca, A. Politano, K. Mahfouz, L. Santini, D. Sergi, and F. Romeo University of Rome, Polyclinic "Tor Vergata", Department of Cardiology, Rome, Italy Objectives: We investigated the performance of a new intrathoracic multi-vector impedance monitoring system for the prediction of heart failure (HF) events in consecutive deviceimplanted patients. Methods: Eighty HF patients implanted with biventricular defibrillators with multi-vectors impedance monitoring capability were prospectively enrolled. Clinical HF status and impedance data were assessed during follow-up and if patients presented with an alert or HF deterioration. Results: During follow-up (8.0 + 4.4 months), 56 events of device-alert for fluid index increase were identified in 29 patients and a total of 39 HF events (defined by worsening of HF signs and symptoms) occurred in 23 patients. The sensitivity and positive predictive value (PPV) for HF deterioration was 61.5% and 42.9%, respectively. False-positive alerts occurred in 19/80 patients (23.8%), for an episode rate of 0.60 a year. Among all clinical HF events, decompensation caused hospitalization in 13 cases (33.3%), 7 of them were preceded by an alert condition (53.8%) resulting in a sensitivity of 53.8% and a PPV of 17.9%. Conclusions: The present study confirms the feasibility and clinical usefulness of this novel multi-vector impedance monitoring system. It is worthwhile to perform larger studies to assess its actual clinical value in HF patients.
G.
Nikcevic2,
S.
Raspopovic2,
V.
Jovanovic2,
Tesic1,
1 Clinical Center of Serbia, Clinic for Cardiology, Belgrade, Serbia; and 2Pacemaker Center, Institute for Cardiovascular Disease, Clinical Center of Serbia, Belgrade, Serbia
Objective: The aim of the study was to assess predictive significance of coronary flow reserve (CFR) and residual contractile reserve for improvement of left ventricular function after cardiac resynchronization therapy (CRT). Background: Although, CRT has become a mainstay in heart failure management, 30% of patients failed to respond to therapy. In patients with non-ischemic dilated cardiomyopathy, abnormal coronary flow reserve and lack of contractile reserve are independent predictors of bad prognosis. Method: Study population included 41 patients (mean age 60 + 10 years, male 38) with heart failure (EF 26 + 5%; 36% with ischemic CMP) and QRS duration of 159 + 22ms. Before CRT implantation, global contractile reserve was assessed with dobutamine echocardiography and CFR was measured noninvasively during hyperemia induced with adenosine. Six months after CRT implantation, responders were defined by decrease in end-systolic volume (ESV) 15%. Results: At inclusion, left ventricular ejection fraction (LVEF), end-systolic volume (ESV), end-diastolic volume (EDV), QRS duration, 6 min walk test distance and coronary flow velocity at rest did not differ in responder vs. nonresponder group ( p=ns). Before CRT implantation, responders, showed a greater increase in coronary flow velocity during hyperemia, and consequently higher CFR: 2.23 + 0.59 vs. 1.67 + 0.54 ( p=0.010). We found significant correlation between CFR and increase in EF during dobutamine before CRT implantation (r=0.64, p , 0.0001), as well as CFR before CRT and LVEF improvement after 6 months (r=0.492, p=0.008). End systolic and end diastolic diameters, left bundle branch block (LBBB), EF at dobutamine and presence of viable tissue as well as CFR before CRT were predictors of LV functional recovery. By multivariate analysis, only CFR before CRT and LBBB were independent predictors of left ventricular recovery in the follow-up period ( p=0.011). Conclusion: Our results demonstrate that, preserved coronary microcirculation demonstrated by adequate CFR response, and contractile reserve, are predictors of positive response to CRT along with LBBB.
P1073
How effective and safe is the cardiac resynchronization therapy (CRT) in patients with heart failure? Data from the German device registry
M.
P1074
Right ventricular strain as a predictor of early mortality in cardiac resynchronisation therapy patients
S. Heiderfazel1, C. Ewertsen1, J. Senges2, and D. Andresen1
K.V. Nagy, G. Szeplaki, A. Kosztin, A. Apor, C.S. Liptai, L. Molnar, E. Zima, L. Geller, and B. Merkely
1 Vivantes Hospital am Urban, Berlin, Germany; and 2Heart Center Ludwigshafen, Cardiology, Research Institute for Heart Attack, Ludwigshafen, Germany
Semmelweis University, Heart Center, Budapest, Hungary
Background: Cardiac Resynchronization Therapy (CRT) is an established therapy in patients with mild and severe heart failure. The amount of implantations is increasing rapidly. Aim of this study was to check efficacy and safety of CRT in a status report from Germany. Methods: 1215 patients with heart failure were enrolled consecutively in a nationwide registry (Heart Attack Research Center, Ludwigshafen), in which a CRT-Implantation was performed. Results: 953/1215 (78%) patients were male and 598/1215 (49%) aged , 70 years. 1132/1215 (93%) had a structural heart disease (CAD: 52%, DCM: 48%). LV-function 30% occurred in 80% of cases. Before CRT-Implantation 17% of the patients referred to NYHA class II, 75% to NYHA class III and 7% to class IV. 74% of the patients were in Sinus rhythm and 82% had a typical left bundle branch block (QRS . 120 – 150 ms: 34%; QRS . 150 ms: 55%). 96% of implanted devices were CRT-D. In-hospital complications like pericardial effusion occurred in 0,7% of the patients, haematothorax in 0,2%, pneumothorax in 1,5% and wound infections in 2,1%. 4 patients died due to cardiac cause. Follow-Up: 888 (73%) patients were followed-up about at least one year yet. 1-year-mortality was 8% (75% cardiac cause). One year after CRT-implantation most of the patients showed an improvement of their NYHA class (I or no NYHA: 35%, II: 34%, III: 25%, IV: 6%). Quality of Life was improved in 63% of cases and declined in 5%. Conclusions: Our status report from a nationwide registry support the efficacy and safety data from the current guidelines based on large randomised trials, in which an CRT-implantation is recommended in patients with mild and advanced heart failure. Further effort is necessary to try to increase the amount of responders to this device-therapy.
Background: Based on the evidence of recent clinical studies, right ventricular dysfunction is predictive of a worse prognosis in chronic heart failure. It is yet to be investigated if right ventricular function has any prognostic importance in CRT-ipmlanted patients. Aims: The present study is aimed to identify echocardiographic right ventricular structural and functional parameters, likely to influence early mortality following CRT-implantation. Methods: In our prospective clinical study, we enrolled 93 consecutive patients, referred to CRT-implantation. Baseline demographic data, concomitant diseases were assessed. Before device implantation, all patients underwent echocardiography. Left ventricular function, right atrial, ventricular diameters, volumes, right ventricular wall thickness and functional parameters (TAPSE, RVFAC) were measured. Right ventricular longitudinal strain analysis was performed with speckle tracking echocardiography. Results: During the 6 months follow up period the mortality rate was 9,6% (9 patients). Among those patients who died, right ventricular end-diastolic wall thickness (6,66 + 1,50 vs 4,13 + 0,44mm, p=0,0001), longitudinal diameter (77,17 + 7,47 vs 71,89 + 9,41mm, p=0,007) and right ventricular global longitudinal strain (GLS) (-10,44 + 5,37 vs -6,17 + 3,11%, p=0,023) were significantly decreased. Risk of cardiovascular mortality was detected to have increased 4-times in patients with low right ventricular wall thickness (cut-off value: 5,5mm) and 2,3-times in those with low right ventricular GLS (cut-off value: 8,43%), (confidence interval: 2,76-5,79; 1,41-3,87, HR:56,12; 6,33). Conclusions: Our results show that right ventricular end-diastolic wall thickness and global longitudinal strain are likely to predict a poor prognosis in patients with implanted CRTdevice. ´ MOP-4.2.2/B-10/1-2010-0013 NKTH-OTKA The scientific project was granted by TA K105555).
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P1075
Impact of baseline anemia on long-term clinical outcomes in patients with heart failure treated by cardiac resynchronization therapy J. Hosoda1, T. Ishikawa1, K. Andoh2, M. Nobuyoshi2, S. Fujii3, S. Shizuta4, T. Kimura4, and T. Isshiki5 1
Yokohama City University, Yokohama, Japan; 2Kokura Memorial Hospital, Kitakyushu, Japan; 3Kurashiki Central Hospital, Kurashiki, Japan; 4Kyoto University Hospital, Kyoto, Japan; and 5Teikyo University Hospital, Tokyo, Japan Purpose: Anemia is recognized as a predictor of mortality and adverse outcome in heart failure patients. However, the long-term clinical outcome of the patients undergoing cardiac resynchronization therapy (CRT) with complication of anemia remains uncertain. Methods: CUBIC study is a multi-center study undergoing CRT of Japanese patients with heart failure. A total of 991 patients enrolled in the CUBIC study were divided into two groups according to a baseline hemoglobin (Hb) quartiles; One is anemia group (Hb ,13g/dl for men, Hb ,12g/dl for women, n=499) and the other is non-anemia group (Hb A13g/dl for men, Hb A12g/dl for women, n=492). The cut-off value is defined by the World Health Organization guideline. Then, we compared clinical outcomes between the two groups. Results: A mean follow-up period was 37.8 + 19.8 months. In the Kaplan-Meyer analysis, allcause mortality was significantly higher in anemia group than non-anemia group (41.7% vs. 25.9% at 3 years, Log-rank p , 0.001). Cardiac mortality was also higher in anemia group than non-anemia group (27.3% vs. 17.0% at 3 years, Log-rank p , 0.001). Multivariate Cox regression analysis revealed that baseline anemia was an independent predictor of all-cause mortality (OR=1.73, 95% CI 1.34-2.23, p , 0.001). Subgroup analysis in the elderly patients (age A65 years, n=684) revealed that all-cause mortality was higher in anemia than non-anemia subgroup (Log-rank p , 0.001). In patients with chronic kidney disease (e-GFR ,60 ml/min, n=697), all-cause mortality was also higher in anemia than non-anemia subgroup (Log-rank p , 0.001). Conclusions: The present study suggests that anemia is quite useful for the prediction of worsening clinical outcome in heart failure patients treated by CRT.
Cardiac arrhythmias
Trends of cardiac implantable electronic device data during time frames preceding death. Results from the HomeGuide Registry A. D’onofrio1, G. Buja2, P. Vaccaro3, L. Vasquez4, D. Pecora5, A. Vaglio6, L. Rossi7, L. Giovene8, F. Chiusso8, and R.P. Ricci9, HomeGuide Registry 1
AORN Monaldi Hospital, Naples, Italy; 2University Hospital of Padua, Department of Cardiac, Thoracic and Vascular Sciences, Padua, Italy; 3Villa Sofia-Cervello Hospital, Palermo, Italy; 4Fogliani Hospital, Milazzo, Italy; 5Foundation Poliambulanza - Institute Hospital, Brescia, Italy; 6SS. Giovanni e Paolo Hospital, Venice, Italy; 7Guglielmo Da Saliceto Hospital, Piacenza, Italy; 8Biotronik Italia, Milan, Italy; and 9San Filippo Neri Hospital, Rome, Italy Purpose: The HomeGuide registry (NCT01459874) is a survey which collected relevant events occurred in a population of cardiac implantable device recipients remotely controlled via Biotronik Home Monitoring (HM). The aim of this analysis was to study the remote trends of the device data during time frames preceding patients’ deaths. Methods: A total of 1650 patients were remotely followed-up via HM according to a specific organizational model. The available HM daily data of deceased patients was analysed starting from one year prior to death. Right ventricular pacing percentage (RVP), frequency of days with relevant atrial fibrillation (AF) burden (10% of 24 hours), heart rate variability (HRV) expressed by the SDNN of atrial intervals, patient daily activity and mean ventricular rate were analysed. The burden of sustained ventricular arrhythmias was examined in ICD recipients. Left ventricular pacing percentage was analysed for patients with a CRT device. Data from one month and from 3 months before death were compared to the trends of the preceding monitored period. Values were reported as medians [interquartile range]; non-parametric tests were used with p=0.05 for statistical significance. Results: During a 20 + 13 month follow-up, 134 (8%) patients died. Among these, 26 (19%) had a pacemaker, 64 (48%) an ICD, 44 (33%) an ICD with CRT: 72% were men and the mean age was 76 + 8.2 years. Deaths were classified as non cardiac (67.3%), cardiac (21.4%) and sudden cardiac (11.2%). HM data was available on average up to 13 days before death. During the three months before death, the following parameters significantly decreased: HRV (from 66 (50.9 – 84.8) to 51 (42.4 – 83.2), p=0.028]; patient activity (from 7.8% [3.5– 17.1%] to 6.3% [1.7 –11.9%], p=0.019). Mean ventricular rate increased from 70.7 bpm [65.8 – 75.4 bpm] to 71.7 bpm [65.9 – 80.5 bpm] (p=0.008). A similar behaviour was also confirmed within one month before death: HRV (from 66.2 [51.8-90.6] to 50.8 [45.0– 73.6], p=0.04); patient activity (from 9.2% [5.3-18.6%] to 5.0% [1.5 – 10.7%], p=0.002); mean ventricular rate (from 69.4bpm [64.7 – 73.5bpm] to 75.6bpm [70.1– 81.3bpm], p=0.0001). A significant reduction of the RVP (from 43.2% [2.8-97.8%] to 10.2% [7.5-95.4%], p=0.016) was observed in this period. We didn’t find a significant difference in CRT percentage and atrial and ventricular arrhythmic burden. Conclusions: During a time frame of one and three months before death, HM daily trends tracked a significant decrease in HRV and patient activity and an increase of the mean heart rate. We did not observe an increase of the arrhythmic burden.
P1077
Implantable loop recorder: a new tool in the diagnosis of cryptogenic stroke M. Garcia Bermudez, J. Merce Klein, X. Ustrell, A. Pellise, R. De Castro, and A. Bardaji Hospital Joan XXIII. IISPV.University Rovira Virgili, Tarragona, Spain Purpose: Approximately 30% of ischemic strokes are considered as cryptogenic after a complete diagnostic workup. Atrial fibrillation (AF) is a common cause of ischemic stroke. The introduction of devices like implantable loop recorders (ILR) that allow detection of silent AF, may improve diagnostic yield in some ischemic strokes. Methods: Consecutive patients referred from Neurology department after a stroke of undetermined etiology between August 2009 and February 2011 were included in the study. All of them had suffered an ischemic stroke with embolic features, and etiology was not apparent after a complete diagnostic approach, that included daily EKG, laboratory tests, brain CT scan, Holter monitoring, transthoracic and transoesophageal echocardiography, brain magnetic angioresonance and brachiocephalic Doppler. An ILR, Reveal w XT (Medtronic Inc), was implanted for detection of AF, within a month after the stroke. Results: Fourteen patients were included. Ten were male and their average age 65.4 + 10.9 years. Hypertension was present in 11 (79%), diabetes in 5 (36%) and ischemic heart disease in 2 (14%). None of them had a history of previous AF or flutter. AF was detected with ILR in 5 patients (35.7%). The moment of detection was 1, 3, 5, 10 and 10 months after insertion of the device. All AF episodes were asymptomatic and lasted for between 4 and 32 minutes. After detection, these 5 patients were treated with oral anticoagulants. In 10 patients (71%), 24 other episodes were classified as AF by the device, but were considered artifacts after manual revision. Conclusions: Our work suggests that ILR with AF detection algorithm, is a tool that should be considered for detection of AF, in patients with ischemic cryptogenic stroke, specially when a cardiac source of stroke is suspected.
P1076
P1078
Detection and early intervention in worsening heart failure episodes with home monitoring. Results from the homeguide registry G. Zanotto1, L. Calo’2, A. Curnis3, G. Mantovani4, E. Bertaglia5, M. Santamaria6, V. Calvi7, L. Giovene8, N. Rovai8, and R.P. Ricci9, HomeGuide registry 1
Mater Salutis Hospital, Legnago, Italy; 2Polyclinic Casilino of Rome, Rome, Italy; 3Civil Hospital of Brescia, Brescia, Italy; 4Civil Hospital of Desio, Desio, Italy; 5University Hospital of Padua, Department of Cardiac, Thoracic and Vascular Sciences, Padua, Italy; 6Fondazione di Ricerca e Cura "Giovanni Paolo II", Catholic University, Campobasso, Italy; 7University of Catania, Ferrarotto Hospital, Division of Cardiology, Catania, Italy; 8Biotronik Italia, Milan, Italy; and 9San Filippo Neri Hospital, Rome, Italy
Purpose: We analyzed the worsening Heart Failure (HF) episodes occurred during the HomeGuide Registry in order to observe recurrent patterns in HF-related index trends remotely transmitted on a daily basis by Home Monitoring (HM) from ICD or CRT devices. Methods: The HomeGuide registry (NTC01459874) enrolled 1229 ICD/CRT patients remotely followed according to a specific workflow model based on cooperation between a responsible nurse and physician. In-hospital visits were scheduled once a year. HM daily provided the following parameters correlated to HF: mean heart rate (MHR), mean heart rate at rest (MHRR), number of mode switches (MS), premature ventricular contraction (PVC) number, patient daily activity percentage (ACT), heart rate variability (HRV) and CRT pacing percentage. The respective trends were downloaded and evaluated in a time-window preceding a worsening HF (wHF) occurrence and defined as the time elapsed between the onset of the parameter alteration and the event detection date. Results: During a 20 + 13 months follow-up, 137 events were adjudicated as HF episodes in 104 patients. Fortytwo (31%) HF episodes in 34 patients resulted in hospitalizations while 95 (69%) in 70 were detected prior to hospitalization. Among these episodes, 59 (62%) were detected through the analysis of the HM data trends. The alteration of the following parameters were observed: increase of MHR in 40 (68%) episodes within 9.0 + 7.6 days prior to episode, increase of MHRR in 28 (47%) within 8.4 + 7.8 days, decrease of CRT in 23 (39%) within 8.6 + 6.0 days, decrease of ACT in 25 (42%) within 6.3 + 6.0 days, increase of MS number in 10 (17%) within 5.7 + 4.6 days, raising of PVC frequency in 7 (12%) within 5.7 + 1.5 days and alteration of HRV trends in 15 (26%) within 6.2 + 4.7 days. One single parameter changed in 16 (28%) episodes, two parameters in 11 (19%), three or more parameters in 32 (54%). The related corrective actions taken by the personnel were: change of pharmacological therapy in 27 (45.8%) cases, recall to prescribed pharmacological therapy in 2 (3.4%), reprogramming of the device in 4 (6.8%), upgrading or surgical revision in 4 (6.8%), AF electrical cardioversion in 1 (1.7%), ablation in 2 (3.4%) and additional diagnostic examinations in 4 (6.8%). In 22 (37.3%) cases the subsequent observation of the HM data trends revealed a spontaneous normalization of the anomalous parameters and therefore no actions were taken. Conclusions: HM trends of HF-related indexes allowed remote detection and early medical intervention in 62% of wHF episodes potentially leading to hospitalization. Time-window may vary across patients
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P1079
P1080
Atrial fibrillation finder: a new option for remote monitoring of patients with cardiac implantable electronic devices
Feasibility of using mobile phone technology to record and transmit 12-lead ECGs
H. Keilegavlen, and S. Faerestrand
A. Hanley1, A. Stack2, P. Kelly1, and GJ. Fahy1 1
Department of Heart Disease, Haukeland University Hospital. University of Bergen, Bergen, Norway Purpose: Occurrence of atrial fibrillation (AF) is common in patients ( pts) with cardiovascular implantable electronic devices (CIEDs). Early detection of AF is important for appropriate initiation of anticoagulation therapy. Further, AF often necessitates reprogramming of the CIEDs and initiation of medical therapy to avoid inappropriate shocks and preserve an optimal effect of cardiac resynchronization therapy. Methods: In this study data from the remote monitoring system CareLink Network were processed by using the new algorithm AFinder designed to identify patients with AF. Different adjustable thresholds for the diagnosis of AF were tested in a cohort of 241 pts with ICDs (n=139) or CRT-D (n=102). To be analysed by the AFinder algorithm the pts must have at least one remote transmission during the last year. Results: The AFinder identified 90 pts (37%) with episodes classified as AF by using a lower threshold of total duration of AF. 6 minutes any day. The data transmissed from these 90 pts were carefully analysed to verify AF. Further, the clinical impact of the diagnosis of AF was analysed. By reviewing the stored electrograms, 11 pts out of 90 pts did not have AF, but were misclassified due to far-field R wave sensing in the atrial channel. The resulting specificity was 93% and the positive predictive value 88%. By resetting the threshold for AF duration to 1 hour, 75 pts (31%) were identified to have AF. Now the sensitivity, specificity and positive predictive value were 89%, 97% and 93%, respectively. Fiftyfive of 241 pts (23%) had episodes of correctly detected AF with a threshold duration . 24 hours. At this setting only 70% of 79 pts with true AF were identify by AFinder. Fourty-one % of the pts had a history of paroxysmal AF before implantation and 72% were treated with warfarin or dabigitran. The average CHA2DS2VASc score for those with AF was 2,78. Twelve pts (16%)with CHA2DS2-VASc score .2 with indication of oral anticoagulation (according the ESC guidelines) were not treated. Seven pts (9%) had experienced inappropriate shocks due to AF with rapid ventricular rate. Conculsion: By using the new AFinder algorithm in remote monitoring of pts with CIEDs reliable detection of AF episodes was achieved. The majority of AF pts had indication for anticoagulation therapy. Many pts experience inappropriate ICD shocks that may be prevented by early AF detection leading to medical therapy to obtain appropriate ventricular rate control. Oversensing of far field R waves in the atrial channel of CIEDs explain the specificity of 9397% in AF detection by the new AFinder algorithm.
Cork University Hospital, Cork, Ireland; and 2Regional Kidney Centre, Letterkenny General Hospital, Department of Medicine, Medical School, NUIG, Letterkenny, Ireland
2
Purpose: Early transmission of ECG data to cardiologists facilitates rapid decision making in the management of cardiac emergencies. Our aim was to evaluate the feasibility and validity of using mobile phones to record and transmit images from standard 12-lead ECGs. Methods: A cardiac electrophysiologist, interventionist and fellow independently interpreted 60 ECGs. Rates of interobserver agreement were assessed using the presence or absence of 11 ECG findings (sinus tachycardia, atrial fibrillation/flutter, myocardial infarction, left ventricular hypertrophy, bundle branch block/intraventricular conduction defect, axis, pacemaker, and normal ECG). The ECGs were randomly divided into two groups (N=30). The first 30 were photographed using an iPhone 3GS (Apple Inc, Cupertino, CA) and the second 30 using an iPhone 4 (Apple Inc, Cupertino, CA). Each group of images was transmitted over local mobile networks to the opposite phone. The validity of images captured on each phone was compared with the original ECG interpretation with calculation of proportions of positive and negative agreement, bias index and the Kappa statistic adjusted for prevalence and bias (PABAK). Interobserver agreement rates were assessed for each iPhone. Statistical analysis was conducted using SAS. Results: Intraobserver rates of agreement between standard ECG and iPhone ECG for the three interpreters were substantial to almost perfect for most ECG findings (Table 1). Interobserver rates of agreement for ECG findings recorded on respective iPhones were similarly impressive. Conclusions: Current mobile phone technology can be reliably used to capture and transmit interpretable images of 12-lead ECGs. Use of these technologies may accelerate point of care diagnosis and treatment of life threatening cardiac events.
Validation Study
N
Positive Agreement
Negative Agreement
Bias Index
Adjusted Kappa
iPhone 3GS ECG vs paper ECG iPhone 4 ECG vs paper ECG Interobserver Agreement Paper ECG iPhone 4 iPhone 3GS
30
0.90 - 1.00
0.67 - 1.00
-0.03 - 0.07
0.72 - 1.00
30
0.92 - 1.00
0.60 - 1.00
-0.10 - 0.13
0.62 - 1.00
60 30 30
0.88 - 1.00 0.87 - 1.00 0.87 - 1.00
0.33 - 1.00 0.40 - 1.00 0.33 - 1.00
-0.15 - 0.08 -0.07 - 0.13 -0.07 - 03
0.63 - 1.00 0.60 - 1.00 0.67 - 1.00
Range of values for identifiable abnormalities
P1081 Clinico-laboratory characteristics and long-term outcome of patients presenting with idiopathic complex right ventricular ectopy. How often we encounter ARVC/D? K.A. Gatzoulis1, S. Archontakis1, I. Vlasseros2, D. Tsiachris1, A. Vouliotis1, P. Arsenos1, S. Sideris2, P. Dilaveris1, I. Kalikazaros2, and C. Stefanadis1 1
Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece; and 2Hippokration Hospital, Department of Cardiology, Athens, Greece Purpose: To further investigate the possibility of an underlying cardiopathy in a population presenting with repetitive ectopic activity originating from the RVOT, initially characterised and treated as “idiopathic”, and to evaluate outcome. Methods: We enrolled and prospectively followed-up 216 patients (118 female, mean age: 48.1 + 17.98 years), presenting with “idiopathic” repetitive RVOT ectopy. All patients underwent a transthoracic echocardiogram and a 12-lead ECG. A 24-hour (h) ECG Holter was performed in 206 cases and omitted in those with documented sustained Ventricular Tachycardia (sVT). Cardiac MRI was held in 28 subjects, Signal-Averaged ECG (SA-ECG) in 174 patients (80.5%) and Electrophysiological Studies (EPS) in 111 patients (51.5%). Differential diagnosis with ischemic cardiomyopathy, ARVC/D and channelopathies occurred in each case individually. Patients were classified, according to arrhythmia burden: group1: ,59ectopies/h, group2: 60-149ectopies/h, group3: 150ectopies/h, group4: sVT. Results: The diagnosis of idiopathic RVOT ectopy was confirmed in 206 patients (subpopulation1) (95.37%). Eight patients (3.7%) were eventually diagnosed with ARVC/D (subpopulation2), one had Coronary Artery Disease and another had long-QT syndrome. Follow-up data were available for 208 subjects (mean follow-up: 56.8 + 43.03months). Survival from cardiovascular causes was 99.51%, however, a young male diagnosed with ARVC/D died. Significant differences were observed between subpopulation1 and subpopulation2: 22.22% (n=48) of patients in the former group were asymptomatic but none in the later. The ECG was insignificant in 53.02% (n=114) in subpopulation1 but only in 12.5% (n=1) in subpopulation2. The burden of arrhythmia was significantly greater in the ARVC/D group. SA-ECG was held in 165 patients of subpopulation1 recording late potentials in 18.78% (n=31), and in 7 patients with ARVC/D with an incidence of 57.14% (n=4). Echocardiographic structural RV abnormalities were recorded in 24.29% (n=52), 22.7% (n=47) and 62.5% (n=5) in the overall population, subpopulation1 and subpopulation2, respectively. Cardiac MRI demonstrated RV abnormalities in 32.14% (n=9), 24% (n=6) and 100% (n=3) in the overall population, subpopulation1 and subpopulation2. Sustained VT was induced in 10.78% of subpopulation1 and in 57.14% of subpopulation2. Conclusions: Patients with repetitive RVOT ectopy demonstrate an excellent long-term prognosis, however previously undiagnosed ARVC/D is occasionally identified. A more detailed investigation is justified in patients showing suspicious clinical or laboratory findings.
P1082 Trends in ablation procedures in greece over the 2008-2012 period: results from the hellenic cardiology society ablation registry V.P. Vassilikos1, M. Efraimidis2, E. Simandirakis3, and A. Billis1, Hellenic Working Group on Pacing and Electrophysiology 1
Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Evangelismos General Hospital of Athens, Athens, Greece; and 3University Hospital of Heraklion, Heraklion, Greece
In 2008 the radiofrequency ablation procedures (RFA) registry of the Hellenic Cardiology Society (HCS) was created. This is a dynamic, web-based application, which acts as the interface for storing and retrieving patients’ demographic data and ablation procedures. Access to the site is permitted only to registered users. The purpose of this study is to report the trends of practice regarding RFA procedures performed in Greece over the 2008-2012 year period. There are 29 licensed centers to perform RFA in Greece. During the 2008-2012 year period more than 6200 RFA procedures were performed. Procedural data are presented at the table. The most common procedure for this time period has always been slow pathway ablation for atrio-ventricular reentry tachycardia (AVNRT). The second has been atrial fibrillation ablation; the trends show that there is a constant rise regarding the frequency of this procedure; the third being ablation for tachycardias involving an accessory pathway (the percentage is declining). Success rates were high (96%), complication rate was 2.3% (serious complications ,1%) and total relapse rate was 2.2% at six months follow-up. The electronic RFA registry confirmed that all RFA procedures are performed in Greece with high success and low complication rates, comparable to the European and US standards. The RFA procedures for atrial fibrillation are increasing constantly with good success rates and low complications, indicating that electrophysiologists have been through the learning curve for the procedure, and the referral pattern is changing. The experience and results from the five -year period use of the application are very interesting and encouraging, thus indicating the need for development of similar national databases at the National level.
Tachycardia type (%) Right Atrial Tachycardia Left Atrial Tachycardia Right Atrial Flutter Left Atrial Flutter Atrial Fibrillation AVRT (WPW) AVRT (concealed AP) AVNRT Ventricular Tachycardia Rest Success rate (%)
2008
2009
2010
2011
2012
2 1.5 10.2 0.6 16.7 12.6 7 40.9 8.6 0.2
3.1 1.8 10.2 0.7 21.5 8.9 7.3 35.9 10.2 0.4
3.1 3.1 11.1 0.3 22.3 9.1 7.1 32.1 11.5 0.4
2.1 2.1 4.7 0.9 25.8 9.3 4.4 31.6 12.4 6.4
2.6 1.6 9.1 0.4 26.5 9.3 3 29.6 13.5 4.3
93.5
92
92
96.6
95.4
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Diagnosis, prognosis, treatment
P1083
P1084
Heart rate variability in the first five minutes of the tilt test to predict cardioinhibitory syncopes Is the calgary syncope symptom score a useful tool for vasovagal syncope diagnosis in the emergency room?
D. Matelot1, N. Khodor2, A. Hernandez2, N. Thillaye-Du-Boullay1, G. Carrault1, and F. Carre2 1
Inserm, CIC-IT 804, Rennes, France; and 2Inserm U1099, Rennes, France
V. Exposito Garcia, F. Rodriguez Entem, S. Gonzalez Enriquez, B. Arnaez, J.M. Gomez Delgado, I. Olavarri, P. Lerena, and J.J. Olalla Antolin University Hospital Marques de Valdecilla, Santander, Spain Background: Syncope remains a big challenge in the emergency room, as it is a very common condition. By far, the most frequent cause of syncope is neurally mediated reflex syncope, of which vasovagal syncope is the most frequent clinical presentation. However, syncope can be a harbinger of sudden death; identification of the patient who is at risk is of utmost importance, even more in an emergency setting. The Calgary Syncope Symptom Score (CSSS) has been validated as a simple point score of historical features to distinguish vasovagal syncope from syncope of other causes with very high sensitivity (89%) and specificity (91%). We studied its performance in the setting of patients included in a Syncope Protocol in the Emergency Room. Methods: During a 6 months period, 163 patients presenting with syncope to the emergency room of our university hospital, and included in an arrhythmia unit coordinated syncope protocol, were enrolled in our study. CSSS was prospectively calculated in all patients. After systematic evaluation, a final diagnosis was reached in 150 patients. We compared diagnosis of vasovagal syncope based on the CSSS with the final diagnosis. Minimum follow up period in our Syncope Clinic was one year for all patients. Results: 99 patients out of 150 were diagnosed as vasovagal syncope, and 51 patients nonvasovagal cause. CSSS sensitivity was 76%(IC95% 84-67), at a specificity of 62% (IC95% 7452). In elderly patients (92 patients . 65 y.o) sensitivity was 67% at a specificity of 53%. In younger patients (58 patients , 65 y.o) sensitivity was 94% at a specificity of 74%. Conclusion: The CSSS showed low sensitivity and specificity in a Syncope Protocol in the Emergency Room, compared to previously validated data, limiting its usefulness in this setting. This difference is primarily driven by its low predictive value in elderly population, although specificity was much lower than the one in the original study even in the younger patients.
Purpose: Vasovagal syncope mechanisms, diagnostic tools and treatments are currently explored and debated. The aim of this study is to specify the early cardiac autonomic adaptations to the tilt test in negative and positive subjects. Method: Healthy men (n=81) from 18 to 35 years old underwent a 45 min 808 tilt test after a 15 min rest. Three clinicians classified each test according to the VASIS classification: negative (NEG), mixed, cardio-inhibitor (CI) or vasodepressive (VD) syncope. Only three groups were studied: the NEG (n=13), CI (n=11) and VD (n=8). ECG was recorded during 5 min of resting (Rest5) and the first 5 min of the tilt test (Early5). ECG signals were analysed with the validated algorithm Segmenta (LTSI, Rennes) to calculate usual heart rate variability (HRV) parameters: Ptot, LF, HF, LFnu, HFnu. Results: First, within group comparisons showed that in NEG subjects from Rest5 to Early5, HF and HFnu decreased ( p , .01) and LF (p , .05) and LFnu ( p , .01) increased. VD subjects showed similar responses ( p , .05). In CI subjects LF, LFnu, HF and HFnu weren’t significantly different between Rest5 and Early5. Second, between groups comparisons of the relative adaptations (%) from Rest5 to Early5 showed that the increase in LFnu was higher in NEG (þ180 + 80%) than in CI (þ66 + 50%) ( p , .01). HFnu decrease was also higher in NEG (-66 + 5%) than in CI (-38 + 9%) ( p , .05). Conclusion: Our results suggest a lack of sympatho-vagal balance activation in the first 5 min of the tilt test in subjects who will develop cardio-inhibitory syncopes, which are the most sudden and harmful ones. A perspective of this work is to set cut-off values from HRV data in the first 5 min of the tilt test (1) to estimate the risk of cardio-inhibitory syncope and (2) to reduce the duration of the tilt to 5 min when relevant.
P1085
P1086
Prognostic value of echocardiography in risk stratification of patients with syncope in the emergency department F. Rodriguez Entem, V. Exposito, S. Gonzalez Enriquez, J.J. Olalla, B. Arnaez, J.N. Gomez Delgado, I. Olavarri, and P. Lerena
Syncope and hypokalemia with mild long term mild cola consumption N. Zarqane, H. Gaid, I. Badea, and N. Saoudi The Princess Grace Hospital Centre, Monaco, Monaco Introduction: Acute heavy cola consumption is known to lead to marked potassium loss. We described a case of severe hypokalemia after long term mild cola consumption. Case report: A 31 years old woman was admitted for traumatic syncope. She had no personal health problem or family history of sudden death. She denied digestive symptoms and any medication or licorice intake. Physical exam was normal. Electrocardiogram showed prolonged QTc (610 ms). Blood tests showed severe hypokalemia (2.4 mmol/L) without neither metabolic nor hormonal abnormalities. No diuretic was found in the urine. Further questioning revealed that since the age of 15 years she had not drunk any water which was exclusively replaced by cola beverages (2L/day).After total cessation of cola consumption, without oral potassium supplements, potassium remained normal (4.1mmol/L at one week, 4.2mmol/L at one month) as well as the QTc duration (430 ms). Pathways of cola induced hypokalemia include potassium wasting via an osmotic diarrhea (due to indigestible high-fructose corn syrup) and osmotic diuresis (due to large glucose load). Furthermore, beta adrenergic stimulation of caffeine produces metabolic alkalosis, diuresis and increased renin level. Conclusion: Long term and exclusive ingestion of cola beverages may lead to severe hypokalemia, QT prolongation and potentially life threatening arrhythmia.
University Hospital Marques de Valdecilla, Santander, Spain Syncope is a common and difficult clinical problem in the emergency department. Risk stratification in this setting is difficult owing to the heterogeneous nature of underlying pathology, ranging from benign causes to potentially fatal arrhythmias. In recent times, emphasis has been placed on this subject and several clinical risk stratification studies have been published. But prognostic accuracy of risk stratification rules for syncope is limited and there is still no compelling evidence that they improve diagnostic accuracy. Due to the fact that the presence of heart disease is the main predictor of bad prognosis, we propound the use of echocardiography, combined with clinical assessment, as an alternative tool for risk stratification of these patients. Methods: A total of 324 consecutive patients presenting to the emergency departments with syncope of unknown cause after initial evaluation were enrolled between February 2005 and February 2010. All patients initially were classified according to OESIL risk score in low risk (OESIL , 2) and moderate- high risk (OESIL 2). All patients underwent an echocardiography as part of our syncope protocol and were followed up for at least the first month. Results: The overall incidence of adverse events during the first month was 32 of 324 (9.8%) patients. According to OESIL 148 patients were classified as low risk and had two adverse events (1.3%) during follow up. The remaining 176 patients were considered at moderate-high risk. In the former group 30 patients had an adverse event (17%). In moderate-high risk patients echocardiography was considered abnormal in 52 and normal in the remaining 124 cases. 29 patients in the group of abnormal echocardiography had an adverse event (55.7%) whereas only one patient with normal echocardiography (0.8%). An abnormal echocardiography identified 29/30 moderate-high risk patients who underwent an adverse event with a sensitivity of 97% (CI 99-95%) and specificity of 85% (CI 90-80%). Conclusions: Echocardiography seems to be a useful tool for risk stratification in patients with syncope of unknown cause. In patients considered at moderate-high risk after first clinical evaluation a normal echocardiogram allowed identifying a subgroup of favorable outcome. This former group could benefit from conservative management, reducing unnecessary testing and admissions and improving efficiency.
ii162
P1087
Pre-implant vector check mapping of implantable loop recorders wastes times and does not improve outcomes
Cardiac arrhythmias, non invasive
P1088
Clinical and electrophysiological charasteristics of paroxysmal supraventricular tachycardias in elderly patients P. Avila Alonso, E. Gonzalez-Torrecilla, A. Uribarri, L. Bravo, A. Arenal, F. Atienza, T. Datino, J. Hernandez, M. Pelliza, and F. Fernandez-Aviles
S. Velu, S. Ahmad, J. Upright, L. Bradley, L. Head, G. Northwood, and S. Petkar
University General Hospital Gregorio Maranon, Department of Cardiology, Madrid, Spain
New Cross Hospital, Wolverhampton, United Kingdom Purpose: ILR’s are invaluable in diagnosing the cause of recurrent unexplained syncope. Automatic detection of arrhythmias by ILR’s is based on accurate R wave sensing with obtained signal quality having an effect on diagnostic yield. Determination of the maximum R wave height (max R) by vector mapping allows determination of optimal site of implant and is recommended by the manufacturer. However, it lengthens procedure time by ~ 10 minutes and its influence on clinical outcomes is unclear. Methods: n=92, retrospective analysis for: site and orientation of implant, max R on FU, under sensing/over sensing artefacts and need for recalibration of device. Pre-implant vector check (n=54) to determine most stable and max R [Mapped Group- MGrp]. Rest (n=38) implanted without vector check, in ECG V2 position (4th ICS, left parasternal area, vertically) [Unmapped Group-UMGrp] as it directly overlies the right ventricular myocardium. Results (Table 1): MGrp and UMGrp comparable for age and sex. Max R on FU, V2 position of implant and vertical orientation significantly higher in the UMGrp. Other sites of implant in MGrp: left 1stICS: 13/54(24%), V3 position: 1/54(2%). Under and oversensing observed more often in MGrp. No difference in need for device recalibration between the two groups. Conclusion: ILR implantation in V2 position, vertically and without pre-implant mapping gives better max R on FU with a trend towards less under and oversensing artefacts. It saves time allowing more implants in a stipulated time period. It also has cosmetic implications, not only at time of implant, but also subsequently, in those patients needing devices as a result of the ILR findings, as a majority of such patients are females.
Variable
Mapped Group n=54(%)
Unmapped Group N=38(%)
P value
Age( years) Male Sex Parasternal position of impalnt Vertical axis of implant Mean R wave height (mV) Undersensing artefacts Oversensing artefacts Device Recaliberation required
65 + 17 26(48) 40(74) 45(83) 9.1 + 5.9 10(18.5) 3(3.7) 1(1.8)
60 + 18 18(47) 38(100) 38(100) 11.61 + 5.3 3(7.6) 0(0) 0(0)
0.20 1.0 0.003 0.009 0.03 0.22 0.50 1.0
Background: Limited clinical data are available regarding the main mechanisms of paroxysmal supraventricular tachycardias (PSVT) in elderly patients. In addition, an external validation of prior predictive clinical-ECG models for differential diagnosis of PSVT in older patients is lacking. Objective: 1) to define the clinical, electrophysiological characteristics and the ablation results in elderly patients with PSVT and 2) evaluate the accuracy of the described predictive model in this group of patients. Methods: We prospectively studied the clinical, ECG and electrophysiological features as well as the ablation outcomes for consecutive patients 65 years (group 1, n=166) who underwent an electrophysiological study for PSVT in our institution from January 2006 to November 2011. They were compared to patients ,65 years (group 2, n=349). Patients with atrial tachycardia were excluded. A structured questionnaire was given to every patient on admission by 1 of the investigators to assess clinical symptoms. The variables of the predictive model were applied to the whole cohort and separately in both groups. Results: PSVT mechanism distribution was 70% AV nodal reentrant tachycardia (AVNRT) (15% atypical forms) and 30% orthodromic tachycardia (ORT) in group 1 vs 81% AVNRT (25% atypical forms) and 19% ORT in group 2 (both, p , 0.05). PSVT showed different clinical and electrophysiological characteristics in group 1 (elderly): despite having a slower cycle length (380 + 78 vs. 337 + 56 ms, p , 0.05) they were poorly tolerated with higher incidence of syncope (24% vs. 11%, p , 0.05), chest pain (41% vs. 28%, p , 0.05) and dyspnoea (32% vs. 15%, p , 0.05) during the episodes. There was also a lower incidence of palpitations (90% vs 99%, p , 0.05) and palpitations in the neck (29% vs. 45%, p , 0.05). In the multivariate analysis, the presence of palpitations in the neck, female sex, the age at the onset of symptoms (cut-off point 30 years) and the ECG were the only independent predictors for AVNRT in the whole cohort and in the younger patients. Nevertheless, only the ECG interpretation (OR 8.5, p , 0.05) and the age at the onset of symptoms (cut-off point 60 years, OR 3.6, p , 0.05) remained as AVNRT predictors in the elderly. Acute success (98% vs. 96%), 1-year recurrence (7% vs. 5%) and complication rates (2% vs. 2%) were similar in both groups. Conclusions: PSVT in elderly patients are poorly tolerated. ECG interpretation and the age at the onset of symptoms emerge as the only useful variables for the differential diagnosis of PSVT mechanism in elderly patients.
P1089 Comparison of left ventricular ejection time measured by three different non-invasive methods T. Krauze, D. Przymuszala, M. Bryl, D. Karbowy, J. Tarchalski, K. Barecka, M. Biczysko, J. Piskorski, A. Wykretowicz, and P. Guzik University of Medical Sciences - Department of Cardiology - Intensive Therapy, Poznan, Poland Purpose: The duration of the ventricular ejection time (ET) is crucial for determining the value of stroke volume and cardiac output which can be used during the optimization of the settings of implanted devices. The ET can be measured by different methods. We compared the ET duration measured by 3 various non-invasive methods in patients with an implanted defibrillating device. Methods: The study was conducted in 356 patients with either a cardioverter-defibrillator (ICD) or a cardiac resynchronization therapy device with defibrillating mode (CRT-D). The ET was measured by means of: (1) transthoracic echocardiography (ECHO) (Acuson, Siemens, Germany); (2) pulse wave analysis of the reconstructed aortic pressure waveform (PWA) (Sphygmocor MX (AtCor Medical, Australia) with Colin BPM 9200 Pilot (Colin, Japan); (3) cardiac impedance (ICG) (Niccomo, Medis, Germany). The ET for different methods was compared with the paired t-test and the mutual relationships were quantified with the parametric Pearson correlation. Results: The shortest ET was measured by ECHO (282.4þ/-38.5 ms), longer by PWA (289.6þ/-31.5 ms) and the longest by ICG (302.7þ/-43.4 ms). For all ET measurements there were statistically significant differences ( p , 0.0001), with the smallest ET difference between PWA and ECHO (7.2þ/-24.4 ms), next between PWA and ICG (13.1þ/-35.4 ms), and the largest between ECHO and ICG (20.3þ/-39.1 ms). Considering echocardiographic measurements of ET as the reference values (for the direct visualization of the aortic cusps motion), the mean relative difference between ETs was 7.3þ/-6.6% for PWA and ECHO, 9.7þ/-9.3% for PWA and ICG, and the largest 12.4þ/-11.1% for ECHO and ICG. All ETs were significantly correlated with the strongest for ET measured by ECHO and PWA (r=0.77; p , 0.0001), next PWA and ICG (r=0.59; p , 0.0001) and the weakest for ECHO and ICG (r=0.55; p , 0.0001). Conclusions: The significant differences in ETs measured by 3 distinct non-invasive methods show that their results are neither equivalent nor interchangeable. These differences can partially explain the lack of agreement in the quantification of stroke volume or cardiac output between echocardiography, aortic pulse wave analysis and cardiac impedance. Our findings are clinically important for all patients with implanted devices. Quite often various settings of such devices are modified to obtain the optimal values of basic hemodynamic parameters. Since the 3 methods give different results, there is a question whether the optimal settings of the implanted devices established by these methods really are optimal.
P1090
Competitive sports induce phenotypic expression of arrhythmogenic right ventricular cardiomyopathy in families of patients with asymptomatic PKP2-mutation carriers J.-L. Pasquie, C. Hedon, S. Thomann, O. Alfalasi, F. Massin, F. Cransac, T.T. Cung, and J.M. Davy University Hospital of Montpellier, Montpellier, France Many questions remain regarding both genetic and environmental modifiers of arrhythmogenic right ventricular cardiomyopathy (ARVC). We report 3 families of ARVC related to a mutation in PKP2 in whom only mutation carriers with competitive sports activites had phenotypic expression of the disease. Three athletes (2 females 14 and 53 yo; male 26 yo) were resuscitated from sudden death during sports practice (.12 hours weekly). They were having intensive sports activity since 6, 12 and 10 years respectively. The oldest patient began intensive sports activity later in life than the 2 others (35 yo). ARVC was diagnosed after resuscitation according to Task Force criterion. All of three had negative T waves in V1-V3 leads, presence of late potentials, . 5000 left bundle branch block pattern premature ventricular complexes (PVC)/day, and major structural abnormalities detected by tranthoracic echocardiography, right ventricular angiogram and MRI. Genetic testing found mutations on PKP2 (2 previously described). Genetic tests were performed in the families. Out of 31 individuals tested, PKP2 mutation was identified in 7, transmitted in an autosomic dominant fashion. Complete evaluation of these families was performed including baseline ECG, 24 hour-Holter recording, exercise test, signal-averaged ECG, echocardiography and cardiac MRI. Mutation-carriers were 4 women, 3 men with a mean age of 48.9 þ/- 28.9 (range 17-80 yo). They all had less than 6 hours of weekly physical activity during their life except one. They had no symptoms that could be related to ARVC. Two of them (2 women, 74 and 80 yo) were treated for hypertension. They all had normal ECG. The patients with no sports activities had no evidence of late potentials, less than 200 PVC/day on Holter ECG recordings, no PVC on exercise tests and no right or left ventricle structural abnormalities. One asymptomatic mutation-carrier (17 yo man)who had . 8 hours sport practice/week(running, soccer) developed frequent PVC on Holter recordings, with echocardiographic and MRI abnormalities that met ARVC diagnosis criterion. In conclusion, in patients with PKP2 mutation, intense endurance sports practice for several years appears to be a strong determinant of ARVC phenotypic development and of malignant ventricular arrhythmias. On the contrary, a sedentary life was associated with the absence of development of ARVC in mutation carriers, suggesting a major role for physical activities in precipitating disease expression and that sports restriction may prevent its development in asymptomatic mutation carriers.
ii163
P1091
Premature ventricular beats in non-compaction cardiomyopathy: consequence of immature development of the cardiac conduction system?
P1092
Resting respiratory rate and the function of the cardiovascular system in patients with an implanted defibrillating device and left ventricular ejection fraction up to 40% T. Krauze, M. Bryl, D. Przymuszala, D. Karbowy, J. Tarchalski, M. Biczysko, M. Jastrzebska, A. Palasz, J. Piskorski, and P. Guzik
S.C.H. Van Malderen, K. Caliskan, F. Akca, and T. Szili-Torok
University of Medical Sciences - Department of Cardiology - Intensive Therapy, Poznan, Poland
Erasmus Medical Center, Department of Cardiology, Rotterdam, Netherlands Introduction: Non-compaction cardiomyopathy (NCCM) is considered to be the result of an arrest in normal embryogenesis of the myocardium. The classical presentation includes severe heart failure, malignant ventricular arrhythmia, thrombo-embolic events and sudden cardiac death. Up to now literature does not provide clear histological, developmental or electrophysiological explanation for the origin of premature ventricular contractions (PVC’s) and arrhythmias in NCCM. The aim of this study was to determine the origin of PVC’s in NCCM. Methods: A total number of 2069 ECG’s of 101 patients with NCCM were analysed by two independent cardiologists to determine the origin of PVC’s. PVC’s were considered monomorphic if only 1 and multiform if 2 or more morphologies were documented. The following cardiac structures were defined as regions with possible his-purkinje connections: aortomitral continuity, outflow tract (LVOT/RVOT), septum, fascicles (upper septal, posteromedial and anterolateral). Non-his-purkinje related structures were classified as mitral and tricuspid annulus, and free left or right ventricular wall. Results: PVCs were seen on 250 ECG’s of 55 patients. 16/55 (29%) patients had monomorphic and 39/55 (71%) patients had multiform PVC’s. 35 ECG’s recorded PVC’s in all 12 leads. On these 35 ECG’s the origin of 20 different types of PVC’s could be determined. 6/20 originated from the posteromedial fascicle, 4/20 from the LVOT, 4/20 from the RVOT, 2/20 from the tricuspid annulus, 1/20 from the upper septal fascicle, 1/20 from the mitral annulus, 1/20 from the right ventricular (RV) septum and 1/20 from the free RV wall. 15/20 (75%) PVC’s originate from regions with possible his-purkinje connections. Conclusion: Our data suggest that PVC’s in NCCM originate predominantly from possible hispurkinje related regions, especially the posteromedial fascicle. Based on these findings we hypothesize that in NCCM the arrest of cardiac embryonic development might also happen at the level of the conduction system which could be the substrate for arrhythmia in NCCM.
Purpose: Dyspnea is one of the most common subjective symptoms reported by patients with heart failure (HF), and the increased respiratory rate is one of its objective signs. This study evaluated the relationship between the resting respiratory rate and the function of the cardiovascular system (CVS) in patients with an implanted defibrillating device and left ventricular ejection fraction (LVEF) up to 40%. Methods: 177 patients with either a cardioverter-defibrillator (ICD) or a cardiac resynchronization therapy device with defibrillating mode (CRT-D) underwent a 30-minute cardiac impedance (Niccomo, Medis, Germany) for resting recording of respiratory rate and hemodynamic parameters. Patients were grouped into one of its tertiles, i.e. T1, T2 or T3 according to the mean value of the 30-minute resting respiratory wave. All studied parameters were compared with the ANOVA with Bonferroni post-tests. Results: Results for continuous data (mean þ/- standard deviation) which were related to the resting respiratory rate are shown Table 1. The mean resting respiratory rate differed by nearly 8 breaths/minute between T1 and T3. The HF patients with LVEF up to 40% and the higher resting respiratory presented a shorter IVRT, a reduction in SV and a higher resting heart rate. Conclusions: The assessment of the resting respiratory rate in HF patients with an implanted ICD or CRT-D and LVEF up to 40% allows the selection of individuals with more severe CVS dysfunction. If the current hemodynamic status is reflected in the resting respiratory rate, it is plausible that any deterioration or improvement in it can be easily found just by counting the respiratory rate. The answer whether the measurement of resting respiratory rate in HF patients with an impaired systolic function will be useful in the monitoring of the HF progress and effectiveness of the applied therapy requires further prospective studies.
Respiratory rate [breaths/minute] isovolumetric relaxation time (IVRT) [ms] stroke volume (SV) [ml] HR [beats/minute] a
T1
T2
T3
p value
11.7þ/-2.4 199.6þ/-55.5 81.1þ/-20.9 64.7þ/-9.5
16.0þ/-0.8 168.8þ/-53.0a 75.7þ/-24.1 69.2þ/-10.4
19.4þ/-2.2 161.5þ/-49.4b 71.2þ/-18.2b 73.4þ/-12.0b
0.0002 0.0418 ,0.0001
p , 0.05 for T1 vs. T2; bp , 0.05 for T1 vs. T3;
P1093
P1094
Sudden paradoxical changes in repolarization dynamics may provide a potential substrate for ventricular arrhythmias in patients undergoing renal replacement therapy AHMED. Talib1, N. Sato1, K. Abe2, N. Yao2, M. Matsuki1, T. Fujino1, T. Hirayama3, J. Maruyama2, Y. Kawamura1, and N. Hasebe1 1 Asahikawa Medical University, Dept Internal Medicine, Cardiovascular, Respiratory & Neurology Div., Asahikawa, Japan; 2Asahikawa Rehabilitation Hospital, internal Medicine, Asahikawa, Japan; and 3Kitasaito hospital Nephrology Department, Asahikawa, Japan
Purpose: to study the effects of hemodialysis (HD) and peritoneal dialysis (PD) on repolarization indexes. Methods: We enrolled 15 PD and 20 HD patients who had no structural heart disease. 24-hour ECG- derived QT, Tp-Te interval, Tp-Te/QT ratio and QT/RR slope were temporally analysed and compared in the following periods: (1) For HD patients, analysis was done in (i) 4 hours before starting HD, (ii) during HD session and (iii) 4 hours after HD .(2) For PD patients, analysis was done in (i) 30 minutes before pack-exchange(PD session) (ii) during dialysate-free phase (usually took 30 minutes) and (iii) 30 minutes after dialysate infusion( next PD session). Results: PD patients exhibited no significant difference in the QT, Tp-Te and Tp-Te/QT in the PD session and dialysate-free phase, however, the QT/RR slope decreased significantly in the dialysate-free phase. Similarly HD patients displayed sudden significant reduction in QT/RR slope during the HD session compared to the pre-and post-HD phases (Table). Conclusions: Sudden paradoxical changes in repolarization dynamics, due to sudden shifts in volume and electrolytes within a short time, may explain the propensity of dialysis patients to develop ventricular arrhythmias in the hours following dialysis
Parameters
CAPD session
Dialysate-free
Next CAPD session
P
QT (ms) Tp-Te Tp-Te/QT QT/RR
402 +43 86 + 21 0.215 + 0.04 0.232+ 0.05 Pre-HD 394 +37 81 + 11 0.205 + 0.03 0.235+ 0.05
409 +30 76 + 11 0.187 + 0.02 0.1 + 0.04 * HD session 397 +30 84 + 10 0.212 + 0.02 0.124 + 0.04 †
416 + 42 83 +16 0.198 + 0.03 0.314+ 0.03 Post-HD 398 + 33 81 +12 0.205 + 0.02 0.229+ 0.03
0.629 0.808 0.088 0.041
QT (ms) Tp-Te Tp-Te/QT QT/RR
0.958 0.827 0.755 0.022
Values are expressed as the mean + SD.*P , 0.05, dialysate-free vs. CAPD session and next CAPD session, using post-hoc Tukey’s test.†P ,0.05: HD session vs. pre-HD and post-HD, using post-hoc Tukey’s test.P values refer to the total significance of differences (ANOVA) among the 3 groups.CAPD: continuous ambulatory peritoneal dialysis, HD: hemodialysis, HR: heart rate. Tp-Te:T-wave peak to end
Clinical and prognostic significance of idiopathic intraventricular conduction disturbances in young subjects G. Allocca1, N. Sitta1, M. Centa1, A. Cati1, E. Marras1, L. Sciarra2, L. Coro’2, and P. Delise2 1
Operative Units of Cardiology, Hospital of Conegliano (Treviso), Conegliano (Tv), Italy; and 2Department of Cardiology, Casilino Policlinic, Roma, Rome, Italy
Purpose: to establish the clinical and prognosis of intraventricular conduction disturbances (IVCD) in the absence of heart disease in young (,50 yrs) subjects. Methods: 80 (65 probands) consecutive subjects (62 males, median age 27 years) with IVCD were enrolled: 24 with RBBB isolated or associated to LAH or LPH, 22 with LBBB, and 34 with isolated LAH or LPH. All were asymptomatic and had no heart disease on the basis of clinical examination and of a normal echocardiogram. Follow up was considered starting from the discovery of the conduction disturbance. Results: 9% (6/65) of probands had family history of (,50 yrs) sudden death and 9% (6/65) had familial conduction disturbances (FCD). In particular FCD were observed in 100% of isolated and associated LPH, in 48% of isolated LAH and 33% if associated to RBBB, 8% and 0% of isolated RBBB and LBBB respectively. In 14% of patients with LBBB a coronary anomaly was found. During follow-up (10/-10 yrs) 75 pts (94%) had not clinical events and normal serial echocardiogram. 5 (6%) had events, 4 with LBBB and with 1 LPH: 2 had a PM , 1 a CRT for a releafe of EF, 1 ACS and 1 SD (in subject with LHP). Conclusions: 1) IVCD in young subjects may be familial ; 2) familial IVCD are observed in particular in LPH, while it is not the case of LBBB; 3) medium-term prognosis of IVCD is good in most pts. 4) How to recognize subjects at risk it is unknown.
ii164
P1095
P1096
Significantly higher peak body surface restitution gradients in patients experiencing ventricular arrhythmias
Ventricular arrhythmias and systolic function in young patients with mitral valve prolapse
W.B. Nicolson1, M.I. Smith2, G. Chu2, P.B. Brown2, A.J. Sandilands3, P.J. Stafford3, F.S. Schlindwein3, N.J. Samani1, G.P. Mccann1, and G.A. Ng1
E. Malev1, S. Reeva2, L. Vasina1, A. Pshepiy1, and E. Zemtsovsky2
1
NIHR Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom; 2University of Leicester, Leicester, United Kingdom; and 3University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom Purpose: Peak action potential duration (APD) restitution gradient greater than unity has been mathematically linked to ventricular arrhythmogenesis. This abstract investigates peak body surface and peak intracardiac APD restitution gradients as predictors of sudden cardiac death (SCD). Methods: Prospective, blinded study of 60 patients with IHD being assessed for ICD and 15 control patients. Standard APD restitution curves were constructed for each lead of the 12 lead ECG using surrogates for APD (QRS onset to T wave peak, QTp) and diastolic interval (T wave peak to QRS onset, TpQ) and for the unipolar signal (45/60 patients). Peak mean 12 lead body surface restitution gradients were calculated from the mean of the gradients across the 12 ECG leads taken at each S1S2 coupling interval. Results: Peak mean 12 lead body surface restitution gradient was significantly higher in study patients experiencing Ax/SCD (16/60) than in those not (1.35[0.60]vs.1.08[0.52], p=0.01) and similar in study patients compared with controls (1.11[0.60]vs.0.98[0.31], p=0.431). Peak unipolar APD restitution gradients were non-significantly higher in study patients receiving Ax/SCD (13/45) than those not (2.94[3.26]vs.2.06[2.19], p=0.43) and similar in study versus control patients (2.21[2.49]vs.2.00[1.03], p=0.27). Figure 1 shows standard error of mean area curves for each patient group. Conclusions: Peak mean body surface restitution gradient shows potential as a marker of SCD. Its superiority over intracardiac data may be due to the tighter distribution of values. Also, an intracardiac catheter can be proximate to or distant from pathology whereas the body surface signal summates cardiac electrical activity.
1
Almazov Federal Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation; and 2State Pediatric Medical Academy, Saint Petersburg, Russian Federation
Purpose: Ventricular arrhythmias are known to be common in symptomatic patients with mitral valve prolapse (MVP). The aim of our study was to investigate the prevalence, echocardiographic and biochemical predictors, and possible mechanisms of ventricular arrhythmias in young asymptomatic patients with MVP without significant mitral regurgitation. Methods: We studied 78 asymptomatic young subjects (mean age 19.7 + 1.6, 72% male) in sinus rhythm with MVP in comparison with 80 sex- and age-matched healthy subjects. Transthoracic echocardiography (Vivid 7 Dimension, GE) and 24-hour Holter monitoring were performed. MVP was diagnosed by billowing of 1 or both mitral leaflets .2 mm above the mitral annulus in the long-axis parasternal view. Longitudinal strain were determined from three apical views, using spackle tracking (EchoPAC’08, GE) with grey-scale frame rate 5055/sec. Concentration of monocyte chemoattractant protein-1 (MCP-1) in serum were determined by enzyme-linked immunosorbent assay. Results: The frequency of isolated ventricular premature contractions (VPCs) was similar in both groups (32.4% N 33.3%; x2=1.2, p=0.90). Ventricular tachycardias were not found in either MVP nor in control group. However, the ventricular couplets were recorded only in patients with MVP (in 8.1% of MVP group; x2=5.2, p=0.01). The presence of couplets negatively correlated with left ventricular (LV) ejection fraction (r= –0.66; p=0.0001), with a global LV longitudinal strain (r=– 0.78; p , 0.0001), but positively correlated with the concentration of profibrotic chemokine MCP-1 (r=0.56; p=0.008). In patients with couplets more often were revealed local wall motion abnormalities (z= –2.0, p=0.04). Based on logistic regression analysis for MVP cases, in the case of ventricular couplets, the longitudinal strain ( p=0.001) and MCP-1 serum level ( p=0.01) were the independent predictors of couplets. Conclusion: in young asymptomatic patients with MVP more often than in the healthy population recorded ventricular couplets, the origin of which may be associated with impaired LV contractility, probably due to fibrosis of the myocardium.
P1097
A new stepwise electrocardiographic algorithm for localizing the atrial flutter circuit :Usefulness of flutter-wave morphology in leads V1 and I K. Sasaki, S. Shingo, M. Kimura, S. Owada, D. Horiuchi, T. Itoh, Y. Ishida, T. Kinjo, and K. Okumura Hirosaki University Graduate School of Medicine, Department of Cardiology, Hirosaki, Japan Purpose: Previously proposed criteria for localizing the reentry circuit of atrial flutter (AFL) may be limited due to the lack of precise mapping during AFL. By analyzing flutter wave (F-wave) morphology and electroanatomic map (CARTO) during AFL, we sought to clarify F-wave characteristics relating to AFL circuit location and propose a new algorithm for localizing AFL circuit. Methods: This study included 128 patients with AFL for retrospective and 40 for prospective analysis. CARTO and entrainment mapping was done in all cases. In the retrospective analysis, F-wave morphology was characterized by positive (Fþ) and/or negative (F-) deflection and isoelectric line (IEL) between F-wave, and thereby a diagnostic algorithm was created. In the prospective one, the diagnostic accuracy of the algorithm was tested. Results: Of the 128 retrospective study patients, 100 (79%) showed right atrial (RA) and 28 (21%) left atrial (LA) AFL. Absence of IEL in lead V1 well differentiated reverse common AFL and lower-loop reentry from the others (18/23 vs 5/105, P , 0.01). Low-amplitude (,0.05mV) or F-/Fþ pattern in lead I well differentiated common AFL and LA AFL ( perimitral and pulmonary vein-related AFL) from the others (88/93 vs 7/35, P , 0.05). Similar F-wave polarity in the inferior leads between LA and common AFL was not uncommon, and the decisive criterion to distinguish LA AFL was F- in V6 appearing before the timing of Fþ in V1 (60/65 vs 1/28, P , 0.01). Of the 40 prospective patients, 23 (58%) showed RA and 17 (42%) LA AFL. The diagnostic accuracy of the algorithm (Figure) was 92% (37/40). Conclusions: By referring to F-wave morphology in the specific leads such as V1 and I, the location of AFL reentry circuit can be predicted more precisely and easily.
P1098
Diagnosis, treatment and outcomes of neonates and fetuses with complete AV- block Single centre experience R. Bejiqi, R. Bejiqi, R. Retkoceri, H. Bejiqi, and N. Zeka University Clinical centre Prishtine, Prishtina, Kosovo, Republic of Background: Complete AV block (CAVB) can have diverse etiology and clinical futures depending from the age of manifestation and diagnosis and caries a significant morbidity and mortality, especially in fetal period of life. CAVB occurs in approximately 1 in 15000 – 18 000 live births and can be as a isolated or associated with complex congenital heart disease (CCHD), when prognosis is much worsens. Method: Reviewing documentations of all patients presented to our Cardiology services with diagnosis of CAVB during the period 2002 - 2012 we investigated etiology, clinical manifestation and outcome of these children in fetal, neonatal period and early childhood. Results: Basing on this data 32 patients were diagnosed with CAVB of which 9 have been diagnosed in antenatal period, 11 were diagnosed in neonatal and 12 during the first year of life. Seven patients had an associated structural heart disease, 6 of them complex anomaly. Among fetal cases, maternal anti-Ro or anti-le antibodies were present in 5. Three fetuses had received prenatally (all in third trimester) Dexamethasone and/or beta mimetic. Total mortality rate was 15.6% (5/32 of which intrauterine and neonatal death was responsible 4. The presence of CCHD, fetal diagnosis, antibody and heart rate lower than 50/bpm were associated with higher mortality. Three children received pacemaker insertion during first year of life. Conclusion: CAVB antenataly diagnosed has association with maternal antibodies and CCHD and has poor outcome compared to that diagnosed postnataly. In selected cases steroids and Beta-mimetics may significantly prevent complication and reduce mortality.
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P1099
Analysis of intra-nocturnal ventricular vepolarization dynamics in early repolarization syndrome: insights into the pathophysiology of sudden cardiac death AHMED. Talib, N. Sato, E. Sugiyama, N. Sakamoto, H. Ota, Y. Tanabe, T. Takeuchi, K. Akasaka, Y. Kawamura, and N. Hasebe Asahikawa Medical University, Dept Internal Medicine, Cardiovascular, Respiratory & Neurology Div., Asahikawa, Japan Purpose: Very few investigations on early repolarization syndrome (ERS) have focused on the repolarization indexes. On the other hand, contemporary data has shown the peak incidence of sudden cardiac death (SCD) in ERS is at night from 0-6 A.M. Our purpose was to investigate some repolarization indexes in ERS patients. Methods: A total of 146 were enrolled: 11 ERS patients, the vast majority of whom are survivors of aborted SCD,45 uneventful ER pattern(ERP) subjects and 90 healthy controls. Ambulatory ECG-derived parameters fQT, QTc, and QT/RR slopeg were measured and statistically compared. Results: Among the groups, there was no significant difference in the age,average QT and QTc; however, the 24hour QT/RR slope was significantly smaller in the ERS than ERP and control groups.Moreover, intra-nocturnal analysis showed the lowest QT/RR slopes were from 0-6 A.M (Table). Conclusions: (1) In contrast to ERP subjects, ERS patients had a continuously attenuated diurnal and nocturnal adaptation of the QT interval to the heart rate. Such abnormal repolarization dynamics might provide a potential substrate for reentry and ventricular fibrillation in the ERS cohort. (2) Importantly, impaired QT prolongation during heart rate deceleration was most evident at midnight. This may explain the propensity of ERS patients to develop SCD during such critical period.
HR (beat/min) QT (ms) QTc (ms) 24-hour QT/RR Diurnal QT/RR N1 QT/RR N2 QT/RR N3 QT/RR
ERS patients (n=11)
ERP (n=45)
Control (n=90)
P
58.1 + 6.1 402.9 + 24 398.8 + 16 0.103+ 0.01 0. 083+ 0.02 0. 091+ 0.02 0. 073+ 0.02 0. 079+ 0.02
66.6+ 9.8 † 400.9+ 17.9 417.4 + 22 0.158+ 0.02‡ 0.131+ 0.04‡ 0.134+ 0.04 0.115+ 0.04 † 0.119+ 0.04 ††
71.4 + 9.5 §} 394.6+ 24 424.8+ 26 0.158+ 0.02 § 0.132 + 0.04 § 0.153 + 0.04 * 0.117 + 0.04 * 0.114 + 0.04 **
,0.001 0.472 0. 202 ,0.001 ,0.001 0.032 0.012 0.003
Values are expressed as mean + SD.*P , 0.05, **P ,0.01, §P , 0.001: control group vs. ERS patients.†P ,0.05, ††P ,0.01, ‡ P , 0.001 : ERP group vs. ERS patients, using post-hoc Tukey’s test.P values refer to the total significance of differences (ANOVA) among the 3 groups.HR: heart rate, ERS: early repolarization syndrome, ERP: early repolarization pattern,N: Nocturnal.Diurnal(06:00-18:00),N1(18:00-00:00),N2 (00:0003:00),N3(03:00-06:00).
P1100
Prevalence of Brugada type ECG pattern and early repolarization variant in Turkish population: results from the HAPPY study B. Hunuk1, O. Cagac2, O. Erdogan2, A. Kepez2, B. Mutlu2, and M. Degertekin3, HAPPY (Heart failure prevalence and predictors in Turkey) study group 1
Maltepe C.I.K. State Hospital, Department of Cardiology, Istanbul, Turkey; 2Marmara University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey; and 3Yeditepe University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey Purpose: Brugada type ECG pattern (BTEP) is defined by a specific ST-segment elevation in leads V1-V3 without distinct clinical history. The clinical significance of BTEP is not well established. Early repolarization variant (ERV) on ECG has traditionally been considered benign, but has recently been associated with vulnerability to ventricular fibrillation. Our aim was to elucidate the frequencies of these two important J wave patterns in Turkish population. Methods: We evaluated ECGs and clinical data obtained from the HAPPY (Heart Failure Prevalence and Predictors in Turkey) study involving randomly selected 4650 subjects 35 years from all regions of Turkey. After the exclusion of subjects with missing ECG or data, established coronary disease, anti arrhythmic use and bundle branch blocks, pre-excitations, atrial fibrillation, ventricular hypertrophies; 3422 subjects ([mean + SD] age, 51 + 11, [range]35-100 years) were enrolled in the study(female n [%overall]:1966 [57,5%]). All ECGs were interpreted manually by two experienced cardiologists for the presence of BTEP (according to the EHRA/ HRS 2005 consensus report) and ERV (J-point elevation (0.1 mV) in the inferior, lateral or both leads with QRS notching). Results: Frequencies in each decade are shown in table-1. No type-1 pattern was found. BTEP and ERV were significantly prevalent in males ,65 years (p , 0,001) in all age groups except for the lateral ERV ( p=0,6). Intergender differences in BTEP ( p=0,160) and ERV (p=0,334) disappeared 65 years. Conclusions: ERV and BTEP prevalence in otherwise healthy Turkish population revealed similar results with other Caucasian populations. Diminished gender difference in elderly may be attributed to hormonal changes.
Age (n) ECG pattern Type 2 Type 3 BTEP ER inferior ER lateral ER inferolateral ERV
35-44 45-54 55-64 (1309) (988) (887) n (female: n) % in age group
65-74 (572)
6(2) 0,5% 14(3) 1,1% 20(5) 1,5% 40(15) 3,1% 12(9) 0,9% 15(4) 1,1% 67(28) 5,1%
5(0) 0,6% 14(2) 1,6% 19(2) 2,1% 23(7) 2,6%
4(2) 0,7% 4(2) 0,3% 8(4) 1,0% 17(8) 3,0%
7(2) 0,8% 4(3) 0,5% 34(12) 3,8%
3(3) 0,5% 1(1) 0,2% 21(12) 3,7%
4(0) 0,4% 14(1) 1.4% 19(2) 1,9% 30(10) 3,0% 8(6) 0,8% 1(1) 0,1% 39(17) 3,9%
P1101
The relationship between T-wave amplitude variability and myocardial viability in patients with cardiac resynchronization therapy
75 (193)
Total n
%(overall)
2(0) 1% 3(0) 1,6% 5(0) 2,6% 2(0) 1,0%
21(4) 47(8) 71(13) 112(40)
0,5 % 1,2 % 1,7% 2,8%
1(1) 0,5% 0 0% 3(1) 1,6%
31(21) 21(9) 164(70)
0,8% 0,5% 4,1%
P1102
Comparations of electrocardiographic patterns of ventricular arrhythmias: differences between ARVC and idiopathetic RVOT tachycardia
M. Cvijic1, D. Zizek1, L. Lezaic2, and I. Zupan1 1
University Medical Centre Ljubljana, Department of Cardiology, Ljubljana, Slovenia; and 2University Medical Centre Ljubljana, Department of Nuclear Medicine, Ljubljana, Slovenia
Purpose: T-wave amplitude variability (TAV), a dispersion of repolarization index, is a non-invasive predictor of arrhythmic events in patients with dilated cardiomyopathy. Identification of scar tissue is also associated with the occurrence of ventricular tachyarrhythmias (VTs) in patients with ischaemic and non-ischaemic cardiomyopathy. The aim of our study was to evaluate the relationship between TAV and the extent of viable myocardium in patients undergoing cardiac resynchronization therapy (CRT). Methods: Thirty-five patients with advanced heart failure (age 63 + 9; 21 male (60%); New York Heart Association class II-IV; EF 26.8 + 7.5%; 17 ischaemic aetiology (48.6%); 11 with previous VTs (31.4%)) were evaluated using single-photon emission computed tomography (SPECT) myocardial perfusion imaging before implantation of CRT combined with a defibrillator. Myocardial viability was determined by number of viable segments (relative tracer uptake 50% of normal myocardium) in a 20-segment model. Echocardiographic parameters and 20-minute high-resolution ECG recordings of TAV were measured at baseline and 6 months after CRT-D implantation. Biventricular pacing at 6 months was temporarily inhibited to record native TAV. The patients were assigned to one of two groups according to the median value of viable segments (17 viable segments). Results: There was no significant difference in baseline median TAV, echocardiographic parameters and QRS duration between both groups. After 6 months of CRT, patients with more viable segments had lower median TAV (22.5 mV (17.9-31.4) vs. 34.9 mV (24.4-48.5); P = 0.034). In addition, decrease of median TAV after CRT was only noticed in patients with more viable myocardium (from baseline 34.0 mV (24.8-67.1) to 22.5 mV (17.9-31.4) after 6 months; P = 0.007). During a mean follow-up of 23.6 + 4.8 months, 12 patients (34.3%) experienced VTs. Reduction of median TAV was only noticed in patients without VTs. Conclusion: TAV after CRT is strongly associated with the extent of viable myocardium. Decrease of TAV observed only in patients with more viable myocardium could suggest that CRT might not ameliorate the scar-related arrhythmogenic substrate in heart failure patients.
L. Ren, Y.-H. Jia, Z. Liu, J.-M. Chu, P.-H. Fang, and S. Zhang Cardiovascular Institute & Fuwai Hospital-PUMC, Center of Arrhythmia Diagnosis and Treatment, Beijing, China, People’s Republic of Purpose: Ventricular arrhythmia with left bundle branch block (LBBB ) QRS morphology and inferior axis exist both in arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathetic right ventricular outflow tract arrhythmia (RVOT-VA). However, the prognosis of the two diseases is different. The purpose of this study was to search for the cardiographic differences in the contours of ventricular arrhythmia between the two diseases. Method: 17 ARVC patients and 24 RVOT-VA patients with structurally normal hearts who underwent radio frequency catheter ablation in our center were involved (16 originate from the septum of RVOT, 8 from the free-wall). Electrocardiographic characteristics such as the mean QRS duration and QRS notching of each lead, precordial R-to-S wave transition leads were measured and compared. Results: Comparing with idiopathetic RVOT-VA , the mean QRS durations were longer in ARVC in each lead, significant differences existed in leads I,III,avL, avF, V1 and V2 (P , 0.05),and the largest mean difference existed in lead I 29.64 + 8.542ms, P=0.001). QRS duration in lead I 129 ms had a sensitivity of 94%, specificity 54 % for ARVC (59% positive predictive value, and 93% negative predictive value). ARVC patients had more R wave transition in lead V5 or later ( 54.5% vs 4.2%, P=0.014) than idiopathetic RVOT-VA, 96% specificity value. QRS notching in each lead was not different between the two groups, but QRS notching simultaneously existing in both lead I and avL was more common in ARVC patients( p=0.008). In multivariate analysis, QRS duration in lead I of 129 ms (odds ratio [OR]: 27.59, p = 0.02), a R wave transition at V5 or later (OR:10.23, p = 0.07), QRS noching both in lead I and avL(OR:7.34,p=0.03) ,these parameters predicted the presence of ARVC. Conclusions: Several electrographic morphologic differences existed in ventricular arrhythmias with LBBB/inferior axis between ARVC and idiopathetic RVOT-VA, which can help to differentiate the two arrhythmia substrates.
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P1103
P1104
Heterogeneity of ventricular repolarization in patients with end stage renal disease
Combinations of qt-prolonging drugs are frequently used in psychiatry T. Marynissen1, E. Vandael2, J. Reyntens3, V. Foulon2, and R. Willems1 1
University Hospitals (UZ) Leuven, Campus Gasthuisberg, Department of Cardiology, Leuven, Belgium; 2Catholic University of Leuven, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium; and 3Sint-Jan Hospital, Eeklo, Belgium Purpose: Drug-induced prolongation of the QT interval is a known risk factor for polymorphic ventricular tachycardia (torsade de pointes (TdP)) and arrhythmic death. Patients who have a reduced repolarization reserve, due to electrolyte disturbances, genetic polymorphisms or the effects of other drugs, are at particularly high risk. The list of QT prolonging drugs is extensive and includes many drugs used in the psychiatric setting. In this study we performed a crosssectional analysis of medication profiles from patients in psychiatric institutions in Belgium to assess the prevalence of drug interactions potentially leading to QT prolongation in this population. Methods: Patients were randomly selected from 6 psychiatric hospitals in Belgium. Demographic characteristics were collected. For each patient, the full medication list was entered in a database and screened for the presence of interactions, with special attention to those with an increased risk for QT prolongation. This was done using the Delphi Care interaction database developed by the Belgian Pharmaceutical Association. The most common drugs and drug classes involved in the interactions were summarized. Current practice on QT monitoring and prevention of drug-induced arrhythmia was assessed. Results: 599 patients (46% female; mean age 52.5 + 17.4 years) were included in the analysis. The median duration of hospital stay at the time of data collection was 366 days (interquartile range 260-722). 116 QT-prolonging interactions were identified in 44 patients (7.3%). QTprolonging interactions occurred most frequently with antipsychotic agents (n = 106) and antidepressants (n = 106). Other drugs involved were indapamide (n = 11), sotalol (n = 4) and lithium (n = 5). Antipsychotic agents interacted with antidepressants in 98 cases, with lithium in 4 cases and with indapamide in 4 cases. Antidepressants interacted with indapamide in 6 cases and with sotalol in 2 cases. The precautions and follow-up provided by the different institutions when adding a second QT prolonging drug were very diverse. In none of the six institutions, a follow-up ECG was performed routinely. Conclusion: Despite the increased awareness and the precautions taken during recent years (e.g. prescription software with automatic interaction alerts), drug combinations that are associated with QT prolongation are frequently used in the psychiatric setting. Persistent efforts should be undertaken to inform caregivers on the risks of QT-prolonging drugs, and to provide them with clear guidelines on how to use these drugs in a responsible and safe way.
AHMED. Talib1, N. Sato1, K. Abe2, N. Yao2, M. Matsuki1, T. Fujino1, T. Hirayama3, J. Maruyama2, Y. Kawamura1, and N. Hasebe1 1 Asahikawa Medical University, Dept Internal Medicine, Cardiovascular, Respiratory & Neurology Div., Asahikawa, Japan; 2Asahikawa Rehabilitation Hospital, internal Medicine, Asahikawa, Japan; and 3Kitasaito hospital Nephrology Department, Asahikawa, Japan
Purpose: Patients with end stage renal disease (ESRD) who undergo hemodialysis (HD) and peritoneal dialysis (PD) are at great risk of sudden cardiac death (SCD). Recently, important ventricular repolarization parameters such as the Tp-Te interval, Tp-Te/QT ratio and QT/RR slope have been considered as useful markers for repolarization instability. Our purpose was to evaluate the repolarization indices in HD and PD patients, in addition to a healthy control group. Methods: After excluding those with organic heart disease , we identified 115 subjects; 20 HD, 15 PD patients, and 80 healthy controls (C). Ambulatory ECG-derived parameters including the QT,Tp-Te interval, Tp-Te/QT ratio and QT/RR slope were calculated and statistically compared. Results: Although there was no significant difference in the heart rate and QT interval among the groups, the TpTe interval, and Tp-Te/QT ratio were significantly larger in the HD and PD groups than in the C group. Similarly both the QTapex/RR and QTend/RR slopes were significantly large in the HD and PD groups. Conclusion: (1) Even in the absence of conventional risk factors of SCD such as low ejection fraction or myocardial infarction, the novel markers of repolarization heterogeneity, Tp-Te and Tp-Te/QT, were significantly increased in the ESRD patients indicating an enhanced dispersion of repolarization. (2) An abnormal QT adaptation to a changing heart in the ERSD patients, reflecting changes in the myocardial vulnerability, may contribute to the increased risk of arrhythmic events and SCD in such a high risk cohort of patients.
HR (beat/min) QT (ms) Tp-Te (ms) Tp-Te/QT QTa/RR QTe/RR
HD (n=20)
PD (n=15)
Control (n=80)
P
78 +15 412 + 42 90 + 22 ** 0.219 + 0.04 * 0.231 + 0.06 ** 0.236 +0.07 **
77 +15 395 + 26 81 +13 ‡ 0.203 +0.04 † 0.222 + 0.04 ‡ 0.235 +0.06 ‡
71 + 10 398 + 33 71 +10 0.174 + 0.02 0.159 + 0.03 0.158 + 0.03
0.062 0.409 ,0.001 0.002 ,0.001 ,0.001
Values are expressed as mean + SD.P values refer to the total significance of differences (ANOVA) among the 3 groups.* p , 0.01, ** , 0.001: HD vs. control groups, using post-hoc Tukey’s test.† p , 0.01, ‡ P , 0.001 : PD vs. control groups, using post-hoc Tukey’s test.HR: heart rate,QTa, QT apex; QTe, QT end. Tp-Te, the interval from the peak to the end of the T wave
P1106
P1107
Late high grade arrhythmic complications in acute myocardial infarction: impact on morbidity and mortality A description of the arrhythmogenic profile in chronic chagasic cardiomyopathy. is it different from other dilated cardiomyopathies?
B. Picarra1, A.R. Santos1, A.F. Damasio1, M. Celeiro1, A. Bento1, J. Aguiar1, and RNSCA. Spc2
D.A. Escobar Gutierrez, J.L. Morales Velazquez, S.R. Nava Townsend, A. Enriquez Silverio, P. Iturralde Torres, L.J. Colin Lizalde, M.F. Marquez Murillo, J.F. Gomez Flores, M. Levinstein Jacinto, and E. Fajardo Flores
Purpose: Arrhythmic complications are frequent in the acute phase of myocardial infarction (AMI), however its late appearance could have important implications in the prognosis of this patients (P). To evaluate the impact on prognosis of late high grade arrhythmic complications in P with AMI. Methods: We analyzed 4776 P with AMI in a multicentre registry. Two groups were defined: Group A – P with late high grade arrhythmic complications and Group B – P without complications. Late high grade arrhythmic complications were defined as the presence high grade atrioventricular block or sustained ventricular tachycardia (VT) after 48 hours of AMI presentation. We evaluated age, gender, cardiovascular risk factors, in-hospital pharmacological treatment, left ventricular ejection function (LVEF) and the number and type of coronary lesions. We compared the prevalence of the follow complications: re-infarction, heart failure (HF), stroke, in-hospital mortality and mortality of a 1-year follow-up. Multivariate analysis was done to determine the impact of each late complications in-hospital mortality. Results: The presence of late high grade complications was verified in 42 P (0,9%), 18 (0,4%) had VT and 24 (0,5%) high grade atrioventricular block. P of Group A were older (75 + 12 vs. 65 + 14 years; p , 0,001), had more prevalence of previous AMI (35,7% vs. 18,6%; p=0,005), stroke (21,4% vs. 8,1%; p=0,006) and were less smokers (7,1% vs. 30,0%; p=0,001). P of Group A received less pharmacological treatment with beta-blockers (54,8% vs. 79,4%; p , 0,001) and more treatment with nitrates (71,4% vs. 51,2%; p=0,009), ivabradine (14,3% vs. 4,1%, p=0,007), diuretics (61,9% vs. 31,1%; p , 0,001), amiodarone (35,5% vs. 8,9%, p , 0,001) inotropes (21,4% vs. 5,2%; p , 0,001). The presence of left main coronary disease (19,4% vs. 7,1%; p=0,02) and right coronary artery disease (85,7% vs. 56,3%; p , 0,001) were more prevalent in Group A. The LVEF was lower in P with late high grade complications (64,9% vs. 39,3%; p=0,001). With the exception of HF more prevalent in Group A (42,9% vs. 19,1%, p , 0,001), there weren’t differences in the other complications (stoke or re-infraction). P of Group A had an increased in-hospital mortality (40,5% vs. 4,0%; p , 0,001) and at 1-year follow-up (50,0% vs. 12,6%; p=0,031). By multivariate analyses the presence of high grade atrioventricular block and sustained VT were both predictors of in-hospital mortality. Conclusions: Late high grade arrhythmic complications are infrequent in AMI, however their presence constitute an independent predictor of in-hospital mortality.
National Institute of Cardiology "Ignacio Chavez", Department of Electrophysiology, Mexico City, Mexico Chronic Chagasic Cardiopathy is probably the most common cause of left ventricular dysfunction in rural communities of Latin America. Few observational studies suggest that CCC have an increased rate of severe ventricular arrhythmias (VA), but this observation has not been demonstrated in comparative studies. The purpose of this investigation were to compare the VA in three different etiologies of dilated cardiomyopathies: 1 Chronic Chagas’(CCC, n= 38), 2 Ischemic (ISC,n=37 ) and 3 Idiopathic (ICM, n=37). All patients had an ICD and were matched according to age and primary or secondary prevention. Mean age was 59.5 + 4.5 years, and the mean follow up was 39.22 + 2.48 months. LVEF was lower in patients with ICM (28.8 + 2.1%) compared with CCC (37.45 + 2.8%) and ISC (35.6 + 2%), p = 0.013. The time between the first event of VT/VF post ICD implantation was earlier in patients with CCC [median 6.7 months (min 1 month, max 58 months)], compared with ISC [median of 14 months (min 1 month, max 40 months)] and ICM [median of 29 months (min 4 months, max 72 months)], p=0.025. A 52.6% of patients with CCC had the event within the first year, compared with 13.5% and 19% patients of the groups with ISC and ICM respectively p = 0.005. The OR to present an event during the first year in CCC was 3.16 (CI 95% of 1.7 to 3.05), furthermore in this group there was more rate of arrhythmic storm (47%) than his counterpart of ISC (8%) and ICM 21% p= 0.034. The OR in CCC was of 5.15 (CI 95% of 2.1 to 12.2). Conclusion: Chronic Chagas Cardiomyopathy has a higher tendency for more frequent and severe ventricular arrhythmias, compared with ISC and ICM.
1
Hospital do Espı´rito Santo, E´vora, Portugal; and 2SPC, RNSCA, Portugal, Portugal
ii167
P1108
Incidence and risk factors of ventricular arrhythmias in patients with acute coronary syndrome O. Kalejs, A. Maca, I. Zakke, I. Mintale, G. Kamzola, M. Zabunova, E. Silina, A. Udre, S. Jegere, and A. Erglis
P1109
Repolarization variability as a predictor of appropriate ICD interventions in patients with the remote myocardial infarction, untreated with amiodarone K. Szydlo, A. Filipecki, W. Orszulak, W. Kwasniewski, D. Urbanczyk, M. Trusz-Gluza, and K. Mizia-Stec
P.Stradins University Hospital, Latvian Center of Cardiology, Riga, Latvia Department of Cardiology, Medical University of Silesia, Katowice, Poland Background: Ventricular arrhythmias (VA) remain a common complication of myocardial infarction (MI), despite the major improvements in the care of patients with acute coronary syndrome (ACS). We have analyzed the rate of VA in first 24 hours after hospitalization in patients presenting with ACS, receiving different treatment strategies and presenting with different risk factors. Methods: Analysis was based on the data from registry of ACS in year 2011. VA was defined as: unsustained/ sustained ventricular tachycardia (SuVT/ NsVT), ventricular fibrillation (VF). We have compared the rates of VA in patients with STEMI/ Non-STEMI after primary PCI, acute PCI, thrombolysis and without reperfusion therapy. In total - 5301 ACS patients , with VA – 225 patients. Correlation between medications before ACS and biomarkers (Troponine and CK-MB mass) and echocardiographic data in early hospitalization time as possible VA prognostic factors were analyzed. We have analyzed pharmacological treatment before ACS event and implication to VA. Results: In STEMI cohort, the incidence of VA was significantly lower in PCI group six hours after ( p , 0.05) than in patients receiving thrombolysis. In first two hours VA incidence was higher in PCI patients, what can be explained with earlier reperfusion changes and electrical instability. In non-STEMI cohort, the incidence of VA was significantly lower than in STEMI patients ( p , 0.01), but it was higher in non-invasive group compared with invasive treatment group. VA rate was significantly reduced in statin users ( p , 0.05). VA rate was significantly higher in patients with immediately elevated biomarkers ( p , 0.001), with left ventricular disfunction ( p , 0.01), but without differences in left ventricular dimensions. 578 STEMI patients – VT/VF 65 (11.2%), which included SuVT 11 (17%), NsVT 11 (17%), VF 43 (66%), 703 Non-STEMI patients – VT/VF 22 (3%), SuVT 3 (14%), NsVT 6 (27%), VF 13 (59%). In 65 patients VA were fixed according to reperfusion: before – 41 (63%), during the procedure – 89 (12%), just after the procedure – 16 (25%). Mortality in ACS: ACS STEMI without VA (6%), with VA 25% ( p , 0.01), ACS Non-STEMI without VA 5.2%, with VA 27% ( p , 0.01). Conclusions: Incidence of VA remains high in ACS patients, despite the more intensive treatment strategy. Ventricular arrhythmias are often observed in STEMI patients, earlier PCI potentially improve survival in STEMI patients. VA in acute period are significant marker on high mortality risk. Elevated myocardial biomarkers are more informative for earlier prognosis for VA. Use of statins before ACS event may decrease risk of VA
Sudden cardiac death (SCD) is a one of the most explored and challenging problems of cardiology. Measurements of the repolarization duration and its variability have been shown in a few epidemiological studies to be associated with an increased risk of SCD, however they still need further studies to prove the usefulness. The purpose of the study was to assess the usefulness of the repolarization variability in the prediction of the ICD appropriate interventions in the patients with remote myocardial infarction, untreated with amiodarone, with ICD implanted as primary or secondary prevention of SCD. Variability of the early (QTp) and late (TpTe) phases of repolarization were also used. The study population consisted of 114 patients. All clinical data and Holter recordings were collected before ICD implantation, there were no patients treated with amiodarone. Repolarization variability parameters were calculated as the standard deviations of QT, QTp and TpTe uncorrected to the heart rate (QTSD, QTpSD and TpTeSD). Repolarization variability ratio (QTV), measured as a QTSD and SDRR ratio was also used. All were computed from the entire Holter recordings (sinus rhythm, .90% of successive QT intervals suitable for analysis). The study population was followed for at least 2 years. The occurrence of any appropriate ICD delivered therapy was used as the endpoint of the study. Appropriate ICD intervention (ARYT) occurred in 64 patients (62 males, secondary prevention in 51 pts, LVEF: 39 + 12%, age: 66+9 years; ARYTþ), and 50 patients were free of malignant ventricular arrhythmias during the follow-up (46 males, secondary prevention in 24 pts, LVEF: 35 + 8%, age: 63+8 years, ARYT-). ARYTþ patients were older ( p=0.02), with ICD implanted as secondary prevention more often ( p , 0.001). ARYTþ patients had higher QTSD 23.9 + 8.6 vs. 20.1 + 6.7 ms, p=0.018; QTpSD 20.4 + 5.9 vs. 18 + 5.9 ms, p=0.029 and QTV: 0.28 + 0.07 vs. 0.23 + 0.05, p=0.049. TpTeSD was similar in both groups: 11.1 + 3.2 vs. 10.3 + 2.5 ms, p=0.438. Univariate Cox analysis revealed that higher QTSD and QTpSD have been related to the higher risk of ARYT occurrence. QTSD 28 ms was associated with significantly higher risk of ICD intervention: HR=1.94 (1.07-3.51), p=0.034. Indices of repolarization variability (entire and early phase, but not late phase) were found to be a powerful predictors of VT/VF occurrence during the long-term follow-up in patients with remote myocardial infarction, untreated with amiodarone, and with ICD implanted as primary or secondary prevention.
