Objectives: EnSite Omnipolar Technology (OT) was recently introduced on the EnSite X EP system in the Asia Pacific region. This technology enables EGMs to be analyzed in 360 degrees, eliminating artifact introduced by the orientation of a recording bipole relative to the activation wavefront. This analysis sought to evaluate utilization and associated mapping settings for this novel technology.
Materials and Methods: Procedural data were collected in cases performed in the Asia Pacific region utilizing the EnSite X mapping system. Procedural characteristics recorded included indication for mapping and ablation, OT utilization and settings, and navigation mode utilization.
Results: Procedural data were prospectively collected in 448 cases from 37 operators at centers in Japan, Australia, and Hong Kong. Indication for mapping and ablation included AF (81.0%), SVT (11.4%), and VT (7.6%). Overall navigation mode selection was VoXel 62.7% of cases; NavX in 37.3%. Considering only those cases utilizing OT, VoXel mode selected for 90.0%. Utilization rate of OT was higher in complex cases (31.4% SVT; 37.0% PAF; 49.5% PersAF; 73.5% VT). The most commonly utilized OT certainty settings were 0.5 (61.4%) and the nominal setting of 0.3 (30.7%).
Conclusion: The initial experience with OT included utilization across a variety of arrhythmias, trending higher in more complex cases which may suggest that the new clinical functionality introduced by this technology aids in substrate characterization and identification of ablation targets during challenging cases. Future study may focus on the impact that this technology has on long-term outcomes.
PP-002-1-AT Chinese experience with a novel Grid-Style mapping catheter in atrial fibrillation ablation Dr. Xia Sheng1, Dr. Nian Liu2, Dr. Jinxin li3, Dr. Kaijun Cui4, Dr. Wei Wang2, Dr. Kuijun Zhang5, Mr Peter Gora6, Dr. Li Lin7 1Sir Run Run Shaw Hospital Zhejiang University School of Medicine, Hangzhou, China, 2Beijing Anzhen Hospital, Beijing, China, 3Guangdong Province Hospital of Traditional Chinese Medical, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong, China, 4West China Hospital of Sichuan University, Chengdu, China, 5Beijing Royal Integrative Medicine Hospital, Beijing, China, 6Abbott, Minneapolis, USA, 7Tongji Medical College of HUST, Wuhan, ChinaObjectives: To characterize and examine the clinical utilization of a high-density grid-style catheter (HD Grid) in atrial fibrillation (AF) ablation procedures in the Chinese population.
Materials and Methods: Self-reported procedural data were prospectively collected in cases utilizing HD Grid during the initial phases of commercialization in China. Procedural characteristics and workflow were recorded and analyzed.
Results: Procedural data were collected in 335 AF cases from 26 operators at 14 centers in China. Among the 335 cases, only 13 were repeat procedures. The primary indication was paroxysmal (n = 218, 65.1%) and persistent AF (n = 117, 34.9%); conscious sedation/monitored anesthesia care was used in 321 cases (95.8%). The use of a steerable sheath with the HD Grid was documented in 125 cases (37.3%). An average of 10,843 ± 11,203 and 4317 ± 6181 points were collected and used; use of the AutoMap module was documented in 238 (71.0%). Pulmonary vein (PV) isolation lesion delivery was most commonly guided by lesion index (LSI) (n = 317, 94.6%), with target value of 4.5–5.0 (n = 298, 89.0%) for the anterior/roof PV segment and 4.0–4.5 for the posterior/inferior PV segment (n = 247, 73.7%). The average procedure and fluoroscopy times were 153.0 ± 52.1 and 13.5 ± 8.8 min, respectively. No mapping catheter-related serious complication was reported.
Conclusion: While procedural characteristics differed depending on ablation strategy and operator preference, the HD Grid can be used in catheter ablation for both de novo and redo AF procedures in the Chinese population without compromising patient safety or ablation workflow.
PP-003-1-AT Grid-mapping catheters versus Pentaray catheters for left atrial mapping on Ensite precision mapping System on Ensite precision mapping system Dr Soichiro Usumoto1, Dr. Jumpei Saito1 1Showa University Yokohama Northern Hospital, Yokohama, JapanObjective: Areas displaying reduced bipolar voltage are defined as low-voltage areas (LVAs). In this study, we compared grid mapping catheter (GMC) with PentaRay catheter (PC) for LA voltage mapping on Ensite Precision mapping system.
Methods: Twenty-six consecutive patients with LVAs and border zone within the LA were enrolled. After achieving PVI, voltage mapping under high right atrial pacing for 600 ms was performed twice using each catheter type (GMC first, PC next). Furthermore, LVA was defined as a region with a bipolar voltage of <0.50, and border zone was defined as a region with a bipolar voltage of <1.0, or <1.5 mV.
Results: Compared with PC, using GMC, voltage mapping contained more mapping points (20,242[15,859, 26,013] vs. 5589[4088, 7649]; p < 0.0001), and more mapping points per minute (1428[1275, 1803] vs. 558[372, 783]; p < 0.0001). In addition, LVA and border zone size using GMC was significantly less than that reported using PC: <1.0 mV (5.9 cm2 [2.9, 20.2] vs. 13.9 cm2 [6.3, 24.1], p = 0.018) and <1.5 mV voltage cutoff (10.6 cm2 [6.6, 27.2] vs. 21.6 cm2 [12.6, 35.0], p = 0.005).
Conclusion: Bipolar voltage amplitude estimated by GMC was significantly larger than that estimated by PC on Ensite Precision mapping system. GMC may be able to find highly selective identification of LVAs with lower prevalence and smaller LVA and border zone size.
PP-004-1-AT Zero-fluoroscopy ablation of premature ventricular contraction originating from moderator band in a pregnant woman Dr Chea Chin Yung1, Dr Abdul Raqib bin Abdul Ghani1, Dr Halwani Habizal1, Dr Hartini Mohd Yusof1, Dr Sathvinder Singh Gian Singh1, Dr Siow Yoon Kee1, Dr Chee Wei Shen1, Dr Aimaduddin mat Daud1, Dr Abdul Kahar Abdul Ghapar1 1Hospital Serdang, Kajang, MalaysiaObjectives: An increased incidence of premature ventricular contractions (PVCs) is observed during pregnancy and may be a potential trigger for cardiac arrhythmias. (1) We report a case of a pregnant lady who presented with syncopy and moderator band PVCs.
Material and methods: A 29 year-old nurse at 17 weeks of gestation presented to us with an episode of syncopy preceded with sustained palpitations. A 12-lead electrocardiogram was performed which revealed frequent unifocal PVCs of left bundle branch block with negative concordance and leftward superior axis. Subsequent investigations includes a normal brain computed tomography, normal transthoracic echocardiography, PVC burden of 1.5% on 24 h HOLTER and presence of moderator band (MB) on cardiac magnetic resonance imaging. In view of the association of moderator band PVCs with sudden cardiac death, we discussed with the patient for a potentially curative ablative therapy.
Results: The electrophysiology procedure was performed with zero-fluoroscopy, guided by intracardiac echocardiography and three-dimensional electroanatomical mapping system. PVCs of similar morphology were mapped and localized to the lateral and septal insertion site of the MB with earliest activation by 31 ms. Radiofrequency energy was delivered to both sites which resulted in acceleration and termination of the PVCs. Procedure was completed with no complications.
Conclusion: PVCs arising from the MB are uncommon and have been described to be a potential source of VT/VF triggers which may result in sudden cardiac death. (2) Successful ablation may be achieved in a pregnant patient with zero-fluoroscopy approach to ensure safety for both the mother and fetus.
SUPPORTING DOCUMENTS
PP-005-1-AT HD-grid for mapping improvement of right posterolateral accessory pathway Mr Irnizarifka Irnizarifka1, MD, PhD Sunu Budhi Raharjo1, MD, PhD Dicky Armein Hanafy1, MD Dony Yugo Hermanto1, MD Alice Inda Supit1, Prof, MD, PhD Yoga Yuniadi1 1National Cardiovascular Centre Harapan Kita, Jakarta, Indonesia
Background: The right posterolateral (RPL) area is a thought-provoking anatomic zone since its stabilization of mapping catheter became a challenge. Accessory pathways (APs) located in this area pose a relatively difficult task for electrophysiologists, especially in patient with significant tricuspid regurgitation (TR). Despite maneuver with long sheath was already well established, the use of HD-grid believed to add precision of intracardiac AP localization.
Case Illustration: A 39-year-old man with manifest right-sided WPW and palpitation of documented aberrant AVRT was scheduled for conventional ablation. He had history of MV repair and currently has severe TR with decrease RV function. Conventional irrigated radio-frequency-ablation (RFA) catheter mapping with SL-0 long-sheath support was challengingly not be able to get accurate site of the AP. This was not unexpected since severe TR tends to undulate the catheter. Hence, HD-grid catheter was used in order to yield meticulous mapping at RPL. Despite there was no antegrade fused AV EGM, right ventricular apical (RVA) pacing evinced retrograde fused VA at RPL (HD-grid at B1-C1). Delta wave disappeared and VA separated after 5 s of RFA (45°C, 40 W, 120 s) delivered to this area during RVA pacing. After 20 min of evaluation, neither delta wave nor inducible tachyarrhythmia were evidenced.
Conclusion: HD-grid catheter could potentially be a secret armament to aid stabilization and thus get meticulous conventional mapping of RPL AP through its stiff shaft and soft-deflectable grid. To the best of our knowledge, this HD-grid guided conventional mapping technique is the first to be reported.
PP-006-1-AT The effect of catheter ablation of typical atrial flutter on atrial remodelling and ventricular function Ms Lukah Q. Tuan1,2, Ms Adriana Tokich1,2, Ms sienna Wu1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev K Pathak1,2,3 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, AustraliaObjective(s): Cavo-tricuspid isthmus (CTI) dependent atrial flutter (AFL) is one of the most common atrial arrhythmias involving the right atrium (RA). Radiofrequency catheter ablation has been widely used as a curative therapy of choice. Patients with AFL often have dilated RA and reduced function. However, there are limited data on the effect of this intervention on cardiac size and function.
Methods: A prospective study was conducted on 89 patients who underwent CTI dependent ablation for clinical typical AFL at a single institution between 2017and 2021. Echocardiographic data were analysed at baseline prior to ablation, and within 1-year post-ablation follow-up. Follow-up echocardiographic data were available for 75 patients.
Results: Of the 89 patients, 79 had typical counter-clockwise flutter. Other 10 had scar dependent or atypical RA flutter. The mean age was 69.2 ± 8.1 years old with 19% female. The average left ventricular (LV) ejection fraction (EF) significantly improved on follow-up echo (43 ± 11% to 52 ± 2%, p = 0.002). Twenty-one (23%) patients had an increased EF of 20% or more. The prevalence of moderate to severe tricuspid regurgitation (TR) was 18% (n = 16) at baseline and 5% (n = 5) at follow-up with no significant difference (p = 0.047). Echocardiography also showed improvement of RA size in 51% and left atrial (LA) size in 43.2% of the patients.
Conclusions: Patients who underwent CTI dependent AFL ablation showed an improvement in cardiac size and function at 12-month follow-up evaluation. These findings suggest that restoration of sinus rhythm from atrial flutter is associated with improvement in TR severity, RA size, LA size, and LVEF.
PP-007-1-AT Pre-clinical assessment of safety and acute efficacy of Pulsed-Field ablation: PULSE-DOSE Study Dr Suraya Hani Kamsani1, prof Prashanthan Sanders1, Mr Darius Chapman2, Mr Twins Yiu3, Mr Milanjot Assi3, Mr Stephen Walsh3, Mr Ian Fong3, Dr Mehrdad Emami1 1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia, 2Flinders University, Adelaide, Australia, 3CathRx, Rydalmere, AustraliaBackground: Pulsed-field ablation (PFA) is a novel ablative technology that delivers high voltage short duration electrical pulses to induce cell apoptosis. Data on the effect of delivering different electrical pulse parameters in pre-clinical settings are limited.
Objectives: We assessed the safety and acute efficacy of PFA for pulmonary vein isolation (PVI) in healthy swine.
Materials and Methods: A total of 13 swine (weight 37.25 ± 3.73 kg) were evaluated. A prototype bipolar biphasic PFA generator system was designed to allow programming of various squared waved biphasic bipolar PFA parameters to the catheter. Three different voltages were studied: four animals in the 1800 V (low voltage) group, four in the 2300 V (intermediate voltage) group and five in the 2800 V (high voltage) group. Electro-anatomical maps were created with a 3D mapping system and pulmonary venous (PV) potentials were recorded at baseline. These veins were isolated using a variable loop multielectrode PFA catheter. Entrance and exit blocks were evaluated post-ablation. Phrenic nerve viability was assessed after a single PFA application to the superior vena cava/right atrium junction.
Results: Twenty-two of 23 PVs (96%) were successfully isolated in 13 swine, with a mean of 8.3 ± 1.8 applications per vein. The only PV that was not isolated was a superior branch which was ablated with eight applications of 2300 V. None of the animals sustained phrenic nerve injury and no acute procedural complication was noted.
Conclusion: In this preclinical study, PFA appears to be safe and efficacious for PVI across low, intermediate and high voltages.
PP-008-1-AT Cavotricuspid isthmus line ablation in porcine models using Pulsed-Field ablation Dr Suraya Hani Kamsani1, Dr Mehrdad Emami1, Mr Darius Chapman2, Mr Twins Yiu3, Mr Milanjot Assi3, Mr Stephen Walsh3, Mr Ian Fong3, Prof Prashanthan Sanders1 1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia, 2Flinders University, Adelaide, Australia, 3CathRx, Rydalmere, AustraliaBackground: Cavotricuspid isthmus (CTI)-dependent atrial flutter commonly co-exist with atrial fibrillation. Pulsed-field ablation is an emerging ablative modality used in pulmonary vein isolation, however, data in CTI ablation are limited.
Objectives: The aim of this study is to evaluate the feasibility and durability of CTI line ablation using PFA technology.
Materials and Methods: Thirteen healthy swine underwent a CTI line ablation and followed up after 12 weeks. An integrated prototype PFA system was used to deliver biphasic bipolar PFA waveforms of different voltages to a linear catheter. Three different voltages were examined: 1800 V (low), 2300 V (intermediate) and 2800 V (high). Baseline and follow-up data including voltage maps, post-ablation conduction blocks and complications were recorded.
Results: At index procedure, 12 of 13 CTI lines (92.3%) demonstrated bidirectional conduction block with a mean of 8.7 ± 2.1 applications per line. The only CTI line that was not adequately ablated was in the low voltage (1800 V) group with 11 applications. Voltage map revealed the presence of an extensive myocardial sleeve in this animal model. Eleven of 13 swine survived to complete the follow-up procedure. Re-map at 12-week showed bidirectional conduction block in 10 of 11 CTI lines (91%). There was only one CTI reconnection which was previously ablated with the lowest PFA dose (six applications of 1800 V). No PFA-related complication was observed in all the animals.
Conclusion: This study showed that PFA is a promising ablative modality for use in CTI line ablation specifically with intermediate and high voltage deliveries.
PP-008A-1-AT Case report: Step-by-step to start ablation by radiofrequency without fluoroscopy Dr Mam Chandara1 1Calmette Hospital, Phnom Penh, CambodiaExposure to radiation during catheter ablation procedures poses a risk to the heath of both the patient and electrophysiology laboratory staffs. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been reported. However, studies on the outcomes of zero-fluoroscopy ablation in Cambodia remain limited. The beginning to do ablation by radiofrequency without fluoroscopy with the simple case by using electro-anatomic mapping remote support at New World Heart Clinic, Cambodia. A case report of frequent ventricular arrhythmia without structural heart disease at Right Ventricular Outflow Tract was mapped and eliminated by Radiofrequency ablation without using fluoroscopy.
Keywords: Cardiac arrhythmia, Ablation by Radiofrequency, Electro-anatomic mapping Remote, Zero-Fluoroscopy
PP-010-2-AT A single-center experience for catheter ablation of premature ventricular complexes Dr yuen Hoong Phang1, Dr Mohanaray Jayakumar1, Dr Chee Wei Leong1, Dr Ahmad Faiz Mohd Ezanee1, Dr Kai Soon Liew1, Dr Vijayendran Rajalingam1, Dr Kantha Rao Narasamuloo1, Dr Saravanan Krishinan1 1Hospital Sultanah Bahiyah/Ministry Of Health, Alor Setar, MalaysiaObjectives: This study reports the demographics, origin, and success rate of our single-center catheter ablation of premature ventricular complexes (PVCs) using a 3D system.
Materials and Methods: This retrospective study included patients who underwent PVC ablation in Hospital Sultanah Bahiyah from March 2016 to March 2022, evaluating patient demographics, PVC burden, success rate (defined as the resolution of symptoms and PVC from 12 leads ECG), and clinical outcome.
Results: There is a total of 122 PVC ablations were done. There are eight patients with non-inducible PVC and five patients (4%) with intraprocedural complications (highest being pericardial effusion 2.4%). All catheter ablation was successful on the first attempt (80%) except for three patients requiring two procedures and two patients requiring three procedures. There are seven patients (six from RVOT, one from parahisian origin) whose ablation failed on one attempt and turned down a repeat procedure, and one patient (suspected mural origin) who failed despite two attempts. Sixty-seven percent of the cohort are females, with a success rate of 84% (74% in males) and an average age of 49 years old (IQR Q1 36, IQR Q3 58). The average PVC burden is 21%. The most common origin of PVC is RVOT (65%), highest in the posteroseptal region (27%). Notably, the success rate was improved (95.4%) in 2021 and 2022.
Conclusion: RVOT PVC is the most common site of PVC. Catheter ablation for PVC is safe and effective. With increasing experience, we believe that the success rate will improve with a lower complication rate.
PP-011-2-AT Using waveform similarity vector field to visualize the activation wave propagation in persistent atrial fibrillation Mr Chia-Hsin Chiang1, Ms Yun-Yu Chen1, Prof Yenn-Jiang Lin1, Dr Ming-Jen Kuo1, Prof Men-Tzung Lo2, Prof Chen Lin2, Dr Fa-Po Chung1, Prof Shih-Ann Chen3 1Taipei Veterans General Hospital, Taipei City, Taiwan, 2National Central University, Taoyuan City, Taiwan, 3Taichung Veterans General Hospital, Taichung City, TaiwanBackground: Atrial fibrillation's dynamical characteristics have been quantified/described through many measurements. Most algorithms, however, only record the momentary activity of regional regions, and it is not clear how complex waves propagate within patients' atriums.
Objective: The purpose of this study is to propose a vector field method to display the overall propagation activities. AF drivers are identified by ensembling the atrium's asynchronous mapping sets.
Materials and Methods: We applied a cellular automaton technique to simulate the electrical wave propagation of the meandering rotor (5000 ms) and used a simulated 20-electrode high-density catheter, Pentaray, to record the EGMs (1000 ms). The EGMs of each asynchronous mapping set was analyzed with the waveform similarity vector field (WSVF) algorithm. The vector in each grid of WSVF maps was derived from the addition of SI vectors of the four adjacent electrodes. By comparing the waveform morphology of local activation waves, SI vectors for bipolar pairs were estimated.
Results: In the computer simulation, waveform propagation patterns in WSVF map were identified within the region with maximal rotational force and divergence force. The size and average vector force of the critical areas detected by the asynchronous WSVF map showed significant contrast between the center and periphery rotors (p < 0.001).
Conclusion: Our results from the WSVF mapping indicated that waveform propagation was consistent in the stable region, which could be used to identify the drivers during AF. WSVF maps reconstructed from the high-density asynchronous mapping were feasible for rotor detection.
SUPPORTING DOCUMENTS
PP-012-2-AT Idiopathic posterior fascicle left ventricular tachycardia: A CASE report Dr Michael Jonatan1, Dr Budi Baktijasa Dharmadjati1, Dr Rerdin Julario1, Dr Muhammad Rafdi Amadis1, Dr Parama Gandi1, Dr Tita Rif'atul Mahmudah1 1Department Of Cardiology And Vascular Medicine, Faculty Of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, Indonesia
Objectives: Idiopathic left ventricular tachycardia (ILVT) is one of the idiopathic ventricular tachycardia (VT) manifestations, with right bundle branch block and left axis deviation electrocardiogram morphology. The mechanism of ILVT is thought to be due to the localized closed reentry in the posterior fascicle.
Materials and Methods: We present an ILVT case of a 15-year-old man with complaints of palpitations while running.
Results: A 15-year-old man was admitted to the emergency department with complaints of palpitations while running. The ECG showed a feature suggestive of ILVT. Vagal maneuvers, adenosine, and intravenous metoprolol were ineffective in terminating the arrhythmia. Conversion of heart rhythm to sinus was achieved after intravenous administration of verapamil. Electrophysiological studies with entrainment demonstrated a macro-reentry mechanism in the posterior fasciculus when a multipolar ablation catheter was placed at the apex of the LV septum, with the orthodromic appearance of Purkinje potential P1 and retrograde diastolic potential P2. Radiofrequency ablation was targeted at the position where PP1 appeared earliest. In addition, there was also a 52 ms Atrial-His bundle (AH) jump, which indicated the presence of Dual AV Node Physiology. Ablation was performed on the apical third of the septum, shifting toward the basal site until successful ablation was achieved to avoid accidental injury to the left bundle branch or His bundles. Successful ablation was indicated by the inability to induce VT.
Conclusion: The first-line treatment for ILVT is the radiofrequency ablation that targets the P1 or early P2 potential to eliminate this type of VT.
SUPPORTING DOCUMENTS
PP-013-2-AT Sex differences in predictors of recurrence after catheter ablation in patients with persistent atrial fibrillation Dr Dongseon Kang1, Dr Daehoon Kim1, Dr Je-Wook Park1, Dr Hee Tae Yu1, Dr Tae-Hoon Kim1, Dr Boyoung Joung1, Dr Moon-Hyoung Lee1, Dr Hui-Nam Pak1 1Yonsei University College Of Medicine, South Korea
Background: Atrial fibrillation (AF) is a progressive disease, and patients with persistent AF (PeAF) have consistent long-term recurrences after AF catheter ablation (AFCA). We explored the possible sex-related differences in the recurrence predictors in patients with PeAF who had a recurrence within 3 years after AFCA.
Methods: Among 3985 consecutive patients who underwent a de novo AFCA and protocol-based rhythm follow-up, we evaluated the predictors of an AF clinical recurrence within 3 years (CR-3yr) of the AFCA in 1387 patients with PeAF (men: 78.4%, 59.5 ± 10.5 years old), in relation to the sex of the patients.
Results: The left atrial (LA) dimension (hazard ratio [HR] 1.04 [1.02–1.06], p = 0.001) and LA voltage (HR 0.71 [0.58–0.87], p = 0.001) were independently associated with a CR-3yr of the AFCA of PeAF. Among 1088 men, the LA dimension (HR 1.04 [1.01–1.07], p = 0.006), an epicardial adipose tissue (EAT) volume ± the median (HR 1.37 [1.04–1.80], p = 0.025), and LA voltage (HR 0.64 [0.51–0.80], p < 0.001) were independent predictors of a CR-3yr. In 299 women, diabetes was independently associated with a CR-3yr (HR 0.48 [0.25–0.93], p = 0.03). There were significant interactions between the sex and effects of the age (p for interaction = 0.042) and EAT (p for interaction = 0.022) on the CR-3yr. In contrast, there were no significant sex differences in the CR-3yr risk factors in patients with paroxysmal AF.
Conclusions: A large EAT volume was associated with a higher CR-3yr, especially in males after PeAF ablation. The absence of diabetes in women was independently associated with AF recurrence after PeAF ablation.
SUPPORTING DOCUMENTS
PP-014-2-AT Acute results from the persistent atrial fibrillation Asia Pacific observational study Dr Pipin Kojodjojo1, Dr Gi-Byoung Nam2, Dr Yung-Lung Chen3, Dr Chin Pang Chan4, Dr Thoranis Chantrarat5, Dr Li-Wei Lo6, Dr Hui Nam Pak7, Dr Chi Keong Ching8, Dr Sang-Weon Park9 1National University Hospital, Singapore, 2Asan Medical Centre, Seoul, South Korea, 3Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan, 4Prince of Wales Hospital, Hong Kong, China, 5Phramongkutklao Hospital, Bangkok, Thailand, 6Taipei Veterans General Hospital (VGH), Taiepi City, Taiwan, 7Severance Hospital, Yonsei University Health System, Seoul, South Korea, 8National Heart Centre Singapore, 9Sejong Hospital, Sejong City, South Korea
Objective: The persistent atrial fibrillation (PerAF) Asia Pacific (APAC) observational study aimed to collect safety and effectiveness data for the TactiCath™ Contact Force Ablation Catheter, Sensor Enabled™ (TactiCath SE) in subjects with PerAF in the Asian population.
Materials and Methods: The PerAF APAC study (NCT04244396) investigated the TactiCath SE catheter for the treatment of PerAF in Asian subjects. Acute data are reported on regarding procedure characteristics, procedural success, and safety. This is an ongoing study collecting data 15 months post-procedure.
Results: Eighty-one PerAF subjects were enrolled at nine APAC centers (mean age 61 years; 74.1% male). All subjects had pulmonary veins (PV) ablated with wide area circumferential ablation (WACA) alone (67.9%), WACA with lines (24.7%), or individual PV isolation (6.2%) strategies. Non-PV targets were ablated in a majority of subjects (76.5%; 62/81), mostly to treat typical atrial flutter (62.9%, 39/62). The average procedure time was 204 ± 66.2 min (first venous puncture to groin sheath pulled or patient left the laboratory) with an average PV radiofrequency (RF) time of 40.8 ± 23.6 min and non-PV RF time of 15.2 ± 13.0 min. 98.8% (80/81) subjects reported successful PVI and 92.6% (75/81) used entrance block to verify isolation. 3.7% (3/81) of subjects experienced a primary safety event (two cardiac tamponade/perforation, one stroke) related to the procedure and/or study device within 7 days of the procedure.
Conclusion: In conclusion, these data demonstrate continued safety and acute efficacy of the TactiCath SE catheter when used to treat PerAF in the APAC patient population.
PP-015A-V-AT Ablation adjacent to the gaps between low-power long-duration and high-power short-duration during pulmonary vein isolation Dr Shih-Huei Liu1, Dr. Fa-Po Chung1, Dr. Yenn-Jiang Lin1, Dr. Li-Wei Lo1, Dr. Shih-Lin Chang1, Dr. Yu-Feng Hu1, Dr. Shih-Ann Chen1 1Heart Rhythm Center & Department of Cardiology, Taipei Veterans General Hospital, Taipei City, TaiwanObjectives: We aimed to investigate gap lesions under different RFA settings and identify the predictor values for gap formation.
Materials and Methods: AF patients who received RFA under lower-power long-duration (LPLD) (power control <45 W) or HPSD (power control ≥45 W) settings were analyzed. Ablation lesion data were collected by the CARTO version 7 system (Biosense Webster, Inc). The parameters of lesions adjacent to the gaps were collected and compared to those of the remaining lesions. Gap lesions under different energy settings were investigated.
Results: In total, 52 AF patients (35 men, mean age 63.71 ± 10.82 years; 31 PAF and 21 PeAF) received RFA under LPLD (N = 12) or HPSD (N = 40) settings were analyzed. The incidence of gap lesions was similar between the LPLD and HPSD patients (1.81 ± 0.93 vs. 2.41 ± 0.80, p = 0.35). In total, 144 gap lesions were identified. The gap lesions either at the anterior or posterior LA wall had a significantly lower impedance drop than successful lesions (Tables 1 and 2), and the above findings were consistent in LPLD and HPSD. There were no significant differences in impedance drop between gap lesions between LPLD and HPSD (Table 3). After multivariable analysis, impedance drop was the only predictor of gap formation during HPSD ablation.
Conclusion: Despite the different lesion characteristics between LPLD and HPSD, the lesions adjacent to the gap were similar. Moreover, irrespective of energy setting, the impedance drop serves as the most important parameter to predict gap formation.
SUPPORTING DOCUMENTS
PP-015-V-AT Pulmonary vein isolation using left atrial 3D images created with a new CARTOSOUND® fam module Dr Tatsuhisa Ozaki1, Dr Koichi Inoue1, Dr Tsuyoshi Mishima1, Dr Takuya Ohashi1, Dr Masayuki Nakamura1, Dr Jynpei Kosugi1, Dr Kuniyasu Ikeoka1, Dr Haruhiko Abe1, Dr Yasunori Ueda1 1Osaka National Hospital, Osaka-City, Japan
Objective: Fast anatomical mapping (FAM), which is a module that creates geometry from trajectories of catheters, is one of the methods to obtain three-dimensional anatomical information of the left atrium (LA) and pulmonary veins (PV) during catheter ablation for atrial fibrillation using the CARTO® system. CARTOSOUND® FAM, a new method to create three-dimensional geometry of the LA and PV based on intracardiac echo images, is under development and is being validated at our institution.
Materials and Methods: Before PV isolation, two-dimensional images of the LA and PV were obtained by SOUNDSATR® catheter from the right atrium and right ventricular outflow tract. Using these images, the CARTOSOUND® FAM module automatically created contours and constructed a three-dimensional geometry of the LA and PV.
Result: A geometry of the LA and PV was successfully created (Figure). We performed CARTOMERGE® between the geometries of the LA and PV created by the CARTOSOUND® FAM and cardiac CT. PVs were successfully isolated based on the images of the CARTOMERGE® using CARTOSOUND® FAM without any complications.
Conclusion: We report a case in which PV isolation was performed using 3D images created by the CARTOSOUND® FAM system. Although some improvements may be required, it can be a promising option to create geometries of the LA and PV for PVI in the future.
SUPPORTING DOCUMENTS
PP-016-V-AT The effectiveness and safety of lesion size index-guided Cavotricuspid isthmus linear ablation Dr. Yusuke Murayama1, Dr. Jun Kishihara1, Dr. Hidehira Fukaya1, Dr. Daiki Saito1, Dr. Gen Matsuura1, Dr. Hironori Nakamura1, Dr. Naruya Ishizue1, Dr. Jun Oikawa1, Dr. Shinichi Niwano1, Dr. Junya Ako1 1Kitasato University School of Medicine, Sagamihara, Japan
Objective: The lesion size index (LSI) predicts radiofrequency (RF) ablation lesion size and is an established parameter for pulmonary vein isolation. However, the effectiveness and safety of LSI for cavotricuspid isthmus (CTI) linear ablation remain unclear. We investigated the efficacy and safety of LSI-guided CTI linear ablation.
Materials and Methods: This single-center retrospective study included 50 patients (67 ± 10 years, 68% male) who underwent de novo CTI linear ablation between July 2020 and December 2020. The LSI target was set at 5.0 and 4.0 for the anterior ⅔ and posterior ⅓ segments, respectively. Acute procedural parameters of ablation were evaluated.
Results: Acute bidirectional CTI block was achieved in all patients with an RF application time of 4.0 min [3.1–5.0 min], RF application number of 15 ± 7, and length of CTI of 36.9 ± 9.3 mm. First-pass bidirectional conduction block of the CTI was achieved in 39/50 (78%) patients. No major complications were observed during or after the procedure. The contact force (CF) per application was significantly lower in the gap tag group than in the no-gap tag group (7 g [7–8 g] vs. 10 g [7–12 g], p = 0.0284).
Conclusion: LSI-guided CTI linear ablation is an effective and safe treatment approach. CF affects gap formation, even when the target LSI is the same.
SUPPORTING DOCUMENTS
PP-017-V-AT Assessment of optimal thresholds for ventricular scar substrate characterization Dr Fatima Bangash1, Mr Jason Collinson1, Dr Jason Dungu1, Dr Swamy Gedela1, Dr Mark Westwood2, Dr Charlotte Manisty2, Dr David Farwell1, Dr Henry Savage1, Dr Konstantinos Vlachos3, Dr John Silberbauer4, Dr Justo Calvo5, Dr Ross Hunter2, professor Richard Schilling2, Dr Neil Srinivasan1 1Essex Cardiothoracic Centre, Basildon, UK, 2Barts Heart Centre, London, UK, 3Onassis Cardiac Surgery Center, Athens, Athens, Greece, 4Sussex Cardiac Centre, Brighton, Brighton, UK, 5Brighton & Sussex University Hospitals N H S Trust, Brighton, UK
Objectives: We aimed to assess the optimal voltage cut-offs for ventricular scar substrate characterization using the HD Grid multipolar mapping catheter compared to standard linear collection.
Methods: A multicentre study of 30 patients undergoing VT ablation was conducted. Substrate mapping was performed using the high-density HD-grid multipolar mapping catheter. Pre-procedure contrast-enhanced imaging data were analysed using ADAS software (Galgo medical). Data points were collected in regions of scar during (1) HD wave mapping with best duplicate algorithm on (Waveon), (2) Mapping with HD wave off and best duplicate on (Waveoff) and (3) with conventional bipolar mapping (Alloff).
Results: The median bipolar voltage for regions of dense CMR scar using (Waveon) HD wave solution and best duplicate algorithm was 0.27 mV (IQR 0.14–0.46). The median voltage with (Waveoff) HD wave off was 0.29 mV (0.15–0.45). The median voltage with (Alloff) HD wave off and best duplicate off was 0.32 mV (0.19–0.5). ROC analysis using AUC suggested the optimal cut-off for endocardial dense scar using (Waveon) HD wave mapping and best duplicate algorithm was 0.30 mV (sensitivity: 69.6%, specificity: 60.74%), (Waveoff) cut-off with the best duplicate and without the HD wave mapping was 0.34 mV (sensitivity: 69.78%, specificity: 64.46%) and (Alloff) without wave mapping or best duplication was 0.36 mV (sensitivity: 84%, specificity: 52%).
Conclusion: Ventricular substrate characterization with newer mapping technology using narrow electrode spacing and smaller electrode size suggests that traditional voltage cut-offs may need revision for delineation of scar characteristics.
SUPPORTING DOCUMENTS
PP-018-1-AF Atrial substrate mapping in atrial fibrillation ablation with Omnipolar technology Professor José Luis Merino1, Doctor Sergio Castrejon1, Doctor Marcel Martínez-Cossiani1, Doctor Leonardo Ciulli1, Doctor Michela Casella2, Doctor Quintino Parisi2, Doctor Laura Cipolletta2, Proffesor Antonio Dello Russo2 1La Paz University Hospital, Madrid, Spain, 2Ospedale Riuniti Torrette, Ancona, Italy
Objective: Left atrial (LA) mapping is a critical component of atrial fibrillation catheter ablation (AF-CA), but carries some limitations, including the sensitivity of signal amplitude to conduction direction. The HDGrid mapping catheter allowed introduction of Omnipolar Technology (OT) which provides information on voltage, conduction velocity, and activation direction, irrespective of catheter orientation. The aim is to assess the feasibility and reliability of OT maps of the LA as compared to bipolar LA maps, among patients undergoing AF-CA for substrate characterization.
Methods: We included 34 patients mean age 63.5 ± 7.5 years, undergoing for paroxysmal AF-CA with prospective (n = 9) and retrospective (n = 25) evaluation; the LA was mapped with HDGrid. Low-voltage areas (LVA; region with voltage values <0.5 mV) were compared between OT maps and bipolar maps. Continuous variables were checked for normality with Shapiro–Wilk test, and statistical comparisons were made with paired t or Wilcoxon matched paired tests.
Results: The mean procedural times measured 253.5 ± 21.5 min. OT mapping acquired a significantly greater number of points than bipolar mapping (OT: 10258 (20,194 ± 7452); bipolar: 7592 (13,531 ± 4640); mean difference 2666, p = 0.000002). LVAs were significantly smaller with OT than with bipolar mapping (OT: 53,795 (110.84 ± 30.9) cm2; bipolar: 57,269 (119.61 ± 34.2) cm2; mean difference 3474 cm2, p = 0.000009).
Conclusion: OT allows rapid acquisition of greater number of points during AF-CA as compared to standard bipolar, and better delineation of areas of clinical interest. The smaller LVAs may indicate that substrate characterization was significantly improved using OT, and may have application in persistent AF substrate characterization.
PP-019-1-AF Renal outcomes in Asian patients with NVAF receiving rivaroxaban versus warfarin: A Nationwide cohort study Dr So-Ryoung Lee1, Prof Eue-Keun Choi2, Dr Sang-Hyun Park3, Dr Hyung-Do Han4, Dr Seil Oh2, Mr Khaled Abdelgawwaad6, Prof Gregory Lip5 1Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea, 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea, 3Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea, 4Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea, 5Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Seoul, Republic of Korea, 6Bayer AG, Berlin, Germany, 7Department of Clinical Medicine, Aalborg University, Aalborg, DenmarkObjectives: We aimed to determine the effect of rivaroxaban versus warfarin on adverse renal outcomes in Asian patients with NVAF.
Materials and Methods: Patients with NVAF who initiated warfarin or rivaroxaban between 1 January 2014 and 31 December 2017 were identified using Korean nationwide claims data, partly linked to laboratory results. Baseline characteristics of the two groups were balanced using IPTW. The primary outcome was incident ESRD, defined as the need for maintenance dialysis or kidney transplantation. Exploratory outcomes were eGFR <15 ml/min/1.73 m2 at follow-up, starting dialysis or undergoing kidney transplantation, ≥30% decline in eGFR, doubling of serum creatinine level, AKI, or a composite of the five outcomes. The groups were compared using Cox proportional hazards regression.
Results: 30,933 warfarin and 17,013 rivaroxaban users were identified (51% received rivaroxaban 15 mg once daily). The mean age was 70 years and the mean CHA2DS2-VASc score was 3.9 in both groups. During a median follow-up of 0.93 years (IQR 0.23–2.10), weighted incidence rates of ESRD for warfarin and rivaroxaban were 0.83 and 0.32 per 100 person-years, respectively. Rivaroxaban was associated with a lower risk of ESRD versus warfarin (HR 0.398, 95% CI 0.300–0.499, p < 0.001), which was consistent in patients with pre-existing CKD or eGFR ≤60 ml/min/1.73 m2. Rivaroxaban demonstrated a lower risk of the composite of the five exploratory renal outcomes versus warfarin (HR 0.798, 95% CI 0.713–0.892, p < 0.001).
Conclusion: Rivaroxaban was associated with lower risks of adverse renal outcomes versus warfarin in Korean patients with NVAF.
PP-020-1-AF The Association of age and sex with TTR in atrial fibrillation patient on warfarin Dr Angga Pramudita1, Dr Muhammad Yamin1, Dr Simon Salim1, Dr Rubiana Sukardi2, Dr Friska Anggraini Helena Silitonga1, Mrs Catur Wulanningsari2, Mr Rohmad Widiyanto2 1Division Of Cardiology, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Indonesia, 2Integrated Cardiac Centre—Cipto Mangunkusumo Hospital, IndonesiaObjectives: To assess association of age and sex with Time in Therapeutic Range (TTR) in patients treated with warfarin for atrial fibrillation in a tertiary hospital in Indonesia.
Materials and Methods: We randomly picked 70 patients with atrial fibrillation on warfarin to see their TTR. TTR was calculated from the last 10 INR value of each patient. Age, sex and comorbidities were then noted as these factors had been identified before to play role in SAMe-TTR score (1).
Results: Overall, only 5.71% patients have good TTR, all of which were between 61 and 70 years old. Age < 60 yo (p = 0.724), female sex (p = 0.436), hypertension (p = 0.095), vascular disease (p = 0.593), and LV dysfunction (p = 0.600) did not associate with poor TTR. Interestingly, our diabetes patients tend to have less poor TTR (33.3%) compared to non-diabetes (61.8%) (p = 0.049).
Conclusion: Age and sex did not associate with poor TTR in our patients. Whereas those with diabetes associate with better TTR, this might partly due to their discipline in dietary habits and taking medicine.
SUPPORTING DOCUMENTSREFERENCE
- Apostolakis S, Sullivan RM, Olshansky B, Lip GYH. Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: The SAMe-TT2 R2 score. Chest. 2013;144(5):1555–63.
TABLE 1 Crosstabulation of Characteristics and TTR
FIGURE 3 Comorbidities and TTR Distribution.
PP-021-1-AF Gender differences in the use of Oral anticoagulants in patients with atrial fibrillation Dr Jo-nan Liao1 1Taipei Veterans General Hospital, Taipei, TaiwanObjective: It is not known how sex affects the use of oral anticoagulants (OAC) and prognosis.
Materials and Methods: From year 2012 to 2016, 141,941 patients with AF were identified from a nationwide cohort, and 34,206 patients taking OAC constituted our study population. The end points include death, ischemic stroke, ICH, major bleeding, and composite adverse events.
Results: Female AF patients were older, had higher CHA2DS2-VASc and HAS-BLED scores. The CHA2DS2-VASc score of female patients remained higher than male patients after excluding the point of gender. NOAC use was more common in females while there were no significant differences regarding warfarin use between genders. There were no significant differences of characteristics of NOAC users between sexes compared to warfarin users. NOACs were associated with lower risks of all end points compared to warfarin in both sexes. The benefit of NOACs in reducing risks of mortality, ischemic stroke, and composite adverse events was more prominent in females than in males. Meanwhile, NOACs related risk reduction of ICH and major bleeding was more obvious in males. (death: aHR 0.826 for male, 0.791 for female; ischemic stroke: aHR 0.729 in males, 0.676 in females; ICH: aHR 0.0577 for males, 0.592 for females; major bleeding: aHR0.727 for males, 0.685 for females; composite adverse events: aHR 0.771 for males, 0.755 for females; all interaction p < 0.001).
Conclusion: OAC was associated with a lower risk of clinical end points than warfarin, but the benefit of risk reduction regarding different end points varied between males and females.
SUPPORTING DOCUMENTS
PP-022-1-AF Impact of atrial fibrillation on prognosis in AMI with reduced, mildly reduced, or preserved LVEF Dr Kyeong Seok Oh1, A/Prof Min Kim1, Dr Sangshin Park1, Assoc Prof Dae-Hwan Bae1, Assoc Prof Dae In Lee1 1Chungbuk National University Hospital, Cheongju, South Korea
Objectives: We aimed to compare the all-cause mortality rate and mode of death in acute myocardial infarction (AMI) patients with atrial fibrillation (AF) and in those without AF according to the left ventricular ejection fraction (LVEF) subtype.
Materials and Methods: Among 13,104 AMI patients from the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) registry, 12,166 male patients surviving during hospitalization (age 64 ± 13, 74%) were classified by the LVEF subtype (Group 1, LVEF <40%; Group 2, LVEF 40%–50%; Group 3, LVEF ≥50%). We investigated the adverse impact of AF on all-cause, cardiac, and non-cardiac mortality rate for 2-year follow-up period in patients with AMI.
Results: The crude all-cause and cardiac mortality rates were significantly higher in AF patients than in non-AF patients across all LVEF subtypes. The adjusted risk of AF for the all-cause and cardiac mortality rates was significantly higher in patients with LVEF ≥40% than in those with LVEF <40% (hazard ratio for all-cause mortality: 1.03 (95% CI 0.72–1.47, p = 0.86) in group I; 1.54 (95% CI 1.06–2.22, p = 0.02) in group II; 1.61 (95% CI 1.10–2.37, p = 0.02) in group III, hazard ratio of cardiac mortality: 1.06 (95% CI 0.69–1.62, p = 0.79) in group I; 2.11 (95% CI 1.35–3.28, p = 0.001) in group II; and 2.55 (95% CI 1.61–4.02, p < 0.001) in group III). AF did not impact non-cardiac mortality rates in all subtypes of LVEF.
Conclusion: AF complicating AMI was associated with increased all-cause and cardiac mortality in patients with LVEF ≥40%, but not with non-cardiac mortality, in all LVEF subtypes.
PP-023-1-AF Association between SGLT-2 inhibitors and risk of AF in type 2 diabetes: Nationwide cohort study Dr Sangshin Park1, Dr Kyeong Seok Oh1, Assoc Prof Dae In Lee1, Assoc Prof Dae-Hwan Bae1, A/Prof Min Kim1 1Chungbuk National University Hospital, Cheongju, South KoreaObjectives: Accumulating evidence shows that sodium-glucose co-transporter-2 (SGLT-2) inhibitors reduce cardiovascular outcomes. However, this favorable effect is unclear for newly atrial fibrillation development compared to other anti-diabetic drugs. We investigated the association of SGLT-2 inhibitor for newly AF development compared to dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes.
Materials and Methods: Using the Korean National Health Insurance Service database, among 2,160,911 type 2 diabetes patients between 1 May 2016 and 31 December 2018, we studied 44,557 patients with SGLT-2 inhibitors and 470,358 patients with DPP-4 inhibitors. Propensity score-matching was used to correct for differences between the groups.
Results: During a median follow-up of 1.3 years, compared with patients with DPP-4 inhibitors, patients with SGLT-2 inhibitors have not shown lower incidence and risk of AF (2.7 and 3.3 per 1000 person-years; hazard ratio 0.79, 95% confidence interval 0.62–1.01; p = 0.058) in overall treatment analysis. In intention-to-treat analysis, these results were consistent (3.4 and 3.9 per 1000 person-years; hazard ratio 0.87, 95% confidence interval 0.72–1.05; p = 0.149). In subgroup analysis, SGLT-2 inhibitors were associated with lower risks of AF in female compared to male patients.
Conclusion: In this nationwide cohort of type 2 diabetes patients treated with SGLT-2 inhibitors or DPP-4 inhibitors, SGLT-2 inhibitors were not associated with protection against newly AF development except for female patients after adjusting for clinical confounders.
PP-024-1-AF A case of reentrant atrial tachycardia associated with epicardial Intercaval bundle Dr Kazumasa Adachi1, Dr Takeshi Matsuura3, Dr Yasutaka Hirayama2, Dr Shinichi Tasaka1, Dr Hitoshi Inanami1, Dr Tomoyuki Takemoto1, Dr Takashi Muro1 1Midori Hospital, Kobe, Japan, 2Akashi Medical Center, Akashi, Japan, 3Itami City Hospital, Itami, JapanIntroduction: The anterior wall area of the right pulmonary vein is connected to the posterior wall of the right atrium with a complex intercaval bundles (IBs) on the epicardial side. It has been reported that this region may be involved in proarrhythmia. A 72-year-old female was referred to our hospital for shortness of breath during exertion in June 2018. She had a persistent atrial fibrillation. The first ablation (extensive encircling pulmonary vein isolation and posterior wall isolation) was performed in February 2019. After that, persistent atrial tachycardia recurred, and second session was performed.
Method: The 4PV isolation and roof-line in the previous session were completed. When the left and right atrium were mapped by HDGC, the earliest excitatory site of AT showed a centrifugal pattern in the anterior lower part of RIPV. The PPI was consistent at the same site, but the tachycardia circuit drawn with 3D mapping system did not satisfy the tachycardia cycle length. Since the area of early activation site was relatively wide, the epicardial side may be involved. And the circuit is estimated by considering the IB, it was suggested that reentrant tachycardia circuit may occur due to epicardial bridge conduction.
Result: Ablation was successful by cauterizing the endocardial side of the left atrial septal attachment site of IB.
Conclusion: In recent years, a ridge-related AT involving the epicardial Marshall bundle in the left pulmonary vein region has been reported. This case may be a right ridge-related AT involving the epicardial IB in the right pulmonary vein region.
PP-025-1-AF Epicardial connections after a conventional pulmonary vein antrum isolation in patients with atrial fibrillation Mr Eiji Nyuta1, Dr Masao Takemoto1, Mr Togo Sakai1, Dr Yoshibumi Antoku1, Dr Shintaro Umemoto1, Dr Masaki Fujiwara1, Ms Kaoru Takegami1, Dr Tomohiro Takiguchi1, Mrs Miyuki Nakahara1, Dr Tokushi Koga1, Dr Takuya Tsuchihashi1 1Steel Memorial Yawata Hospital, Kitakyushu City, JapanObjectives: The existence of epicardial connection(s) (ECs) between the pulmonary veins (PVs) and atrium may hinder establishing a complete PV antrum isolation (AI) (PVAI) in patients with atrial fibrillation (AF). Thus, the purpose of this study was to determine the incidence and location of ECs inside the conventional PVAI lines.
Materials and Methods: Three hundred consecutive patients with non-valvular AF were evaluated. The ECs were defined as the existence of RPs (remaining potentials), which were located at a distance exceeding at least 5 mm from complete conventional PVAI lines.
Results: This study revealed that (1) the prevalence of patients with ECs and number of ECs per patient between the PVs and atrium became significantly greater, respectively, in accordance with the progression of paroxysmal to long-lasting AF and left atrial enlargement, (2) some ECs were located at sites far distal to the PVAI lines, (3) 25% of ECs could be detected only by high-density mapping catheters, but not by conventional circular mapping catheters, (4) a BNP level of 176.6 pg/ml and LAV of 129.0 ml may be important predictors of the presence of ECs, and (5) the rate of conduction of ECs from the right PVs was dominantly to the atrium and His-bundle, and that from the left PVs to the coronary sinus was most dominant.
Conclusion: The PVAI may not be completed by only a conventional PVAI, and additional EC ablation inside the PVAI lines detected using high-density mapping may be able to achieve a more complete PVAI.
PP-026-1-AF Effect of heart rate control on clinical course of non-ischaemic cardiomyopathy with atrial fibrillation Dr Kwai-Kuen Irene Chung1 1TTSH, SingaporeBackground: The optimal rate control strategy in patients with AF and heart failure (HF) remains unknown.
Methods: Four hundred and forty-seven patients with heart failure and reduced left ventricular ejection fraction (LVEF <40%) due to non-ischemic cardiomyopathy (NICMP), with mean LVEF at follow-up were categorized into two groups, improved LVEF ≥40% (group 1) or LVEF remain <40% (group 2).
Continuous variables were compared by Student's t tests and categorical variables compared by use of the Fisher exact test. Composite endpoints include ventricular arrhythmias (VA), cardiovascular death (CVD), death and hospitalizations for heart failure. Statistical significant difference was denoted as p < 0.05.
Results: One hundred and seventy-two patients with AF. Mean age and LVEF of AF versus sinus rhythm patients were 69.64 ± 11.67 years versus 58.99 ± 14.11 years and 25.78 ± 8.60% versus 21.19 ± 8.00% respectively (p = 0.001). Patients with diabetes mellitus 33%, hypertension 84%. Patients taking ivabradine 10%, b-blocker 91%, Angiotensin inhibitors/Angiotensin Receptor Blocker 71%, Sacubitrial/Valsartan 19%, spironolactone 42%, SGLT-2 inhibitor 5%.
Mean follow-up duration of 6.18 ± 4.16 years. Forty-nine per cent patients LVEF improved to >40%. The mean LVEF of group 1 and 2 was 50.07 ± 7.30% and 26.45 ± 8.80% respectively (p < 0.001). The heart rate was 72.09 ± 13.19 and 82.04 ± 20.44 beats/min respectively (p < 0.001). Group 2 have significantly higher CVD (p = 0.03), death (p = 0.017), VA (p = 0.012), hospitalizations for heart failure (p < 0.001) and composite endpoints (p < 0.001).
Conclusions: This study suggests more optimal heart rate control in patients with NICMP and AF improve clinical endpoints.
PP-027-1-AF Arrhythmic risks post-acute myocardial infarction (MI) in the modern era Dr Kwai-Kuen Irene Chung1 1Ttsh, SingaporeCurrent data on arrhythmic risks after acute MI in the modern era of early revascularization in the Asian population are limited.
Objective: To investigate the incidence of arrhythmias after acute ST elevation MI in a contemporary cohort of Chinese patients in the era of early revascularization.
Method: Three hundred and ninety-four patients admitted with ST elevation MI who under emergency revascularization, 88% male, mean age of men and women 68.07 ± 13.13 and 58.66 ± 12.42 respectively, mean follow-up of 577 ± 118 days. Pain to needle time (onset of chest pain to primary angioplasty) 4.88 ± 4.60 h. One hundred and thirty patients had left ventricular ejection fraction (LVEF) ≤35%, mean LVEF 29.74 ± 5.95% improved to 39.85 ± 10.13% (p < 0.001) after 6 months.
Results: Twelve deaths, eight non-arrhythmic cause, one cardiac arrest due to ventricular fibrillation and three of unknown cause. Risk of arrhythmic death/death of unknown cause and atrial fibrillation is 0.64% versus 2.4% per year respectively. Fourteen patients developed atrial fibrillation, 11 and 3 in men and women respectively (p = 0.433). Seven occurred at day 1, 5 at day 2 and 2 at day 3 post-MI.
Conclusion: The arrhythmic risks after acute myocardial infarction in the modern era of early revascularization in the Asian population is lower than previously reported. AF is the commonest arrhythmia and 86% occurred within 48 h post-MI may be due to ischaemia and inflammation. Women presented 10 years later than men and there is no significant difference in the incidence of AF.
PP-028-1-AF An Unusual treatment to reduce atrial fibrillation burden Dr Kwai-Kuen Irene Chung1 1Ttsh, SingaporeA 94-year-old woman diagnosed with paroxysmal atrial fibrillation (AF), diabetic mellitus, chronic kidney disease, hypertension, giant cell arteritis (GCA) and hypothyroidism was presented with 1 day history of chest pain and palpitation. Her ECG showed AF with ventricular rate of 130 bpm. She went to sinus pause of 8 s probably due to high vagal tone during passing motions and subsequently underwent dual chamber pacemaker (PPM) implantation. She was readmitted 3 days post-PPM implant with palpitation and fever 37.9°C. ECG showed AF with ventricular rate 126 bpm. This was complicated by acute decompensated heart failure requiring intravenous diuretic. Her AF was incessant despite IV amiodarone and b-blocker. Extensive infectious workup was negative and there was no sign of inflammation at her PPM site. CRP was elevated 65 mg/L and continued to increase despite escalation of antibiotic but procalcitonin was 0.08 μg/L. Repeat echocardiogram showed normal left ventricular ejection fraction with a small pericardial effusion noted and myocardial perfusion scan showed normal perfusion. It was thought that an acute inflammatory response following implantation of PPM precipitated the AF with a background of GCA and hence patient was treated with increased dosage of prednisolone of 20 mg. Patient reverted to sinus rhythm within 24 h and remained so at 8 months follow-up.
This case illustrates the temporal relationship of systemic inflammation to AF burden and highlights the need for anti-inflammatory pharmacological intervention to reduce AF burden and improve haemodynamic of patient.
SUPPORTING DOCUMENTS
PP-029-1-AF Predictor of the recurrence over 3 years after Cryoballoon ablation for paroxysmal atrial fibrillation Dr Akira Sato1, Dr Masayo Minegishi1, Dr Shin Meguro1, Dr Kentaro Nakata1, Dr Gaku Narita1, Dr Yuhei Isonaga1, Dr Shunichi Kato1, Dr Toshikazu Kono1, Dr Hiroaki Ohya1, Dr Takamitsu Takagi1, Dr Yasuaki Hada1, Dr Miki Kanoh1, Dr Yukihiro Inamura1, Dr Tsunehiro Yamato1, Dr Ken Negi1, Dr Osamu Inaba1, Dr Yutaka Matsumura1 1Japanese Red Cross Saitama Hospital, Saitama Chuoku, Japan
Background: Recently, the catheter ablation for paroxysmal atrial fibrillation is improving safety and efficacy. Especially cryoballoon ablation is easier and faster than radiofrequency ablation, therefore spread rapidly. However, the long-term outcome of cryoballoon ablation for paroxysmal atrial fibrillation is unknown. We investigated the predictors of the recurrence over 3 years of cryoballoon ablation for paroxysmal atrial fibrillation.
Subjects/Methods: We investigated 495 patients (the mean age 64.4 ± 10.7 yo, male 350, the mean observation 1507.1 ± 342.2 days) that had undergone the first session of cryoballoon ablation for paroxysmal atrial fibrillation without recurrence of atrial fibrillation for 3 years from 2014 to 2018.
Results: Between 3 and 8 years after catheter ablation, 86 patients had atrial fibrillation recurrence and 409 patients had no recurrence. That independent predictors were female gender (39.5%/27.1%, 95% CI 1.16–3.25, OR 1.94, p = 0.0116), atrial fibrillation under no anti-arrhythmic drugs in admission (34.9%/16.2%, 95% CI 1.67–4.98, OR 2.89, p = 0.000144).
Conclusion: We need to give attention to atrial fibrillation recurrence over 3 years after catheter ablation in patients that characterized female gender, atrial fibrillation in admission:
PP-030-1-AF Effect of blood pressure on the prevalence of atrial fibrillation in DM ESRD Asst Prof Youmi Hwang1, R.T Jae Hoon Kim1 1St.Vincent's Hospital, Catholic University Of Korea, Suwon, South KoreaBackground: Atrial fibrillation (AF) prevalence is increasing as elderly population increases. Even after eliminating impact of aging, chronic kidney disease, diabetes and hypertension are known risk factors of AF occurrence. Since multi-morbidity exists in chronic kidney disease patients, it is difficult to determine impact of hypertension solely. Besides, little is known about impact of hypertension to predict AF in diabetic end-stage renal disease (ESRD). To evaluate sole effect of hypertension in ESRD, we aimed to evaluate the effect of differential blood pressure control status on developing AF among diabetic ESRD population.
Methods: From 2,717,072 individuals with diabetes who underwent health examinations during 2009–2012 from the database of the Korean national health insurance service, total 13,859 individuals with diabetic ESRD without prior history of AF were included for the analysis. Based on blood pressure level and previous hypertension medication history, we subdivided as five blood pressure categories.
Among five levels of blood pressure status, new onset hypertension (HR 1.609 [1.045–2.477]), controlled hypertension (HR 1.792 [1.295–2.482]), and uncontrolled hypertension (HR 2.291 [1.651–3.18]) showed higher risk of AF orderly. Impact of hypertension was mainly due to diastolic hypertension and increased pulse pressure.
Conclusion: In diabetic ESRD patients, overt hypertension and history of hypertension impacts on AF. The effect of hypertension in this population is mainly due to diastolic hypertension and increased pulse pressure.
SUPPORTING DOCUMENTS
PP-031-1-AF Long-term patient and health service outcomes in atrial fibrillation: A systematic review Assoc Prof Sanjeewa Kularatna1, Prof Steven McPahil, Prof William Parsonage, Dr Sameera Senanayake, Dr Victoria McCreanor, Dr Linh Ngo, Prof Isuru Ranasinghe, Dr Paul Martin, Dr Jason Davis, Dr Tomos Walters 1Australian Centre for Health Services Innovation, Queensland University Of Technology, Kelvin Grove, Australia
Atrial fibrillation (AF) is a prevalent problem worldwide and a common cause of hospitalization, poor quality of life and associated with increased mortality. Previous studies have largely focused on short-term outcome effects of these treatments. This systematic review aims to determine the effect of ablation compared to antiarrhythmic drugs for AF on long-term patient and health service outcomes of mortality, hospitalization, and quality of life.
Studies were included if they were published in the past 10 years, in English, and reported long-term outcomes of more than 12 months comparing ablation and antiarrhythmic drugs for treating AF. The details of the search were recorded according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses report (PRISMA). Risk-of-Bias tool for randomized trials (Rob2) and risk-of-bias in non-randomized Studies of Interventions (ROBINS-1) were used for assessing the risk of bias.
A total of 2224 records were identified. Finally, 12 papers were included in the analysis. Eight studies reported mortality indicating ablation was superior, two studies reported hospitalization with opposing outcomes, and five quality of life studies indicating ablation was a better treatment.
In studies assessing long-term outcomes, beyond 12 months, following ablation or rhythm control drugs for atrial fibrillation, most found a lower risk of death and greater improvement in quality of life in the ablation group.
PP-032-1-AF Association of bundle branch block with recurrence of atrial fibrillation after catheter ablation Assoc Prof Sung Ho Lee1, Assist Prof Ji-Hoon Choi2, Assoc Prof Seung-Jung Park3, Prof Kyoung-Min Park3, Prof June Soo Kim3, Prof Young Keun On3 1Division Of Cardiology, Department Of Internal Medicine, Kangbuk Samsung Hospital, Seoul, South Korea, 2Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Seoul, South Korea, 3Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South KoreaAssociation of bundle branch block with recurrence of atrial fibrillation after catheter ablation.
Objective: The association between bundle branch block (BBB) and recurrence of atrial fibrillation (AF) after catheter ablation is unclear. The aim of this study was to determine whether AF combined with BBB is associated with AF recurrence after catheter ablation.
Materials and Methods: A total of 477 consecutive AF patients who underwent catheter ablation were included. The AF patients were divided into three groups according to BBB: AF without BBB (n = 427), AF with RBBB (n = 16), and AF with intraventricular conduction disturbance (AF with IVCD) (n = 34).
Results: Of the 477 AF patients (mean age 57 years, 81% men, median CHA2DS2-VASc score of 1), 16 (3.4%) patients had RBBB and 34 (7.1%) patients had IVCD. During a mean follow-up of 15.2 ± 6.7 months, 119 patients (24.9%) had recurrence of AF. Of these, 111 (26%) patients were in the AF without BBB group, with two (12.5%) and six (17.6%) patients in the RBBB and IVCD groups, respectively. The Kaplan–Meier estimate of the rate of recurrent AF was not significantly different among the three groups (p = 0.39). Multivariable analysis showed that persistent AF (HR 1.7, 95% CI 1.15–2.50, p = 0.007), chronic kidney disease (HR 2.94, 95% CI 1.20–7.17, p = 0.01), and left atrial diameter (HR 1.04, 95% CI 1.009–1.082, p = 0.01) were significantly associated with AF recurrence.
Conclusion: AF with BBB was not significantly associated with recurrence of AF after catheter ablation in middle-aged patients with low-risk cardiovascular profile.
SUPPORTING DOCUMENTS
PP-033-1-AF High-frequency, low-tidal-volume mechanical ventilation during radiofrequency ablation of atrial fibrillation: A single center experience Dr Nath Limpruttidham1, Dr David Singh2 1University of Hawaii Cardiovascular Disease Fellowship Program, Honolulu, USA, 2The Queen's Medical Center, Honolulu, USA
Pulmonary vein isolation (PVI) is a radiofrequency catheter ablation technique commonly used to treat atrial fibrillation (AF). Recent studies have shown that a high-frequency, low-tidal-volume mechanical ventilation strategy (HFLTV) may improve catheter stability and the overall efficiency of the ablation procedure. We hypothesized that PVI with HFLTV had higher first-pass isolation than PVI with standard mechanical ventilation.
We prospectively collected demographic and procedural data for patients who underwent PVI for the treatment of AF at the Queen's Medical Center in Honolulu, HI between July 2019 and July 2022. The HFLTV protocol was defined by using mechanical ventilation with a respiratory rate of 30 breaths/min and a tidal volume of 200 ml only during the ablation part of the PVI procedure. The primary outcome was first-pass isolation, achieved if both veins on one side of the left atrium were isolated after the first ablation lesion set. Statistical analysis was performed using logistic regression.
A total of 127 patients were included in the study (39 HFLTV group; 88 control group). HFLTV strategy was associated with higher first-pass isolation (OR 2.15 [1.11–4.16]; p = 0.023). The primary outcome is primarily driven by significantly higher first-pass isolation of the left pulmonary vein bundle (OR 5.03 [1.42–17.81]; p = 0.012).
HFLTV strategy was associated with a statistically significantly higher chance of achieving first-pass isolation for PVI. From our experience, HFLTV is a feasible and safe technique to perform during PVI.
PP-034-1-AF Irregular atrial tachycardia after the maze procedure Dr Sou Takenaka1, Dr Ayano Enzan1, Dr Akihiko Ueno1, Dr Soihiro Ogura1, Dr Daisuke Iida1, Dr Nobuhiro Hara1, Dr Masahiro Yamauchi1, Dr Motohiro Nakao1, Dr Tomonobu Okuno1, Dr Masayoshi Sakakibara1 1Department Of Cardiology, Ims Katsushika Heart Center, Tokyo, JapanA 76-year-old male presented to our clinic with a chief compliant of shortness of breath on exertion. Seven years ago, he was admitted to another institute for heart failure due to atrial fibrillation (AF). At that time, a thrombus was found in the left atrial appendage. He took a left atrial appendage resection and a left atrial maze procedure were performed. Six years ago, biventricular pacing was performed for sick sinus syndrome with low left ventricular function, and 5 years ago, radiofrequency ablation was performed for recurrent AF. However, the atrial fibrillation had recurred. The ECG showed AF and ventricular pacing. The ultrasonic echocardiography finding was 40% of left ventricular ejection fraction, and enlargement of the left atrium (LA) and ventricle. When electrode catheters were inserted into the atria, the right atrium showed irregular and slow excitation. Three-dimensional mapping revealed that excitation in the region closer to the septum of the LA was synchronous with the right atrium, and irregular and relatively slow. The origin of this slow excitation was located at the anterior wall of LA, arising from the electrically isolated line during the maze procedure. The lateral site of this line also exhibited AF-like excitation. After radiofrequency ablation of the earliest site of this slow excitation, he was restored to atrial pacing rhythm. But that lateral site also continued AF-like excitation. There was no recurrence after ablation, and the shortness of breath on exertion improved. We report a case of unique atrial conduction after maze procedure.
SUPPORTING DOCUMENTS
PP-035-1-AF Distributions of GAP and dormant conduction site of AI-guided Box isolation in persistent AF patients Dr Nobuhiro Nishiyama1, Dr Ryohei Miyamoto1, Dr Masahiro Morise1, Dr Takahide Kodama1 1Department of Cardiology Toranomon Hospital, Tokyo, Japan
Objectives: For the catheter ablation of persistent atrial fibrillation (AF), the clinical benefit of box has been reported. However, electrical conduction gap (GAP) and dormant conduction (DC) can be unwantedly produced. We aimed to clarify the distributions of GAP and DC site.
Methods: One hundred five consecutive patients AF underwent ablation index (AI)-guided single ring box isolation (BOX). AI-guided BOX was performed target values with 550, inter-lesion distance of ≤6 mm and RF energy was delivered with 35 W everywhere except the bottom line near the esophagus. In the absence of first-pass isolation, the residual and reconnected GAP were mapped, touch-up ablation was delivered. After achievement of BOX, adenosine was given. In case of reconnection, the site of DC was treated with touch-up ablation.
Results: Their mean age was 59.7 ± 9.4. The median duration of AF was 16 months. Acute Box was achieved in all cases, however, 64 GAP in 44 patients were observed after initial encirclement. (Figure) And, 27 DC in 22 patients were observed. (Figure) The mean duration of follow-up was 2.3 ± 1.3 years. One year freedom from any atrial tachyarrhythmia ≥30 s without AAD was 88.4%. There was no relation between recurrence and GAP or DC.
Conclusion: AI-guided BOX may have some limitation in making a first-pass isolation especially at the center portion of roof line and the bottom line near the esophagus due to their anatomical features. For improving ratio of a first-pass isolation of Box, new technologies or tools may be needed.
SUPPORTING DOCUMENTS
PP-036-1-AF Association of catheter ablation and different types of dementia in atrial fibrillation during long-term follow-up Dr Guan-Yi Li1, Mrs Yun-Yu Chen1,2,3, Professor Yenn-Jiang Lin1,2, Dr Fa-Po Chung1,2, Professor Yu-Cheng Hsieh2,4, Professor Kuo-Liong Chien3, Professor Shih-Ann Chen1,2,4 1Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, 2Cardiovascular Research Center, School of Medicine, National Yang-Ming University National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan, 4Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
Objectives: Epidemiologic characteristics of new-onset dementia in patients with AF were investigated, as well as the effect of catheter ablation on different types of dementia.
Materials and Methods: AF patients were identified using Taiwan's National Health Insurance Research Database (2013–2014) and new-onset of dementia events were followed till 2019. The ages of controls and AF patients were matched at baseline. We studied 68,387 patients with AF (>18 yo) without a prior history of dementia. Non-AF controls with the same age groups were matched to AF patients without prior AF diagnoses in 2013–2014. A competing risk model was used to investigate three subtypes of dementia.
Results: During follow-up, 8704 new-onset dementia events occurred. Subtypes of dementia in AF patients were reported: 73% attributed to Alzheimer's disease, 16% attributed to vascular dementia, and 11% attributed to other/mixed dementia. The crude incidence of dementia in AF patients was higher than in non-AF controls (total dementia: 18.9 vs. 23.2, Alzheimer's disease: 15.3 vs. 16.8, vascular dementia: 2.08 vs. 3.88, and other/mixed dementia: 2.01 vs. 2.59 [per 1000 person-years]; all p < 0.001). In AF patients receiving ablation, the total dementia risk decreased significantly (HR: 0.74, 95% CI: 0.58–0.94) after multi-variable adjustment, but only for the subtypes of Alzheimer's disease (HR: 0.79, 95% CI: 0.60–0.98).
Conclusion: AF patients have a higher risk of developing all types of dementia, including Alzheimer's disease, vascular dementia, or a mix type of dementia. Alzheimer's disease was less likely to occur in patients with AF who received ablation, but not vascular dementia.
SUPPORTING DOCUMENTS
Study flow chart
FIGURE Characterization of the dementia types in AF patient. PP-037-1-AF Effect of SGLT-2 inhibitors on adverse outcomes in patients with AF and DM Dr Bo Kyung Jeon1, Dr Yeji Kim1, Dr Moo-Nyun Jin1, Dr Dong Hyeok Kim1, Dr Min-ho Kim1, Dr Junbeom Park1 1Ewha Woman's University Medical Center, Yangcheon-gu, South Korea
Objectives: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors, one of the commonly used medications for diabetes mellitus (DM), are well known to have beneficial for heart failure (HF). Atrial fibrillation (AF) and HF have similar pathophysiological features and similar risk factors including DM. In this study, we hypothesized that SGLT-2 inhibitors would be effective on the prognosis of AF with DM.
Materials and Methods: This is a retrospective study using the common data model (CDM) database, converted using the patients' clinical information in several tertiary hospitals in South Korea. Three hundred patients who were first prescribed oral diabetic medication before or within 60 days of diagnosis of AF were enrolled from 2001 to 2020. Major adverse cardiac and cerebrovascular events (MACCE) were regarded as the primary endpoint. Student's t-test and Cox regression analysis were used for statistical analysis.
Results: A significant difference was not seen between the incidence of MACCE, hospitalization rate and all-cause mortality between the two groups. Using multivariable cox-regression analysis, the use of SGLT-2 inhibitors was not significantly associated with higher MACCE incidence and hospitalization rate before and after adjusting for potential confounders. However, upon comparing hospitalization periods using student's t-test, lower all-cause hospitalization periods with borderline significance (p = 0.091) were seen in the SGLT-2 inhibitor group.
Conclusion: Thus, to conclude, no significant difference was seen between the SGLT-2 inhibitor administration and control groups in terms of MACCE incidence, hospitalization, and all-cause mortality. However, the hospitalization period was shorter in the SGLT-2 inhibitor administration group with borderline significance.
SUPPORTING DOCUMENTS
TABLE 1 Incidence, hospitalization rate, and mortality of SGLT-2 inhibitor administration and control group
| SGLT-2 inhibitor | Other medications | p value | |
| Incidence (MACCE) | 139 (54.30) | 21 (47.73) | 0.513 |
| Incidence (ischemic heart disease) | 11 (25.00) | 52 (20.31) | 0.548 |
| Incidence (stroke) | 15 (34.09) | 104 (40.63) | 0.505 |
| Hospitalization rate (total) | 22 (50.00) | 143 (55.86) | 0.514 |
| Hospitalization rate (MACCE) | 9 (20.45) | 60 (23.44) | 0.846 |
| Hospitalization rate (ischemic heart disease) | 4 (9.09) | 22 (8.59) | 1.000 |
| Hospitalization rate (stroke) | 6 (13.64) | 43 (16.80) | 0.825 |
| Mortality (total) | 0 (0.00) | 7 (2.73) | 0.599 |
Note: Values are presented as n (%); SGLT-2, sodium-glucose co-transporter inhibitor 2; MACCE, major adverse cardiac and cerebrovascular events.
TABLE 2 Multivariable Cox-regression analysis table, comparing incidence of MACCE and hospitalization rate.
| Unadjusted HR (95% CI) | p value | Adjusted HRa (95% CI) | p value | |
| Incidence (MACCE) | 0.891 (0.563–1.412) | 0.624 | 1.015 (0.590–1.748) | 0.955 |
| Incidence (ischemic heart disease) | 1.346 (0.700–2.591) | 0.373 | 1.065 (0.473–2.398) | 0.879 |
| Incidence (stroke) | 0.846 (0.492–1.456) | 0.546 | 1.073 (0.554–2.079) | 0.836 |
| Hospitalization rate (total) | 0.957 (0.608–1.506) | 0.849 | 1.212 (0.705–2.083) | 0.487 |
Abbreviations: MACCE, major adverse cardiac and cerebrovascular events; SGLT-2, sodium-glucose co-transporter inhibitor 2.
aAge, sex, hypertension, cardiovascular disease, heart failure, cerebrovascular disease, and the use of antiplatelet, anticoagulant, statin, antiarrhythmic agent, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, beta blocker, calcium channel blocker and diuretics were regarded as confounding variable and adjusted.
TABLE 3 Average hospitalization period between SGLT-2 inhibitor administration and control group.
| SGLT-2 inhibitor | Other medications | p value | |
| Hospitalization period (total) | 4.78 ± 6.27 | 7.38 ± 10.01 | 0.091 |
| Hospitalization period (MACCE) | 6.60 ± 6.45 | 10.95 ± 13.94 | 0.101 |
| Hospitalization period (cardiovascular) | 8.00 ± 8.72 | 8.29 ± 10.48 | 0.954 |
| Hospitalization period (stroke) | 7.33 ± 6.12 | 12.97 ± 15.98 | 0.106 |
Note: Values are presented as mean ± SD.
Abbreviations: MACCE, major adverse cardiac and cerebrovascular events; SGLT-2, sodium-glucose co-transporter inhibitor 2.
PP-038-1-AF The clinical relevance of underweight on treatment outcome of catheter ablation for atrial fibrillation Dr Shuhei Yamashita1, Dr Hiroshi Miyama1, Dr Ryo Nakamaru1, Dr Yasuyuki Shiraishi1, Dr Yoshinori Katsumata1,2, Dr Takehiro Kimura1, Dr Keiichi Fukuda1, Dr shun Kohsaka1, Dr Seiji Takatsuki1 1Department of Cardiology, Keio University School of Medicine, Shinanomachi, Japan, 2Sports Medicine Research Center, Keio University School of Medicine, Shinanomachi, JapanObjectives: Underweight is known to relate to complications and recurrence of atrial arrhythmia in patients undergoing catheter ablation (CA) for atrial fibrillation (AF). However, little is known about the clinical implication of underweight on patients' quality of life (QoL) among AF patients. We investigated the association between underweight and QoL improvement after CA for AF.
Materials and Methods: Using a prospective, multicenter Japanese registry, we analyzed 1127 patients with AF who underwent CA within 12 months after registration. Patients were categorized into four groups based on body mass index (BMI): underweight (BMI < 18.5), normal (18.5 ≤ BMI <25), overweight (25 ≤ BMI < 30), and obesity (30 ≤ BMI). Patients' QoL was assessed and compared at registration (baseline) and 1 year after registration by using the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire.
Results: Patients with underweight were more likely to be older, female, had smaller left atrial size, and had a greater proportion of paroxysmal AF. There were no significant differences in AFEQT overall summary (AFEQT-OS) scores at baseline among the four groups. Compared to baseline, AFEQT-OS scores improved significantly at 1-year follow-up in each group. Mean changes of AFEQT-OS scores in four groups were 9.73 ± 20.37, 14.05 ± 16.48, 14.25 ± 15.12, and 12.89 ± 18.79, respectively. After adjustment, underweight was independently associated with poor improvement of AFEQT-OS score 1-year after registration (adjusted difference −4.32 points, 95% CI, −8.52 to −0.11 points; p = 0.044).
Conclusion: In contemporary Japanese clinical practice, underweight was associated with poor improvement of QoL after CA for AF. Careful assessment and tailored treatment strategy may be required for underweight AF patients.
PP-039-1-AF Association of coronary artery calcium score with recurrence after catheter ablation for persistent atrial fibrillation Dr Hirofumi Kujiraoka1, Dr Taku Kanzaki1, Dr Seiya Komine1, Dr Masataka Sunagawa1, Dr Wataru Tsuno1, Dr Yoshiaki Mizunuma1, Dr Takahumi Sasaki, Dr Koichiro Yamaoka1, Dr Tomoyuki Arai1, Dr Dai Inagaki1, Dr Kiyotaka Yoshida1, Dr Takashi Kimura1, Dr Masao Takahashi1, Dr Rintaro Hojo1, Dr Takaaki Tsuchiyama1, Dr Seiji Fukamizu1 1Tokyo Metropolitan Hiroo Hospital, Shibuya, JapanObjectives: Cardiac computed tomography (CT) is often performed before catheter ablation (CA) for atrial fibrillation (AF) for preoperative treatment planning and thrombus evaluation. Although the coronary artery calcium score (CACS) is known to be associated with the risk of developing AF, there are few data on the association of CACS with recurrence of AF after CA. The purpose of this study was to investigate the association of CACS with AF recurrence after CA for persistent AF.
Materials and Methods: We included 153 consecutive patients who underwent initial pulmonary vein isolation and left atrial posterior wall isolation for persistent AF at our institution from January 2018 to December 2021, and analyzed 105 patients who underwent coronary CT. We divided the patients into two groups according to the Agatston score: CACS >100 (N = 35) and CACS ≤100 (N = 70), and compared them with respect to recurrence of atrial arrhythmias after CA.
Results: Patients with CACS > 100 had higher prevalence of diabetes mellitus (37% vs. 11%, p = 0.004) and dyslipidemia (66% vs. 24%, p < 0.0001) and higher left atrial volume (87 ± 30 vs. 75 ± 25 ml, p = 0.045). Mean observation time was 19 months. The chronic recurrence rate 3 months after CA was significantly higher in the CACS > 100 group (26% vs. 5%, p = 0.0013). On multivariate analysis, diabetes mellitus and CACS > 100 (OR: 10.2; CI: 1.73 to 60.3, p = 0.01) were factors associated with AF recurrence.
Conclusion: In patients with persistent AF undergoing CA, CACS may be associated with risk of chronic phase AF recurrence.
PP-040-1-AF Esophageal injury after radiofrequency catheter ablation or Cryoballoon ablation in atrial fibrillation Dr Yun Young Choi1, Dr. Prof. Jong-Il Choi1, Dr. Joo Hee Jeong1, Dr. Hyoung Seok Lee1, Dr. Kyongjin Min1, Dr. Prof. Yun Gi Kim1, Dr. Prof. Seung-Young Roh1, Dr. Prof. Jaemin Shim1, Dr. Prof. Jin Seok Kim1, Dr. Prof. Young-Hoon Kim1 1Korea University, Seoul, South KoreaAims: Esophageal lesion (EL) is one of the complications after catheter ablation of atrial fibrillation (AF). However, the comparison of EL between radiofrequency catheter ablation (RFCA) and cryoballoon ablation (CBA) is not well known. Hence, we aimed to investigate the association with EL after catheter ablation.
Methods: Consecutive patients with AF who underwent RFCA or CBA, including pulmonary vein isolation, were studied. We compared clinical outcomes between patients with EL and those without EL.
Results: Among 584 patients (mean age 62.8 ± 11.2 years, 68.6% men), 30 (5.14%) had EL after RFCA (25/504, 4.96%) or CBA (5/80, 6.25%). When patients with EL were classified by Kansas City Classification, Class I was 17 (68%) and 3 (60%) in RFCA and CBA, respectively. Patients with EL had significantly reduced ejection fraction (EF) (48.9 ± 8.7 vs. 52.8 ± 6.8, p = 0.023) and lower body mass index (BMI) (24.5 ± 3.9 vs. 25.9 ± 3.4, p = 0.030) compared to patients without EL. EL after RFCA had more history of diabetes, previous stroke, and congestive heart failure compared to CBA. Multivariate analysis using logistic regression showed a lower BMI (odds ratio (OR) 0.82, 95% confidence interval (CI) 0.71–0.93, p = 0.003) and a reduced EF (OR 2.29, 95% CI 1.08–4.86, p = 0.031) were significantly associated with EL.
Conclusion: This study showed that the incidence of EL after catheter ablation was low and the degree of EL was mostly mild. A reduced EF and lower BMI were significantly associated with an increased risk of EL after RFCA or CBA, suggesting that post-ablation EGD may be useful for detecting early EL.
SUPPORTING DOCUMENTS
TABLE Logistic regression between with esophageal injury and without esophageal injury
| Univariable | Multivariable | |||
| OR (95% CI) | p value | OR (95% Cl) | p value | |
| Paroxysmal atrial fibrillation | 2.08 (0.82–5.31) | 0.118 | ||
| TEE before RFCA | 1.55 (0.63–3.82) | 0.337 | ||
| Roof line | 1.58 (0.35–7.08) | 0.548 | ||
| Posterior line | 1.04 (0.24–4.58) | 0.960 | ||
| SVC | 0.64 (0.15–2.80) | 0.555 | ||
| Lt PV additional ablation | 2.21 (0.99–4.97) | 0.049 | 2.32 (1.01–5.35) | 0.048 |
| Male | 0.13 (0.59–3.05) | 0.483 | ||
| Congestive heart failure | 1.39 (0.60–3.22) | 0.441 | ||
| Hypertension | 0.90 (0.40–2.02) | 0.792 | ||
| Diabetes mellitus | 1.10 (0.40–3.00) | 0.859 | ||
| Stroke/TIA | 1.71 (0.56–5.20) | 0.338 | ||
| Vascular disease | 2.00 (0.44–9.06) | 0.362 | ||
| Body weight (kg) | 0.99 (0.96–1.01) | 0.247 | ||
| Height (cm) | 1.02 (0.98–1.06) | 0.349 | ||
| BMI (kg/m2) | 0.85 (0.75–0.97) | 0.017 | 0.82 (0.71–0.93) | 0.003 |
| Age > 60 (years) | 1.12 (0.48–2.58) | 0.793 | ||
| CHADS-Vasc ≥2 | 1.03 (0.43–2.43) | 0.953 | ||
| LA size ≥40 (mm) | 2.35 (0.79–6.96) | 0.114 | ||
| LVEF <50 (%) | 2.97 (1.32–6.68) | 0.006 | 2.98 (1.28–6.94) | 0.011 |
| E/e' | 0.94 (0.84–1.07) | 0.352 | ||
| Pulmonary artery pressure (mmHg) | 1.03 (0.98–1.08) | 0.301 | ||
| LVEDD (mm) | 1.07 (0.99–1.15) | 0.110 | ||
| LA volume ≥ 100 (ml) | 1.60 (0.63–4.09) | 0.320 | ||
Objective: We aimed to demonstrate the feasibility and safety of zero-fluoro approach for the repeat AF procedures after initial cryoballoon ablation.
Methods: We have performed a retrospective study on patients who have undergone repeat PVI procedures in our institution since we started the zero-fluoro program in 2020. All patients received CB ablation for the initial procedure. Procedures were performed under conscious sedation with the help of intracardiac echo and 3D mapping system, without the use of fluoroscopy. Right-sided femoral vein was used for two introducers. Single transseptal puncture was performed guided by ICE. Steerable sheath was used and high-density voltage map of LA was created to evaluate the PV reconnections. Contact-sensing RF ablation catheters were used to reisolate the reconnected veins and in the case of no reconnections, posterior wall isolation was performed.
Results: We have analyzed in total 30 patients (76% male, 59.9 ± 9.3 years old), 55% of which suffered from paroxysmal AF. The mean LVEF was 61.8 ± 7.5% and mean LA diameter was 42.0 ± 6.4 mm. In two (6.7%) patients RF energy was required to cross the intraatrial septum. The mean procedure time was 101.3 ± 27.0 min and the mean RF time was 878 s ± 436 s. The mean of 1.24 ± 0.87 veins was reconnected per patient and 23.3% of patients did not have PV reconnections. In all patients successful PV/PW isolation was performed confirmed by entry and exit block. No periprocedural complications were observed.
Conclusion: In our small cohort of patients, zero-fluoro approach for repeat PVI procedures ablation proved to be feasible and safe.
PP-042-1-AF The morphology of left atrial roof might influence recurrence after atrial fibrillation ablation Dr Yukihiro Uehara1, Dr Kazuo Kato1, Dr Makito Kaneshiro1, Dr Hiroki Yabuta1, Dr Shun Kikuchi1, Dr Shin Hasegawa1, Dr Nobuo Ishiguro1, Dr Akimitsu Tanaka1, Dr Miyuki Ando1, Dr Hidekazu Aoyama1, Dr Hiroko Goto1, Dr Ryosuke Kametani1 1Nagoya Tokushukai General Hospital, JapanThe morphology of the left atrium (LA) would not only vary among individuals depending on the severity of the atrial fibrillation, but also could influence the difficulties of the procedures of the ablation. The shape of the left atrial (LA) roof might affect the outcome of the atrial fibrillation (AF) ablation.
Methods: We enrolled 632 patients to whom we performed initial box pulmonary vein (PV) isolation (BoxPVI) for various severities of AF, and 101 patients for redo procedures after BoxPVI. We measured the distance and the angle between superior PVs in order to evaluate the shape of the LA, and analyzed the parameters associated with the recurrence of AF during follow-up periods of 679.0 (307.0–1195.0) days.
Results: The distance and the angle of the LA roof varied among different severities of AF and redo cases. The redo cases showed longer distance and more acute angle than those of other cases, and also showed the worst prognosis in the Kaplan–Meier curves (p = 0.0021).
Conclusions: The recurrence after the second BoxPVI would depend upon the shape of LA roof, suggesting that we had better consider beyond BoxPVI procedures in redo cases of AF ablation if their shape of the LA roof showed such characteristics.
SUPPORTING DOCUMENTS
PP-043-1-AF The Association of Poor Outcomes in patients with newly diagnosed atrial fibrillation after stroke (AFDAS) Dr Cheng-I Wu1,2,3, Dr Li-Chi Hsu3,4 1Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, 2Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taipei, Taiwan, 3School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, 4Division of Cerebrovascular Diseases, Neurological Institute, Taipei, Taiwan
Objectives: The purpose of this study is to evaluate the adverse effect of atrial fibrillation diagnosis after stroke (AFDAS) on the outcome of stroke patients.
Materials and Methods: A total of 3336 consecutive patients with ischemic stroke between 2016 and 2018 were retrospectively enrolled from our stroke registry database. All patients were classified into one of the four groups based on the past medical recordings and admission 12-lead electrocardiography (ECG)/Holter findings: normal sinus rhythm (NSR), paroxysmal atrial fibrillation (PAF), persistent atrial fibrillation (PeAF), and AFDAS. The severity of the stroke was evaluated by the National Institutes of Health Stroke Scale (NIHSS), and we also estimated the risk of recurrent thromboembolic stroke in all patients by the CHA2DS2VASc score. All patients were followed at admission, discharge, 1, 3, 6, and 12 months after ictus.
Results: The admission NIHSS was statistically higher in AFDAS (13.3 ± 10.0) than in the other three groups (10.2 ± 8.2, 10.1 ± 9.7, 8.1 ± 9.5 for PeAF, PAF, and NSR, respectively, all p values <0.05). The CHA2DS2VASc of AFDAS was lower than the scores of PeAF (2.90 ± 1.33 vs. 3.28 ± 1.47, p = 0.01) and higher than that of NSR (2.90 ± 1.33 vs. 2.17 ± 1.54, p < 0.01). All-cause mortality was significantly high in AFDAS patients compared with NSR patients (24.0% vs. 14.9%, p < 0.01). In addition, among patients with CHA2DAS2VASc >4, AFDAS resulted in a lower survival probability than PAF (Log Rank p value < 0.05, by the Kaplan–Meier analysis).
Conclusion: AFDAS had a potentially adverse effect on patients with ischemic strokes. Further investigation of the underlying pathophysiology beneath AFDAS is warranted.
PP-044-1-AF Impact of cerebral microbleeds on decreased cognitive function in atrial fibrillation patients Ms Yun-Yu Chen1,2,3, Dr Yenn-Jiang Lin1,2, Dr Li-Chi Hsu4, Dr Shih-An Tang4, Pro Li-Fen Chen5, Pro Lian-Yu Lin6, Pro Kuo-Liong Chien3,6, Pro Shih-Ann Chen1,2 1Heart Rhythm Center, Division Of Cardiology, Department Of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, 2Cardiovascular Research Center, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan, 4Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, 5Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan, 6Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, TaiwanObjectives: We aimed to investigate the association of cerebral microbleeds with cognitive function in atrial fibrillation (AF) patients.
Materials and Methods: We collected 38 non-AF controls and 36 AF patients prospectively from multicenter in Taiwan. Participants were followed every 6 months. At baseline, all participants received brain magnetic resonance imaging (MRI) to check for cerebral microbleeds. During baseline and follow-up visits, cognitive function was assessed. To account for the effects of repeated measurements and different enrollment sites, generalized estimating equations were used.
Results: After multivariable adjustment, AF (β: −0.74, 95% CI: −1.26 to −0.22; Table 1) was associated with decreased cognitive function (MoCA) in short-term memory compared than non-AF controls. In patients with AF, MRI revealed more cerebral microbleeds (β: 1.13, 95% CI: 0.04–2.22; Table 1). The presence of microbleeds in brain MRIs (β: −0.39, 95% CI: −0.59 to −0.18; Table 2), old ischemic strokes (β: −0.80, 95% CI: −1.59 to 0.006), depression (β: −0.15, 95% CI: −0.24 to −0.06), thyroid disease history (β: −2.39, 95% CI: −2.91 to −1.87), current smoking status (β: −12.0, 95% CI: −13.0 to −11.1), and alcohol consumption (β: −2.17, 95% CI: −2.26 to −2.08) all contributed to lower total MoCA scores. Higher quality of life (QoL) in the psychological and environment domains were related to higher total scores of MoCA.
Conclusion: AF patients with cerebral microbleeds, old ischemic strokes, thyroid disease, smoking status, and alcohol consumption had cognitive function decline as MoCA scores. Patients at higher risk of cognitive decline should be considered for health interventions to prevent future dementia.
SUPPORTING DOCUMENTS
PP-045-1-AF Atrial fibrillation as contributor to the mortality in patients with dementia: A Nationwide cohort study Ms Yun-Yu Chen1,2,3, Pro Yenn-Jiang Lin1,2, Dr Fa-Po Chung1,2, Dr Yu-Cheng Hsieh2,4, Pro Kuo-Liong Chien3, Pro Shih-Ann Chen1,2,4 1Heart Rhythm Center, Division Of Cardiology, Department Of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, 2Cardiovascular Research Center, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan, 4Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
Objectives: The purpose of this study was to evaluate the effect of AF on all-cause mortality and other factors associated with death in AF patients with dementia.
Materials and Methods: Using Taiwan's National Health Insurance Research Database (NHIRD, 2013–2014), we conducted a nationwide cohort study. An evaluation of the risk of mortality was conducted on 17,384 patients diagnosed with dementia for the first time after entry into the study. Subjects under the age of 18 years or with follow-up period <15 days were excluded. Age was matched for 8707 non-AF controls and 8677 AF patients in the dementia database. To calculate the hazard ratios (HRs) for mortality events, the conditional Cox proportional hazards model was used.
Results: A history of AF was associated with a higher risk of all-cause death in dementia patients (HR: 1.36, 95%: 1.28–1.45). AF patients with dementia (mean age: 75.3 years) had a higher risk of death due to higher age (HR: 1.057, 95% CI: 1.051–1.063), diabetes mellitus (HR: 1.27, 95% CI: 1.14–1.42), chronic kidney disease (HR: 1.72, 95% CI: 1.47–2.02), and prior stroke (HR: 1.35, 95% CI: 1.23–1.48). Anti-arrhythmic drugs (HR: 0.91, 95% CI: 0.84–0.99), NOAC (HR: 0.80, 95% CI: 0.74–0.87), ARNI (HR: 0.51, 95% CI: 0.32–0.79), and SGLT2i (HR: 0.54, 95% CI: 0.34–0.85) significantly reduced death risk in AF patients with dementia.
Conclusion: This study found that AF is a deterioration factor of mortality in patients with dementia, and explored several risk factors of mortality for AF patients with dementia.
SUPPORTING DOCUMENTS
PP-046-1-AF Effects of SGLT2i on reducing dementia risks in atrial fibrillation patients with diabetes: A Nationwide cohort Ms Yun-Yu Chen1,2,3,4, Pro Yenn-Jiang Lin1,2, Dr Fa-Po Chung1,2, Pro Yu-Cheng Hsieh2,3, Pro Kuo-Liong Chien4, Pro Shih-Ann Chen1,2,3 1Heart Rhythm Center, Division of Cardiology, Department Of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Taipei, Taiwan, 2Cardiovascular Research Center, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Cardiovascular Center, Taichung Veterans General Hospital, Taipei, Taiwan, 4Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
Objectives: The effects of sodium-glucose cotransporter-2 inhibitor (SGLT2i) on reducing new-onset cognitive dysfunction in atrial fibrillation (AF) patients with diabetes remain unknown. This study aimed to investigate whether the uses of SGLT2i reduce 5-year dementia risk among AF patients with diabetes.
Materials and Methods: We identified AF patients using the Taiwan's National Health Insurance Research Database (2013–2014). A total of 17,925 AF patients with diabetes under the age of 18 years without prior history of dementia were studied. Among AF patients, 1374 patients were prescribed for SGLT2i. SGLT2i group was 1:2 matched with patients without the uses of SGLT2i (N = 2747) using the same propensity score. Dementia events were followed till the end of 2019. Subtypes of dementia were investigated using competing risk models.
Results: During a follow-up period of 5 years, a total of 354 new-onset dementia events occurred during follow-up. Total dementia events significantly decreased in AF patients with diabetes receiving SGLT2i (HR: 0.71, 95% CI: 0.56–0.90). Considering the risks of dementia subtypes, SGLT2i uses were only associated with decreased risks of vascular dementia (HR: 0.42, 95% CI: 0.22–0.79), especially in those who aged <65 years (HR: 0.28, 95% CI: 0.08–0.94; p-value for interaction = 0.06), but not for those who aged ≥65 years (HR: 0.77 95% CI: 0.59–1.01).
Conclusion: For AF patients with diabetes, the uses of SGLT2i were associated with decreased risk of vascular dementia. The study results indicate that SGLT2i may improve 5-year cognitive outcomes in AF patients by reducing the effects of vascular risk factors.
SUPPORTING DOCUMENTS
TABLE Risk factors of dementia risk in patients with atrial fibrillation
| Events | Total number | 5-year cumulative rate (%) | Incidence rate (per 1000 person-years, 95% confidence interval) | Cox proportional hazards regression | Interaction analysesa | |||
| Crude hazard ratio, 95% confidence interval | Adjusted hazard ratioa, 95% confidence interval | Age < 65 years: Hazard ratioa, 95% confidence interval | Age ≥ 65 years: Hazard ratioa, 95% confidence interval | p-value for interaction | ||||
| Total dementia | ||||||||
| Non-SGLT2i | 2747 | 250 (9.10%) | 14.7 (12.9–16.5) | Reference (HR = 1) | Reference (HR = 1) | Reference (HR = 1) | Reference (HR = 1) | 0.07 |
| SGLT2i | 1374 | 104 (7.57%) | 11.6 (9.36–13.8) | 0.78 (0.62–0.99); p = 0.037 | 0.71 (0.56–0.90); p = 0.005 | 0.60 (0.36–0.99); p = 0.048 | 0.77 (0.59–1.01); p = 0.058 | |
| Vascular dementia | ||||||||
| Non-SGLT2i | 2747 | 66 (2.40%) | 3.87 (2.94–4.81) | Reference (HR = 1) | Reference (HR = 1) | Reference (HR = 1) | Reference (HR = 1) | 0.06 |
| SGLT2i | 1374 | 16 (1.16%) | 1.78 (0.91–2.66) | 0.44 (0.24–0.82); p = 0.010 | 0.42 (0.22–0.79); p = 0.008 |
0.28 (0.08–0.94); p = 0.040 |
0.52 (0.24–1.11); p = 0.09 |
|
| Alzheimer's dementia | ||||||||
| Non-SGLT2i | 2747 | 166 (6.04%) | 9.75 (8.26–11.2) | Reference (HR = 1) | Reference (HR = 1) | na | na | na |
| SGLT2i | 1374 | 82 (5.97%) | 9.14 (7.16–11.1) | 0.94 (0.72–1.22); p = 0.64 | 0.82 (0.62–1.08); p = 0.82 | |||
| Other/mixed dementia | ||||||||
| Non-SGLT2i | 2747 | 37 (1.35%) | 2.17 (1.47–2.87) | Reference (HR = 1) | Reference (HR = 1) | na | na | na |
| SGLT2i | 1374 | 12 (0.87%) | 1.34 (0.58–2.09) | 0.60(0.30–1.22); p = 0.16 | 0.65 (0.29–1.47); p = 0.30 | |||
Note: AF, atrial fibrillation; na, not available; SGLT2i, sodium-glucose cotransporter-2 inhibitor.
aModel was adjusted for age, sex, status of AF ablation, underlying diseases (e.g., sleep apnea, hypertension, hyperlipidemia, liver cirrhosis, chronic obstructive pulmonary disease, thyroid disease, peripheral vascular disease, prior stroke, rheumatic heart disease, atrial flutter, paroxysmal supraventricular tachycardia), and medications (e.g., anti-arrhythmic drugs, warfarin, non-vitamin K antagonist oral anticoagulant, anti-platelets, metformin, and dipeptidyl peptidase 4 (DPP4)).
bInteraction analyses were performed if SGLT2i is a significant factor in reducing dementia risk.
PP-047-1-AF Biomarkers and recurrence of atrial fibrillation after successful cardioversion: Results of a Meta-Analysis Ms Lukah Q. Tuan1,2, Ms Adriana Tokich1,2, Ms Sienna Wu1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev Pathak1,2,3 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, AustraliaObjectives: An increasing body of evidence suggests the role of inflammation in the genesis and perpetuation of atrial fibrillation (AF). However, inconsistent results have been published with regard to the role of inflammatory markers in predicting the maintenance of sinus rhythm after a successful direct current cardioversion (DCCV).
Methods: Using Ovid and EMBASE, we searched for literature published prior to December 2011. Of the 405 studies identified, 16 studies with 1054 patients (501 with and 553 without AF relapse) were included for analysis.
Results: Mean CRP, BNP group levels from each study were recorded and the standardized difference in mean and odds ratio was calculated. Using the fixed effects model (FEM), CRP and BNP group levels were significantly higher in patients with recurrence of AF post-DCCV (odds ratio (OR) for CRP = 2.30 (CI: 1.63–3.26); for BNP = 4.44 (CI: 3.11–6.33)). There was some evidence of heterogeneity (p-value for CRP < 0.002; p-value for BNP group = 0.001). Using random effects model, the effect size for CRP increased to 2.53 (CI: 1.33–4.82) and for BNP group the effect size increased to 6.38 (CI: 1.58–25.82). Publication bias was not evident for CRP and BNP group (p-value 0.43 and 0.24 respectively).
Conclusion: Increased CRP and BNP levels are associated with greater risk of AF recurrence after successful DCCV. The use of these markers for the prediction of those who maintain sinus rhythm after DCCV appears promising but requires further study.
PP-048-1-AF The effect of inflammation on incident atrial fibrillation: Results of a systematic review and meta-analysis Ms Lukah Q. Tuan1,2, Ms Adriana Tokich1,2, Ms Sienna Wu1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev K. Pathak1,2,3,4 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, Australia, 4The University of Canberra, Bruce, CanberraObjectives: Inflammation is considered an important component of the substrate predisposing to atrial fibrillation (AF). Recent data suggest inflammation may predict response to therapy and that treatment may improve outcomes in AF. Furthermore, the role of inflammation in the development of thrombogenesis in AF has been suggested. The aim is to determine the association between raised inflammatory markers and AF.
Methods: Ovid and EMBASE were searched to identify prospective cohort and case–control studies that have reported an association between raised inflammatory markers and incident AF.
Results: Of the 405 articles identified, 17 studies that enrolled a total of 3439 individuals met the inclusion criteria. Mean C-reactive protein (CRP), B-type natriuretic peptide (BNP) and IL-6 levels from each study were recorded and the standardized difference in mean and odds ratio was calculated. Using the fixed effects model (FEM), CRP and IL-6 levels were significantly higher in AF patients (odds ratio (OR) for CRP = 2.34 (CI: 1.82–3.01); for IL6 = 2.78 (CI: 1.79–4.32)). There was no evidence of heterogeneity (p-value for CRP = 0.44; p-value for IL-6 = 0.28). Under FEM, the OR for BNP was 4.15 (CI: 3.42–5.04) and heterogeneity was present (p-value <0.001). Using random effects model, the effect size increased to 7.08 (CI: 3.93–12.76). Publication bias was not evident for CRP, IL-6 or BNP (p-value 0.83, 0.20 and 0.11, respectively).
Conclusion: Raised inflammatory markers are associated with an increased incident risk of AF. The underlying mechanisms whereby inflammation may promote the genesis of AF warrant further investigation.
SUPPORTING DOCUMENTS
FIGURE 2 Relation Between raised CRP and risk of incident AF.
FIGURE 3 Relation Between raised BNP values and risk of incident AF.
PP-049-1-AF Left atrial strain predicts stiff left atrial syndrome after catheter ablation for atrial fibrillation Dr Hee-jin Kwon1, Prof Seung-Jung Park2, Prof Young Keun On2, Prof June Soo Kim2, Prof Kyoung-Min Park2 1Chungnam National University Hospital, Daejeon, South Korea, 2Samsung Medical Center, South KoreaObjectives: The purpose of this study was to compare the LA strain before and after catheter ablation for AF to predict the development of LA stiffness syndrome by using speckle tracking echocardiography.
Materials and Methods: This prospective observational study was designed to enroll 127 patients who underwent catheter ablation for AF and to perform serial echocardiography including LA strain after the procedure. In these data, 127 patients who underwent PV isolation between July 2019 and June 2021 were included. LA systolic strain was assessed with 2D- and 3D-speckle tracking method at baseline and after 1 year of follow-up.
Results: In 127 patients, 76 patients (60%) were paroxysmal AF (mean age 57 ± 9 year). LA volume index was significantly decreased after the ablation (43 ± 7 vs. 40 ± 15 ml/m2, p < 0.001), whereas right ventricular systolic pressure was not changed (p = 0.983). The reservoir (LASr) and contraction LA strain (LASct) values were significantly increased after 1 month of ablation (22 ± 9 vs. 26 ± 8, p < 0.001 and 6 ± 7 vs. 9 ± 5, p = 0.004) which were consistent in 3D-LA strain. Eighty-two patients (65%) patients were increased LASr after ablation, but 40 patients (32%) were decreased LASr.
Conclusion: The LA strain and volume were improved after 1 month of AF ablation in these data. However, a significant number of patients (32%) showed deterioration of LA function. Serial follow-up is needed to predict the occurrence of stiff LA syndrome in these patients.
PP-050-2-AF A novel predictor of permanent pacemaker implantation in patients with catheter ablation of tachycardia–bradycardia syndrome Asst Prof Hye Ree Kim1, Prof Young Keun On2, Asst Prof Hee-jin Kwon3 1Gyeongsang National University Hospital, Jinju, South Korea, 2Samsung medical center, Irwin dong, South Korea, 3Chungnam National University Hospital, Chungnam, South KoreaObjective: The relationship between sinus node dysfunction and atrial fibrillation (AF) is unclear about which comes first, and reversibility of sinus node dysfunction is very important in determining the treatment strategy in patients with tachycardia–bradycardia syndrome (TBS). We aimed to evaluate a new predictive factor related to the reversibility of sinus node dysfunction for requirement of a permanent pacemaker (PPM) in TBS patients.
Methods: Patients with TBS admitted to our center for catheter ablation (CA) from 2012 to 2021 were reviewed, and a total of 113 patients were enrolled. Patients were divided into two groups based on whether a “sinus node dysfunction (SND)-independent episode of AF” coexist (TBS + SND group, n = 20) or not (TBS group, n = 93).
Results: Compared to the TBS group, baseline characteristics showed that the TBS + SND group was comprised of more female gender (p = 0.043), with hypertension (p = 0.033), and with enlarged left atrium (p = 0.003). Reevaluation after an average 3-year follow-up found that eight patients (8/113, 7%) had a permanent implanted pacemaker (PPM) 5/20, 25% in TBS + SND group versus 3/93, 3.2% in TBS group, p = 0.001. Using a multivariate model, a “SND-independent episode of AF” was associated with PPM implantation after ablation in patients with TBS HR 10.387, 95% CI 2.174–49.628, p = 0.003. However, no patient with implanted PPM progressed to persistent AF.
Conclusion: In patients with TBS, an episode of sinus pause without AF predicts the need for implantation of PPM after AF ablation. In addition, even with PPM implantation after CA, we expect better clinical outcomes with decreased AF burden through catheter ablation in TBS patients.
SUPPORTING DOCUMENTS
TABLE 1 Baseline characteristics
| Factor | TBS + SND group (n = 20) | TBS group (n = 93) | p-value |
| Age (years) | 61.1 ± 57.3 | 57.3 ± 9.2 | 0.097 |
| Female (n, %) | 11 (55) | 29 (31.2) | 0.043 |
| BMI (kg/m2) | 25.7 ± 3.5 | 24.5 ± 2.8 | 0.087 |
| Longest pause (seconds) | 5.9 ± 1.9 | 5.3 ± 2.0 | 0.220 |
| CSNRT (ms) | 595.6 ± 457.8 | 411.5 ± 370.2 | 0.141 |
| Symptom (n, %) | |||
| Dizziness | 15 (75.0) | 72 (77.4) | 0.816 |
| Presyncope | 3 (15.0) | 15 (16.1) | 0.900 |
| Syncope | 2 (10.0) | 30 (32.3) | 0.045 |
| Palpitations | 15 (75.0) | 60 (64.5) | 0.368 |
| Hypertension (n, %) | 12 (60.0) | 32 (34.4) | 0.033 |
| Diabetes (n, %) | 4 (20.0) | 12 (12.9) | 0.409 |
| Stroke/TIA (n, %) | 2 (10.0) | 12 (12.9) | 0.721 |
| PCI history (n, %) | 1 (5.0) | 3 (3.2) | 0.697 |
| CHAD2DS2-VASc score | 2.0 ± 1.3 | 1.4 ± 1.3 | 0.054 |
| Echocardiographic parameters | |||
| LVEF (%) | 63.3 ± 5.6 | 61.6 ± 5.4 | 0.214 |
| LA diameter (mm) | 45.0 ± 5.2 | 39.7 ± 7.2 | 0.003 |
| E/E' | 10.1 ± 3.0 | 8.8 ± 3.5 | 0.144 |
| Anti-arrhythmic drugs before the procedure (n, %) | 0.285 | ||
| No medication | 14 (70.0) | 47 (50.5) | |
| Class Ic | 4 (20.0) | 31 (33.3) | |
| Class III | 2 (10.0) | 15 (16.1) | |
| Catheter ablation type (n, %) | 0.940 | ||
| RFCA | 15 (75.0) | 69 (74.2) | |
| Cryoablation | 5 (25.0) | 24 (25.8) | |
| AF duration (months) | 27.4 ± 27.1 | 28.7 ± 37.1 | 0.884 |
| Baseline heart rate (bpm) | 65 ± 19 | 65 ± 14 | 0.929 |
| Follow-up (months) | 33.2 ± 36.6 | 36.8 ± 29.2 | 0.636 |
Abbreviations: AF, atrial fibrillation; BMI, body mass index; CSNRT, corrected sinus node recovery time; LA, left atrium; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; RFCA, radiofrequency catheter ablation; TIA, transient ischemic attack
TABLE 2 Predictors of pacemaker implantation following AF ablation
| Factors | HR (univariate analysis) | p-value | HR (multivariate analysis) | p-value |
| Female | 2.021 (0.504–8.107) | 0.321 | ||
| Age | 1.035 (0.957–1.119) | 0.391 | ||
| Hypertension | 1.942 (0.346–10.899) | 0.451 | ||
| LA diameter | 1.030 (0.923–1.150) | 0.594 | ||
| LVEF (%) | 0.953 (0.849–1.071) | 0.420 | ||
| SND-independent episodes of AF | 10.241 (2.400–43.710) | 0.002 | 10.387 (2.174–49.628) | 0.003 |
| Longest pause before CA | 1.041 (0.778–1.392) | 0.788 |
Note: Values are expressed as hazard ratio (HR) with CI 95%
Abbreviations: AF, atrial fibrillation; CA, catheter ablation; LA, left atrium; LVEF, left ventricular ejection fraction; SND, sinus node dysfunction.
TABLE 3 Rhythm outcomes over a 3-year follow-up period.
| CA + PPM (n = 8) | CA (n = 105) | p-value | |
| Baseline heart rate (bpm) | 58 ± 15 | 66 ± 15 | 0.159 |
| >3 s Pause after CA ablation | 8 (100) | 10 (9.5) | <0.001 |
| Recurrence of AF | 3 (37.5) | 30 (28.6) | 0.592 |
| Redo/Trido-RFCA | 1 (12.5) | 15 (14.3) | 0.889 |
| Rhythm outcome at last FU | 0.001 | ||
| Sinus rhythm | 5 (62.5) | 97 (92.4) | |
| Paroxysmal AF | 3 (37.5) | 4 (3.8) | |
| Persistent AF | 0 (0.0) | 4 (3.8) | |
| 12-month AAD Off NSR | 1 (12.5) | 58 (55.2) | 0.020 |
Abbreviations: AAD, anti-arrhythmic drug; AF, atrial fibrillation; CA, catheter ablation; FU, follow-up; NSR, normal sinus rhythm; PPM, permanent pacemaker; RFCA, radiofrequency catheter ablation.
FIGURE 1 Enrollment and flowchart of the study. AF, atrial fibrillation; NSR, normal sinus rhythm; PPM, permanent pacemaker; RFCA, radiofrequency catheter ablation; SND, sinus node dysfunction; TBS, tachycardia–bradycardia syndrome; TTA, totally thoracoscopic ablation. FIGURE 2 Comparison in rate of permanent pacemaker implantation. PPM, permanent pacemaker; SND, sinus node dysfunction; TBS, tachycardia–bradycardia syndrome.
FIGURE 3 Time of pacemaker implantation after catheter ablation. SND, sinus node dysfunction; TBS, tachycardia–bradycardia syndrome.
PP-051-2-AF LAAO: Retrospective analysis of cases done In a center from north of peninsular Malaysia Dr Mohanaraj Jayakumar1, Dr Ahmad Faiz Mohd Ezanee1, Dr Kantha Rao Narasamuloo1, Dr Saravanan Krishinan1 1Ministry of health Malaysia, Cheras, MalaysiaAtrial fibrillation (AF) confers a four–fivefold increased risk for ischemic stroke.
Left atrial appendage occlusion (LAAO) lowers the risk of stroke by excluding the left atrial appendage from the systemic circulation and preventing thrombus formation and embolization especially in patients with poor socio-economic status where they are not able to comply to follow-ups for warfarin due to logistic issues and unable to afford DOACs. LAAO also helps in patients with history of life-threatening bleeding events.
From the year 2017 to 2022, we have implanted 19 patients with LAAO device out of which 12 patients had Watchman, four patients had Lambre and three patients were implanted the Amulet device.
Patients were selected based on HASBLED score, and those unable to afford DOACs or comply to warfarin treatment due to bleeding reasons or logistical issues. Patients age ranged from 60 years old to 86 years old. Fifteen were male and four were female patients.
Before implantation, TOE assessment done to assess LAA size and clots. During implantation, the procedure was guided by TTE assessment. No major complications; perforation of the appendage, pericardial effusion, death or major vascular complications occurred. These patients were followed up with TOE assessment at day 45.
Eleven patients had good seal but five patients noted significant leak (>5 mm) from the device during TOE assessment. Three patients did not undergo TOE assessment due to various reasons. None of these patients had developed stroke till date and no longer on anticoagulation except the five with leak.
SUPPORTING DOCUMENTSGraph showing outcome of 16 patients underwent laao procedure at hospital sultanah bahiyah from 2017 to 2022.
PP-052-2-AF Warfarin dose adjustments and bleeding events in patients: Receiving warfarin and amiodarone versus warfarin alone Dr Apinut Pengruangrojanachai1 1Vajira Hospital, Ratchathewi, Thailand
Background: Warfarin is the most frequently used to prevent a cardioembolic stroke in atrial fibrillation (AF) patients. Amiodarone is concurrently used with warfarin for rhythm control. However, the interaction of the drugs can increase INR levels and may cause more bleeding events.
Objectives: To assess the correlation of mean dose change and bleeding events between patients with AF receiving warfarin and amiodarone compared with warfarin alone.
Methods: This is a retrospective cohort study with a matching propensity score in a 1:1 ratio according to age and gender enrolled between 2018 and 2020 from the warfarin clinic. Baseline characteristics and mean doses of warfarin were analyzed with Chi-square and Pearson correlation coefficient. Kaplan–Meier analysis and Cox proportional hazard models assessed the bleeding events.
Results: Among 1172 eligible patients, a total of 224 patients were included (mean age 73 years and female = 121). The mean warfarin doses in patients with amiodarone were significantly lower than warfarin alone (13.7 ± 0.8 mg/week vs. 18.8 ± 0.6 mg/week, p < 0.0001). The mean time in therapeutic range in both groups was nearly equal (48% vs. 53%, p = 0.17). The total bleeding events in patients with amiodarone were slightly lower than warfarin alone (14.2% vs. 17.9%, p = 0.46).
Conclusions: The mean doses of warfarin in patients receiving amiodarone were significantly lower than warfarin alone, about 27%. However, total bleeding events were non-significantly different in both groups.
PP-053-2-AF Amplitude of S wave in Lead V1: A new predictor of AF recurrence after cardioversion Dr Tara Ruengvirayudh1, Dr Sarawuth Limprasert1 1Pharmongkutklao Hospital, ThailandBackground: Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and recurrence of AF or atrial flutter (AFL) can be found in after electrical cardioversion (ECV). Many factors were associated with AF recurrence, including electrocardiogram (ECG) and echocardiographic findings. Hence, identifying these predictors after elective ECV might be beneficial in selecting the appropriate patients who are appropriate for this procedure.
Methods: Medical records of all patients with AF who were scheduled for ECV between November 2017 and July 2021 in Phramongkutklao hospital were reviewed. The primary outcome was recurrent AF or AFL after ECV. The patient's baseline characteristics, ECG, and echocardiographic findings were collected, and Cox-proportional hazard model analysis was used to identify the predictors of AF/AFL recurrence.
Results: A total of 172 patients were scheduled for ECV. The mean age of 66.16 ± 12.12 years, 67.44% were male, and 38.95% were diagnosed with paroxysmal AF. Over a median of 127 days, recurrent AF/AFL occurred in 121 patients (70.35%). S wave amplitude >7 mm in lead V1, left ventricular mass index (LVMi) >130 g/m2, and left atrial (LA) diameter > 40 mm were significantly correlated with the AF/AFL recurrence with the hazard ratio of 0.52 (95% CI of 0.31–0.87), 1.66 (95% CI of 1.03–2.69) and 1.88 (95% CI of 1.15–3.07) respectively.
Conclusion: Early AF/AFL recurrence after ECV is common. Left ventricular hypertrophy (LVH) and dilated LA are strong predictors of AF/AFL recurrence. Deep S wave in lead V1 appears to be a new promising protective predictor for AF/AFL recurrence.
SUPPORTING DOCUMENTS
PP-054-2-AF Prevalence of risk factors In patients with first episode of atrial fibrillation In Indian subcontinent Dr Rahul Singhal1 1Fortis Heart Institute Jaipur Rajasthan, Jaipur, India
Background: AF, most common sustained arrhythmia in clinical practice, major public health impact, due to increased risk of stroke. Therapeutic failures in AF, paradigm shift towards subclinical remodelling related to RFs causing chronic atrial overload, in hope that “upstream” therapy might improve prognosis. Data in Indian perspective lacking.
Objective: To evaluate AF prevalence, study risk factors with first episode of AF, having no significant SHD.
Methods: Evaluated aged ≥18 years during camp conducted in Jaipur. Collected demographics, recorded BP, height, weight, 12-lead ECG. Presence of DM, HTN recorded by self-reported history. Also registered patients attending the ER for first episode of AF. With coexistent SHD were excluded. FU done 7–10 days after discharge.
Results: 829 pts. randomly selected, 0.22% have AF. Mean age with AF 58.6 years, 54.5% male. 31.7% had HTN, 20.9% were diabetic; 15.8% CAD; 7.7%OSA; 5.4% each had obesity, COPD, RHD 4.9%, 6.01%hyperthyroidism; 1.64% excess alcoholic, 0.55%practiced high level sports. 33.9% no RFs. One RF in 24.04%, 2 in 22.95%, ≥3 19.13%.
Conclusion: Prevalence of AF found to be consistent with previous studies, there was predominance of RFs like HTN, DM, CAD, mostly these could be corrected with purpose of maintaining NSR once it has been achieved. A high ‰ of patients have no Rfs and follow-up should reveal if they have a better prognosis for AF control. In patients with no RFs and recurrence of AF, seems important to rule out triggering arrhythmias which could be treated with an ablation such as atrio-ventricular tachycardias and arrhythmogenic foci in pulmonary veins.
PP-055-2-AF Evaluation of safety and durability of pulsed-field ablation in preclinical setting: PULSE-DOSE Study Dr Suraya Hani Kamsani1, Prof Prashanthan Sanders1, Mr Darius Chapman2, Mr Twins Yiu3, Mr Milanjot Assi3, Mr Stephen Walsh3, Mr Ian Fong3, Dr Mehrdad Emami1 1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia, 2Flinders University, Adelaide, Australia, 3CathRx, Rydalmere, AustraliaBackground: Pulsed-field ablation (PFA) is an emerging ablation modality with myocardial tissue selectivity which works through the delivery of electrical pulses to cause irreversible electroporation and cell death. This technology has been shown to be safe and efficacious in the acute setting.
Objectives: The purpose of this study is to evaluate the safety and durability of PFA lesions for pulmonary vein isolation (PVI) in animal models.
Materials and Methods: Thirteen swine were divided into three different cohorts according to PFA dose (1800 V/low, 2300 V/intermediate and 2800 V/high voltage). They underwent an index ablation procedure to isolate the pulmonary veins with a follow-up re-map after 12 weeks. Baseline and follow-up data including voltage maps, venous potentials, entrance and exit blocks, phrenic nerve palsy and complications were recorded.
Results: Eleven of 13 swine (85%) completed the follow-up procedure. Repeat voltage mapping showed successful PVI in all 21 veins (100%). Interestingly, one PV in the intermediate voltage group (eight applications at 23,000 V) that was not acutely isolated post-ablation showed complete isolation at follow-up. No phrenic nerve palsy was observed at follow-up. Two animals died prior to re-map procedure due to cardiac tamponade and ventricular fibrillation during transseptal puncture.
Conclusion: Durable PFA effects with possible delayed electroporation can be observed at 12-week follow-up. Intraprocedural complications were not directly related to the PFA delivery itself.
PP-056-2-AF Comorbidities of atrial fibrillation in Indonesia Dr Alice Supit1, Yoga Yuniadi1, Dicky Hanafy1, Sunu Raharjo1, Dony Hermanto1 1National Cardiovascular Center Harapan Kita, Jakarta Barat, IndonesiaObjective: Atrial fibrillation (AF) is the most common form of cardiac arrhythmia resulting from structural and/or electrophysiological abnormalities with abnormal impulse formation. The risk of AF progression is associated with demographic and lifestyle factors, cardiovascular conditions, and comorbidities. Therefore, this study was conducted to determine the prevalence of AF and its comorbidities in Indonesia.
Methods: This was a multicenter collaborative study using an observational cross-sectional design from 2018 to 2019 in tertiary care population in Indonesia. Variables collected were age, gender, and comorbidities such as heart failure, hypertension, diabetes, stroke, coronary heart disease, peripheral arterial disease, and previous history of atrial fibrillation. An electrophysiologist in each center professionally evaluated the interpretation of the electrocardiogram.
Result: There were a total of 9773 subjects included in this study (54.5% were women) with mean age of 44.40 ± 14.80 years. Prevalence of AF was 3.5%. AF was found in 7.4% subjects older than 65, in 14.2% of those with heart failure, 5% of those with hypertension, 7.3% of those with diabetes, 13.9% of those with stroke, 6.6% of those with coronary artery disease, and 10% of those with peripheral arterial disease.
Conclusion: Around 7 of 200 people (3.5%) in Indonesia suffer from AF. AF was more common among subgroups older than 65 years, male gender, history of heart failure, hypertension, diabetes, stroke, coronary artery disease, stroke, and peripheral artery disease.
PP-057-2-AF Smartphone electrocardiogram for atrial fibrillation screening in Malaysian elderly DR Jian-Gang Ang1, DR Hazleena Mohamed Hasnan2, DR AHMAD Faiz Mohd Ezanee3, Dr Gerard Jason Mathews3, DR Yi Zhi Cheng4, DR Shu Feng Tan5, DR Kai Soon Liew3, DR Dharmaraj Karthikesan3, DR Kantha Rao Narasamuloo3, DR Saravanan Krishinan3 1Hospital Taiping, Taiping, Malaysia, 2Hospital Raja Permaisuri Bainun, Ipoh, Ipoh, Malaysia, 3Hospital Sultanah Bahiyah, Alor Setar, Malaysia, 4Hospital Selayang, Gombak, Malaysia, 5Hospital Serdang, Serdang, MalaysiaObjectives: Atrial fibrillation (AF) is the commonest cardiac arrhythmia that is associated with increased risk of stroke, heart failure, and cardio-vascular mortality. Systemic screening at community level for atrial fibrillation with smartphone electrocardiogram had shown to pick up undiagnosed AF, but the data in Asia Pacific region are scarce. Hence, the aim of this study is to assess the feasibility of smartphone electrocardiogram for atrial fibrillation screening in Malaysian elderly.
Methods: In the period between 1 January 2018 and 31 December 2018, 2149 participants were screened with smartphone electrocardiogram using Kardia Mobile (AliveCorVR, Mountain View, CA, USA) in the community-based AF screening program. The inclusion criteria included age ≥65 years old who consented to the study. The electrocardiograms were classified into three groups, namely sinus rhythm, AF and uninterpretable. Participants with uninterpretable electrocardiogram were referred conventional 12-lead ECGs, which were reviewed by the prime investigator.
Results: 137 (6.4%) of 2149 smartphone electrocardiogram were uninterpretable. Forty-four (2%) participants had newly diagnosed AF, with 31 (70.4%) were asymptomatic. The prevalence rates of AF detected by smartphone electrocardiogram was 6.9% and prevalence rates of AF detected by smartphone electrocardiogram or self-reported by participants was 8.1%. Independent predictors of AF such as male gender, history of stroke, heart failure, valvular heart disease and thyroid disease were identified utilizing multivariable logistic regression analysis.
Conclusion: Community screening for AF with smartphone electrocardiogram was feasible and effective. High proportion of asymptomatic AF (70.4%) illustrated the importance of community screening in elderly population.
SUPPORTING DOCUMENTS
PP-058-2-AF No anchor technique on creation of left atrial bottom lesion with Cryoballoon for atrial fibrillation Dr Miki Amemiya1, Dr Atsushi Suzuki1, Dr Saki Kawakatsu1, Dr Yuma Yamakawa1, Dr Shiho Kawamoto1, Dr Michio Usui1, Dr Yasuteru Yamauchi2, Dr Shinsuke Miyazaki3, Dr Masahiko Goya3, Dr Tetsuo Sanano3 1Tokyo Yamate Meical Center, Japan, 2Yokohama City Minato Red Cross Hospital, Japan, 3Tokyo Medical and Dental University, Japan
Objectives: Recent study reported that the efficacy of posterior wall isolation (PWI) created by cryoballoon for atrial fibrillation (AF). The success rate of left atrial roof block (LA-RB) creation has generally exceeded 90%. On the other hand, there is a limited outcome of left atrial bottom block (LA-BB) creation. To improve the success rate of LA-BB creation, we devised a “No-Anchor Technique”, which is a new method of applying the balloon in sufficient contact with the appropriate position by inverting the sheath without using the Achieve catheter as an anchor. This study aimed to clarify whether No-Anchor Technique could improve the success rate of LA-BB creation.
Materials and Methods: The study population included consecutive 16 patients (12 males, 71.6 ± 2.1 years) who underwent PVI and PWI using cryoballoon for AF from January 2022 to May 2022. We evaluated the success rate of LA-BB and PWI, efficacy and safety of No-Anchor Technique.
Results: All patients underwent PWI using cryoballoon. First pass bidirectional LA-BB creation using No-Anchor Technique was achieved in 10 of 16 patients (62.5%). Final success of PWI was achieved in 15 of 16 patients (93.8%). After a median follow-up of 4 months, the clinical recurrence rate was 18.8%. Complications were absent except for one patient with pericarditis.
Conclusion: Although LA-BB creation by cryoballoon sometimes have difficulty to apply the balloon to the targeted site with sufficient contact, No-Anchor Technique allowed us to maintain a high success rate of PWI using cryoballoon without touch-up radiofrequency ablation.
PP-059-2-AF Risk factors of new onset atrial fibrillation in breast cancer survivors Asst Prof Do Young Kim1, Prof Seongwoo Han, Prof Jong-Chan Youn 1Hallym University Dongtan Sacred Heart Hospital, Hwaseong, South Korea, 2Hallym University Dongtan Sacred Heart Hospital, Hwaseong, South Korea, 3Catholic University St. Mary Hospital, South KoreaBackground: The risk of atrial fibrillation (AF) is increased among breast cancer survivors, and it is supposed that multiple risk factors are involved. However, the contribution of risk factors to the development of AF is not well established.
Method and Results: The study cohort consisted of 1256 female BC patients from four medical centers in Korea. During 48.7 months of follow-up, 19 (1.5%) patients were diagnosed with AF. Multiple Cox regression model identified that the number of conventional risk factors (hypertension, diabetes, chronic kidney disease, body mass index ≥30 kg/m2, prior myocardial infarction, and prior heart failure) is associated with newly diagnosed AF. But, cancer-treatment-related risk factors including doxorubicin dose and radiation to the left breast were not significant predictors of new-onset AF in these patients. In the multiple Cox regression model for prediction of major adverse cardiovascular events (MACE), new-onset AF was not significantly associated with MACE.
Conclusion: Number of conventional risk factors of AF significantly predicts new-onset AF with adjustment of cancer-related risk factors. Individualized screening for AF and preventive measures in breast cancer patients with multiple risk factors for AF may improve the CV outcome.
PP-060-2-AF Low dose dopamine and new onset atrial fibrillation after coronary artery bypass surgery Mr Aldo Ferly1, Ms. Averina Geffanie1 1National Cardiovascular Center Harapan Kita, Jakarta, IndonesiaObjectives: To determine whether the administration of low dose dopamine is related to the incidence of new onset atrial fibrillation in patients who had undergone coronary artery bypass surgery procedures.
Materials and Methods: A systematic review were conducted in the following database: PubMed, Embase and Google Scholar. The following keywords and its variations were used: New Onset Atrial Fibrillation, Low Dose Dopamine, Post-Coronary Artery Bypass Surgery. From the initial keywords search, seven literatures were identified. Further reading of the literature revealed that two literatures discusses about the topic and critical appraisal using CEBM critical appraisal tool were done. Appraisals were done by two distinct appraisers.
Results: Two retrospective cohort studies were included in this paper. The first article was a retrospective cohort study involving 1731 patients administered renal dose dopamine. This study found that administration of renal dose dopamine may increase the risk of the appearance of paroxysmal AF by 74%. The second article showed that dopamine administration does not influence the incidence of paroxysmal atrial fibrillation. The benefit of the dopamine administration was also controversial: in the first study, no hemodynamic benefits were seen in the patients whereas in the second study, there is a significant hemodynamic benefits of dopamine administration. Critical appraisal analysis showed that the first study has higher VIA score compared to the second.
Conclusion: Low dose dopamine administration may lead to increased risk of the paroxysmal atrial fibrillation appearance.
PP-061-2-AF Association of concomitant use of proton pump inhibitor with effectiveness and safety of Oral anticoagulants Dr Kwang-no Lee1, Dr Do-Young Kim2, Dr Seung-Young Roh3, Dr Haeyoung Lee4, Dr Gyo-Seung Hwang1 1Ajou University Medical School, Suwon, South Korea, 2Hallym University Dongtan Sacred Heart Hospital, South Korea, 3Korea University Medical college, South Korea, 4Inje University Medical college, South KoreaObjectives: A drug interaction can affect the drugs' effects. Proton pump inhibitor (PPI) is one of the most common drugs used in patient with oral anticoagulant. We hypothesized that the concomitant use of PPI would affect the effectiveness and safety of oral anticoagulant in patient with atrial fibrillation.
Materials and Methods: The cohort was identified from four tertiary referral hospitals. Concomitant use of drug was defined as total overlapping period with oral anticoagulant more than 70% of total period of anticoagulant. Drugs were classified as warfarin, nonvitamin K antagonist anticoagulant, PPI, nonsteroid anti-inflammatory drug, antiplatelet, renin-angiotensin system inhibitor, diuretics, beta blocker, calcium channel blocker, statin, and P-glycoprotein inhibitors for dabigatran and edoxaban.
Results: Data were analyzed for 20,750 episodes (median [IQR] age, 71 [63–78] years; female, 42.5%; warfarin, 37.3%; median [IQR] CHA2DS2-VASc score, 3 [2–5]). The incidences of ischemic stroke, systemic embolism, or intracardiac thrombus were 64.7 and 22.2 per 1000 patient-year with concomitant use and no or less use of PPI, respectively. The incidences of major bleeding were 44.3 and 19.6 per 1000 patient-year, and with concomitant use and no or less use of PPI, respectively. Compared with no or less use of PPI, concomitant use of PPI was associated with higher risks of thromboembolism and bleeding (adjusted hazard ratio, 2.12 [95% CI, 1.75–2.56] and 1.45 [1.17–1.81], respectively).
Conclusion: Among patients with oral anticoagulant for atrial fibrillation, incidences of thromboembolism and major bleeding were higher in patients with concomitant PPI.
PP-062-2-AF Racial differences in stroke and mortality associated with atrial fibrillation Dr Dongseon Kang1, Dr Daehoon Kim1, Dr Hee Tae Yu1, Dr Tae-Hoon Kim1, Dr Jung-Hoon Sung2, Dr Hui-Nam Pak1, Dr Moon-Hyoung Lee1, Dr Pil-Sung Yang2, Dr Boyoung Joung1 1Yonsei University College Of Medicine, Seoul, South Korea, 2CHA Bundang Medical Center, Seongnam, South KoreaObjectives: The adverse outcomes associated with atrial fibrillation (AF) in Asians have not been fully elucidated yet. We evaluated the race-specific associations of AF with total, ischemic and hemorrhagic stroke, and all-cause death.
Materials and Methods: The UK Biobank and Korean National Health Insurance Service (NHIS) study are prospective and observational cohorts. During the registration period (UK 2006–2010; NHIS 2002–2003), 959,932 adults were enrolled. Participants with the following history at baseline were excluded: AF, valvular heart disease and hyperthyroidism. Also, participants who died within 180 days from registration were excluded. Outcomes Total, ischemic and hemorrhagic stroke and all-cause death (adjudicated using hospital discharge codes, and death certificates) after one-to-one propensity score matching.
Results: After propensity score matching, each race included 166,410 participants (mean [SD] age: 55.0 [8.3] years in UK, 55.7 [8.2] years in NHIS; men: 55.2% in UK, 54.7% in NHIS). During the follow-up (mean: 11.7 years in UK, 7.3 years in NHIS), the incidence rates of all types of stroke were significantly higher in Koreans than in whites irrespective of AF status. Hazard ratios of AF for total, ischemic and haemorrhagic stroke and all-cause death were approximately 2.5, 3.0, 2.0 and 7.0, respectively, and there were no significant interactions between the impact of AF and race.
Conclusion: Although the incidence of stroke events in Koreans was greater than that of whites, our results suggest that AF is unlikely to be the cause of this. Continued investigation is essential to explain race differences in AF-related outcomes, especially stroke.
SUPPORTING DOCUMENTS
PP-063-2-AF The long-term renal outcomes of Taiwan atrial fibrillation patients underwent novel Oral anticoagulants therapy Dr. Jie-Ywi Ong1, Dr. Chye-Gen Chin2, Dr. Wei-Ta Chen2, Dr. Jong-Shiuan Yeh2, Prof. Yung-Kuo Lin2, Dr Ming-Hsiung Hsieh2 1Department Of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, 2Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
Objective: The aim of this study is to investigate the long-term renal outcomes of Taiwan AF patients who underwent novel oral anticoagulant (NOAC) therapy in a single tertiary center.
Methods: Two hundred and fifty-two AF patients were retrospectively enrolled between the years of 2014 and 2021 in our hospital. They underwent antithrombotic therapy at outpatient department with regular follow-up the renal function. The renal outcomes were defined as ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level and kidney failure.
Results: Total 234 patients had regular renal function data for renal outcomes analysis. During the mean follow-up of 48 months, the renal function was not significantly decline after 6 years when compared with baseline (creatinine 1.14 vs. 1.09 mg/dl, and eGFR 67.6 vs. 69.5 ml/min/1.73 m2, both p values >0.05). During the long-term follow-up, 12 patients (5.1%) had doubling of the serum creatinine level, ≥30% decline in eGFR occurred in 63 (26.9%) patients and two patients (0.85%) developed kidney failure. The NOAC treatment group (176 patients) had significantly less doubling of the serum creatinine level (1.7% vs. 15.5%, p < 0.05) and non-significantly less ≥30% decline in eGFR (25% vs. 32.8%, p > 0.05) and kidney failure (0% vs. 3.4%, p > 0.05) when compared with the non-NOAC treatment group (58 patients).
Conclusion: Our AF patients had preserved renal function during the long-term follow-up with or without NOAC treatment. However, the NOAC treatment group had better renal outcomes (significantly less doubling of the serum creatinine level) when compared with non-NOAC treatment group.
PP-064-2-AF Baseline anemia and complications after atrial fibrillation/atrial flutter ablation: A Meta-Analysis Dr Chanavuth Kanitsoraphan1, Dr Chaval Srisakvarakul2, Dr Raktham Mekritthikrai1, Dr Jakrin Kewcharoen3, Dr Parthav Shah4, Dr Todd Nagamine4, Dr Jihun Yeo4, Dr Leenhapong Navaravong5 1Department of Cardiovascular Disease, Cook County Health, Chicago, USA, 2Cardiology Center, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand, 3Division of Cardiovascular Medicine Loma Linda University Health, Loma Linda, USA, 4Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA, 5School of Medicine, Division of Cardiovascular Medicine, Department of Internal Medicine University of Utah, Salt Lake City, USAObjective: Several factors have been identified as poor prognostication factors in patients undergoing atrial fibrillation/atrial flutter ablation. Baseline anemia has been proposed as one of the risk factors for poor outcomes, although the data were unclear. We conducted a meta-analysis to investigate the effect of baseline anemia on complications following atrial fibrillation/atrial flutter ablation.
Methods: We conducted a literature search from inception through December 2021 in the databases of EMBASE and MEDLINE. We included randomized controlled trials or cohorts that compared complications in atrial fibrillation/atrial flutter ablation between patients with and without baseline anemia. Data were combined using the random-effect, generic inverse variance method of DerSomonian and Laird to calculate the weighted mean difference (WMD), odds ratio (OR), and 95% confidence interval (CI).
Results: Four studies were included in the study (134,654 patients, and 7017 patients with baseline anemia). Baseline anemia is associated with significantly increased complications following atrial fibrillation/atrial flutter ablation (OR 1.68, 95% CI 1.17–2.40).
Conclusion: Our study suggested that baseline anemia increase complications after AF/AFL ablation. Anemia should be optimized to improve the outcomes in patients undergoing AF/AFL ablation.
SUPPORTING DOCUMENTS
PP-065-2-AF Real-World outcomes of a rhythm control strategy for atrial fibrillation with reduced left systolic function Dr Ji-Hoon Choi1, Dr Change Hee Kwon1 1Konkuk University Medical Center, Neungdong-ro, Gwangjin-gu, South Korea
Objectives: It has not been well known how effective is rhythm control strategy in atrial fibrillation (AF) patients with reduced left ventricular ejection fraction (LVEF <50%). We aimed to evaluate the real-world prognosis of AF patients with reduced LVEF who received a rhythm control strategy.
Methods: We retrospectively reviewed medical records of AF patients with reduced LVEF who received rhythm control strategy between March 2015 and December 2021.
Results: A total of 84 patients were included (Age, 63.4 ± 11.0; Men, 81.0%; LVEF, 34.1 ± 8.2%). Initial rhythm control was performed in 68 patients (81.0%), whereas 16 patients (19.0%) received rate control. In short-term echo follow-up, a significant improvement in LVEF was observed in both the rhythm control group (pre vs. post; 34.8 ± 8.0% vs. 54.7 ± 9.1%; p < 0.001) and the rate control group (pre vs. post; 32.7 ± 8.9% vs. 43.0 ± 9.1%; p < 0.001). However, improvement in LVEF was more significant in the rhythm control group (rhythm control vs. rate control; 54.7 ± 9.1% vs. 43.0 ± 9.1%; p < 0.001). Rhythm control was continued except for two patients in the initial rhythm control group, and all patients in the rate control group received rhythm control therapy thereafter. Significant improvement in LVEF was observed after rhythm control in the initial rate control group (pre vs. post; 42.6 ± 9.3% vs. 54.8 ± 10.1%; p < 0.001).
Conclusion: In real-world practice, a rhythm control strategy is feasible and effective for improving LVEF in AF patients with reduced LVEF.
SUPPORTING DOCUMENTS
TABLE 1 Baseline characteristics.
| Rhythm control group (n = 68) | Rate control group (n = 16) | p-value | |
| Age, years | 64.2 ± 11.2 | 59.9 ± 9.5 | 0.161 |
| Male sex, n (%) | 56 (82.4) | 12 (75.0) | 0.493 |
| Body mass index, kg/m2 | 25.4 ± 3.5 | 25.8 ± 3.2 | 0.660 |
| Atrial fibrillation type | 0.033 | ||
| Paroxysmal | 7 (10.3) | 0 | |
| Persistent | 50 (73.5) | 9 (56.3) | |
| Longstanding persistent | 11 (16.2) | 7 (43.8) | |
| Hemoglobin, g/dl | 14.6 ± 1.6 | 14.5 ± 2.3 | 0.924 |
| Creatinine, mg/dl | 0.99 ± 0.27 | 1.30 ± 1.18 | 0.309 |
| Hypertension, n (%) | 34 (50.0) | 9 (56.3) | 0.653 |
| Diabetes, n (%) | 17 (25.0) | 8 (50.0) | 0.068 |
| Congestive heart failure, n (%) | 25 (37.3) | 10 (62.5) | 0.067 |
| Coronary artery disease, n (%) | 12 (17.6) | 3 (18.8) | 1.000 |
| Stroke/TIA, n (%) | 5 (7.4) | 1 (6.3) | 1.000 |
| CHA2DS2VASc score, mean | 2.3 ± 1.6 | 2.9 ± 2.3 | 0.355 |
| LVEF, % | 34.4 ± 8.1 | 32.7 ± 8.9 | 0.474 |
| LA diameter, cm | 4.6 ± 0.5 | 4.6 ± 0.5 | 0.781 |
| LA volume index, ml/m2 | 51.2 ± 15.5 | 55.4 ± 18.4 | 0.380 |
| Beta-blocker, n (%) | 63 (92.6) | 15 (93.8) | 1.000 |
| ACEi/ARB, n (%) | 53 (77.9) | 15 (93.8) | 0.286 |
| MRA, n (%) | 49 (72.1) | 12 (75.0) | 1.000 |
| NDH-CCB, n (%) | 17 (25.0) | 4 (25.0) | 1.000 |
| Digoxin, n (%) | 17 (25.0) | 9 (56.3) | 0.032 |
Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; LA, left atrium; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; NDH-CCB, non-dihydropyridine calcium channel blocker; TIA, transient ischemic attack.
PP-066-2-AF Diagnostic value of wearable electrocardiogram patch for new onset atrial fibrillation In high-risk patients Dr Ju Seung Kwun1, M.D., Ph.D Changwhan Yoon1 1Seoul National University Bundang Hospital, Seongnam-si, South Korea
Objectives: We designed to investigate: (1) the rate of detection of new-onset atrial fibrillation by ATP-C120 in high-risk groups, (2) its advantage(s) over conventional 12 lead ECG monitoring systems in diagnosing new-onset atrial fibrillation, and lastly (3) the incidence of death, stroke, myocardial infarction, or systemic embolism in the diagnosed new-onset atrial fibrillation group.
Methods: This study is a non-randomized, multi-center, prospective cohort study. We are planning to enroll 320 adults aged 19 years or older using the following inclusion criteria: (1) patients who provide written and informed consent to participate; and (2) those whose calculated CHA2DS2-VASc score is ≥2. A patch-type device, ATP-C120 will be attached to individuals for 11 days and analyzed for record of new-onset atrial fibrillation. If atrial fibrillation is not detected by the device, participants will be scheduled to visit on the 90th and 180th days for basic clinical assessment.
Results: Two hundred and forty participants have been enrolled in this study. The mean age was 73.3 ± 7.9, and the average of CHA2DS2-VASc score was 3.7 ± 1.3. Among the population, 14 participants were diagnosed as paroxysmal atrial fibrillation (5.8%), and one participant presented an episode of atrial flutter (0.4%).
Conclusion: Prolong ECG monitoring has been proven to increase the detection rate of paroxysmal atrial fibrillation, and therefore, we predict a higher diagnostic yield by this new patch-type device. Due to its conveniences, it will become largely used in real-world and it may improve patients' participation and promote overall good health.
SUPPORTING DOCUMENTS xxxx
PP-067-2-AF Cost-effectiveness of NOACs versus warfarin for atrial fibrillation in patients with intermediate stoke risk Dr. Young Shin Lee1, Dr., Ph.D. Jung Myung Lee1, Dr., Ph.D. Hyemoon Chung1, Dr., Ph.D. Woo-Shik Kim1, Dr., Ph.D. Jin-Bae Kim1 1Kyung Hee University Medical Center, Republic of KoreaObjectives: Atrial fibrillation is the most common type of arrhythmia, especially among older people with high prevalence and incidence rates. With the aging of Korean society, the prevalence rate of AF is expected to rise to 5.8% by 2060. Newly diagnosed non-valvular AF patients over 18 years of age were extracted from the National Health Insurance Review and Assessment Service database, and the intermediate stroke group was based on the CHA2DS2-VASc score. In addition, only patients who received non-vitamin K antagonist oral anticoagulants (NOACs; rivaroxaban, apixaban, dabigatran, edoxaban) and warfarin during the study period were included in the participants group.
Materials and Methods: The Markov Chain model was used to evaluate the cost-effectiveness, and the transition probability was set to be 1-year, and a total of 20 cycles were carried out.
Results: The total cost of warfarin, rivaroxaban, dabigatran, apixaban, edoxaban in non-valvular AF patients was 2874$, 6379$, 5761$, 5151$ and 5851$, respectively. The gained Quality-adjusted life years were 10.83, 10.95, 10.49, 11.10, and 10.99 years, respectively. The incremental cost-effectiveness ratio of warfarin, rivaroxaban, dabigatran, apixaban, edoxaban is 29,743.99$, −8483.04$, 8426.71$ and 18,483.55$ each. The result of analysis indicated that rivaroxaban, apixaban were had lower cost than willing to pay 32,000$. Thus, rivaroxaban, apixaban had cost-effectiveness.
Conclusion:
Our findings represented that apixaban showed the best cost-effectiveness and rivaroxaban was also investigated to be cost-effective than warfarin in the intermediate stroke risk group. The results of this study are expected to be a good basis for making policy decisions.
SUPPORTING DOCUMENTS
Cost-effectiveness scatterplot of Warfarin versus NOACs for prognosis in AF with intermediate stroke risk group.Abbreviations: AF, atrial fibrillation; ICER, incremental cost-effectiveness ratio; NOACs, non-vitamin K antagonist oral anticoagulants.
Changes in ICER estimates for NOACs compared to warfarin with different time horizon acceptability CE curve.
PP-068-V-AF Clinical characteristics and efficacy of Cryoballoon atrial fibrillation ablation in Ramathibodi hospital Dr Chutimon Junkrasien1, Ms Sirin Apiyasawat 1Ramathibodi, Bangkok, Thailand
Background: Atrial fibrillation (AF) is the common arrhythmia especially in older and multiple comorbidities patients. Pulmonary vein isolation (PVI) is recommended strategies for rhythm control of AF. The traditional strategy for PVI was radiofrequency ablation, however, cryoballoon ablation was novel technology for PVI in Thailand and we have done cryoballoon AF ablation for 4 years.
Objective: The purpose of our study was to describe clinical characteristics and efficacy of cryoballoon AF ablation in Ramathibodi Hospital.
Methods: To describe clinical characteristic and efficacy of cryoballoon ablation in 17 patients with AF underwent PVI with cryoballoon in Ramathibodi between January 2018 to December 2021.
Results: From January 2018 to December 2021 in Ramathibodi hospital, cryoballoon AF ablation had done for 17 patients, all of these patients were paroxysmal AF, mean age was 59.5 years old, mean LA diameter was 62.1 mm. There were five patients (29%) who had recurrent paroxysmal AF and all of these patients were prescribed antiarrhythmic drug to control rhythm.
Conclusion: Cryoballoon technique for AF ablation is feasible and low complication, however, most of the patients were paroxysmal AF. The study about the outcome of cryoballoon AF ablation in persistent AF should be further investigated.
SUPPORTING DOCUMENTS
TABLE 1 Clinical characteristics
| Clinical characteristics | All patients (N = 17) |
| Age—year (mean ± SD) | 59.6 ± 2.1 |
| Body weight—kg (mean ± SD) | 70.3 ± 2.9 |
| LVEF—% (mean ± SD) | 64.0 ± 2.4 |
| LA diameter—cm (mean ± SD) | 3.6 ± 0.5 |
|
Comorbidities—No. (%) CAD Hypertension Diabetes mellitus Dyslipidemia Obstructive sleep apnea Stroke None |
1 (5.9) 5 (29.4) 2 (11.8) 5 (29.4) 1 (5.9) 1 (5.9) 7 (41.2) |
|
Antiarrhythmic drug—No. (%) Amiodarone Dronedarone Beta blocker CCB Flecainide None |
4 (23.6) 2 (11.8) 11 (64.7) 1 (5.9) 1 (5.9) 2 (11.8) |
TABLE 2 Procedural details
| Procedural details | All patients (N = 17) |
| Total procedural time—minutes (mean ± SD) | 118.2 ± 34.1 |
| Fluoroscopic time—minutes (mean ± SD) | 27.0 ± 12.0 |
| Contrast volume—ml (mean ± SD) | 38.2 ± 20 |
|
Numbers of PV founded PV potential—No. (%) 0 1 2 3 4 |
1 (5.9) 3 (17.6) 7 (41.2) 6 (35.3) 0 (0) |
|
Minimal temperature—oC (mean ± SD) LSPV LIPV RSPV RIPV |
−48.9 ± 7.2 −44.7 ± 5.6 −51.1 ± 5.8 −37.6 ± 16.6 |
| Cardioversion post-procedure—No. (%) | 5 (29) |
|
Complications Groin hematoma Phrenic Stroke Cardiac perforation Atrioesophageal fistula Contrast reaction Death |
1 0 0 0 0 0 0 |
|
Rhythm at the end of procedure—No. (%) Sinus AF |
17 (100) 0 (0) |
|
Rhythm at first mo. follow-up—No. (%) Sinus AF |
14 (82.4) 3 (17.6) |
|
Rhythm at third mo. follow-up—No. (%) Sinus AF |
14 (82.4) 3 (17.6) |
|
Rhythm after third mo. follow-up—No.(%) Sinus AF |
13 (76.5) 4 (23.5) |
Background: Cryoballoon ablation (CBA)-based pulmonary vein isolation (PVI) may improve the procedural outcome. However, the frequency and distribution of electrical conduction gap (GAP) and dormant conduction (DC) after CBA remains unclear. The incidence and distribution of GAP and DC after CBA-based PVI and the recurrence rate of atrial fibrillation (AF) were investigated.
Method: Two hundred and two patients with paroxysmal AF underwent CBA based PVI with variable ring catheter (Ring) from August 2017 to December 2021. After isolation of each pulmonary vein by CBA, a 20-mg bolus of ATP was administered and the location of GAP and DC in each pulmonary vein using a ring catheter(ring) was analyzed.
Results: The mean age was 61.5 ± 10.7 years, 163 patients (80.6%) were male, their mean CHADS2 score was 0.9 ± 0.98. Sixteen PVs in 14 patients showed GAP and 15 PVs in 14 patients showed DC, so additional touch up ablation was performed. Both GAP and DC were more common at the bottom of the RIPV. There was no significant difference between those with and without GAP or DC regarding the recurrence rate of AF (p = 0.92, p = 0.13). An average of 2.41 years have passed, 86.6% patients remained in sinus rhythm without AAD.
Conclusions: The location of GAP and DC may have anatomical background. It is important to be aware of the use of guidewires and deflectable sheaths to contact areas where GAP and DC are likely to remain.
SUPPORTING DOCUMENTS
PP-071-2-AF Antithrombotic management in atrial fibrillation patients with chronic coronary syndrome: A single-center cohort study Assoc Prof Wen-Yu Lin1, Dr. Chiao-Chin Lee1, Assoc Prof Yuan Hung1, Dr. Zong-Yu Yu1, Prof Wei-Shiang Lin1 1Tri-service General Hospital, Taipei, Taiwan
Objectives: The optimal antithrombotic therapy in atrial fibrillation (AF) patients with chronic coronary syndrome (CCS) remains unclear. The aim of this cohort study is to investigate the contemporary antithrombotic strategy and clinical outcomes.
Materials and Methods: Tri-Service General Hospital-Coronary Heart Disease (TSGH-CHD) registry is a single-center, prospective and longitudinal cohort database. Patients with AF who underwent percutaneous coronary intervention or coronary artery bypass grafting more than 1 year or angiographically confirmed coronary artery disease not requiring revascularization were included and analyzed. The study endpoints were major bleeding, all-cause mortality, and adverse cerebral cardiovascular events, including stroke, systemic embolism, non-fatal myocardial infarction (MI), and coronary revascularization.
Results: A total of 297 patients with AF and CCS were included into analysis, of which 116 were treated with a single antiplatelet agent (SAPT), 107 with an oral anticoagulant (OAC) monotherapy, and 74 with a combination of SAPT and OAC. The prevalence of diabetes, previous MI, and end-stage renal disease was significantly higher in patients treated with SAPT compared with other groups. During follow-up, there were no significant differences in the risk of major bleeding and all-cause mortality between three groups (p = 0.74 and 0.11, respectively). Regarding adverse cerebral cardiovascular events, SAPT group had a significantly higher risk than other two groups, while those on OAC monotherapy and those on SAPT plus OAC had no differences (p = 0.40).
Conclusions: Among AF patients with CCS, OAC-based strategy may be associated with lower risk of adverse cerebral cardiovascular events than SAPT treatment, without increased risk of major bleeding.
SUPPORTING DOCUMENTS
FIGURE 1 Kaplan–Meier curve of each study endpoints.
PP-072-2-AF General anesthesia improves contact force variability and reduces gap formation in pulmonary vein isolation Dr Haruna Tabuchi1, Dr Hidemori Hayashi2, Dr Gaku Sekita2, Ms Asuka Takano1, Dr Kikuo Isoda1, Dr Masataka Sumiyoshi1, Dr Tohru Minamino2 1Juntendo Nerima Hospital, Nerima-ku, Japan, 2Juntendo University Hospital, Bunkyo-ku, JapanBackground: Compared to conscious sedation (CS), the use of general anesthesia (GA) in pulmonary vein isolation (PVI) is associated with a lower recurrence rate of atrial fibrillation (AF). GA may improve catheter stability and mapping system accuracy compared to CS, but its influence on contact force (CF) parameters during PVI is unclear.
Objectives: The purpose of this study is to evaluate improve catheter stability and PVI success rate by GA.
Methods: This retrospective study included 100 consecutive patients (50 in GA group and 50 in CS group) who underwent initial PVI for paroxysmal or persistent AF using the CARTO system, open-irrigated contact force catheter and the VisiTagTM module. We retrospectively assessed CF parameters, and First-pass PV isolation rate.
Results: First-pass PV isolation was achieved in 48 patients (96%) in the GA group, but only 37 patients (74%) in the CS group (p = 0.05). Average CF parameters were same in the GA group than in the CS group (average CF: 14.4 ± 14.6 g vs. 14.5 ± 14.6 g, p = n.s) and CF variability is lower in the GA group than in the CS group (CF variability: 6.85 vs. 8.22, p < 0.01).
Conclusions: GA improve catheter stability and CF variability, reduced gap formation after ipsilateral PVI.
PP-073-2-AF Comparing Cryoballoon and radiofrequency catheter for persistent atrial fibrillation with performing Posterior Wall intervention Dr Kenji Hashimoto1, Dr Susumu Ibe1, Dr Terumasa Yamashita1, Dr Hiroshi Miyama1, Dr Yoshinori Katsumata1, Dr Takehiro Kimura1, Dr Seiji Takatsuki1 1Keio University School Of Medicine, Shinjuku, JapanObjectives: We aimed to investigate atrial fibrillation (AF) patients who underwent posterior wall ablation in addition to pulmonary vein (PV) isolation.
Materials and Methods: This single-center retrospective study included 99 consecutive patients (64.2 ± 8.3 years old, 13 woman) who underwent the posterior wall ablation in addition to PV isolation in their initial AF ablation; box isolation using RF catheter in 64 patients (the RF group) and PV isolation and roof line ablation using cryoballoon in 35 patients (the cryoballoon group). If PV isolation or roof line was not accomplished by cryoballoon, RF applications were added. The baseline characteristic, procedural data and AF recurrence were evaluated.
Results: The RF group included younger population and longer persistent duration (61.6 ± 7.5 vs. 68.8 ± 7.9 years old, p < 0.01 and 14.5 ± 15.4 vs. 8.5 ± 9.1 months, p = 0.04). There was no significant difference in comorbidities and examination data such as left atrium parameter and brain natriuretic peptide. Among the cryoballoon group, 17 patients (48.6%) needed additional RF application. The procedure and fluoroscopy time were not different between the RF and cryoballoon group (209.3 ± 73.3 vs. 192.9 ± 66.4 min, p = 0.27 and 32.5 ± 10.7 vs. 35.1 ± 12.3 min, p = 0.28). During the follow-up (360 ± 260 days), 14 patients had AF recurrences. Using univariate COX regression analysis, using cryoballoon tended to be the risk for recurrences (hazard ratio 2.7, p = 0.08).
Conclusion: PV isolation and roof line ablation using cryoballoon catheter have more recurrence comparing to box isolation using RF catheter. The different background data such as age might influence the result. Further research should be performed in the future.
PP-074-2-AF Failure of internal cardioversion before catheter ablation of atrial fibrillation predicts clinical recurrence Dr Man Wah, Amy Chu1,2, Professor Jaemin Shim1, Dr Arsha Pramudya1,3, Dr Huoung Seok Lee1, Dr Joo Hee Jeong1, Dr Kyongjin Min1, Dr Yun Young Choi1, Prof Yun Gi Kim1, Prof Jong-Il Choi1, Prof Young-Hoon Kim1 1Korean University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea, 2United Christian Hospital, Hong Kong, 3Hasna Medika Cirebon Heart Hospital, Cirebon, IndonesiaObjectives: Radiofrequency catheter ablation is a well-established treatment for atrial fibrillation (AF) 5–9. However, many patients required repeat procedures and late recurrences are not infrequent 10–12. This study sought to investigate whether the success or failure of internal cardioversion before AF ablation is a significant predictor of AF recurrence.
Materials and Methods: This is a single center retrospective cohort study. A total of 94 patients who underwent catheter ablation of AF ablation from January 2019 to August 2019 were included. Patients in AF or atrial tachycardia were routinely cardioverted to sinus rhythm before ablation. AF ablation was then performed under atrial pacing. For patients who failed cardioversion (CV) or with immediate recurrence of AF (IRAF), ablation was done under AF. The patients were followed up for any late recurrence of AF which was defined as 8 weeks after ablation. The mean follow-up was 29 ± 12 months.
Results: Among 94 patients who were included in this study, seven patients failed initial CV (failed CV group), in which four patients developed AF recurrence during the follow-up period. In contrast, 87 patients did not require or had successful cardioversion initially (successful CV group), in which 22 patients developed AF recurrence during the follow-up period. Kaplan–Meier analysis showed a shorter time to recurrence in patients who failed initial CV (p = 0.045, Figure 1).
Conclusion: Patients who failed initial internal cardioversion had a shorter time to recurrence than those who did not require or had successful cardioversion.
PP-075-2-AF Haplotype analysis of phagocytic NADPH oxidase polymorphisms in atrial fibrillation Dr Hong-Ju Kim1, M.D, PhD Dong-Gu Shin1 1Yeungnam University Medical Center, Daegu, South KoreaObjectives: Cardiac myocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) activity within the atrial tissue is an important source of oxidative stress during atrial fibrillation (AF). This study aimed to verify the effect of the polymorphisms of phagocytic NOX on AF and the systemic oxidative stress burden in Korean AF patients.
Materials and Methods: A total of 220 consecutive patients were divided into two groups: 103 non-AF and 117 AF (52 non-paroxysmal AF) groups. We analyzed 25 single nucleotide polymorphisms (SNPs) of six subunits of the phagocytic NOX and compared the difference between the groups. To evaluate the in vivo oxidative stress burden between groups, the plasma level of 8-iso-prostaglandin F2α (8-iso-PGF2α) was also measured.
Results: A difference in the distribution of the haplotypes of p22phox between groups was found in the likelihood ratio tests (p = 0.0380). The distribution of the C-C-G-G-T and C-T-A-G-T haplotypes differed between the groups. The oxidative stress burden (8-iso-PGF2α) was higher in the AF group (72.62 ± 46.29 vs. 47.55 ± 38.38 pg/mL, p = 0.00004). The presence of AF (β = 22.6, p = 0.001) and the C-C-G-G-T haplotype (β = 17.1, p = 0.049) were significant determinants of plasma 8-iso-PGF2α level. AF patients carrying a haplotype C-C-G-G-T showed higer8-iso-PGF2α levels than AF patients without haplotype C-C-G-G-T (91.04 ± 57.64 vs. 68.79 ± 42.93 pg/ml, p = 0.05).
Conclusion: The polymorphism in the gene coding phagocytic NOX subunit p22phox significantly differed between the AF and non-AF groups. The specific haplotype C-C-G-G-T was associated with AF and a more elevated oxidative stress burden in the Korean AF population.
SUPPORTING DOCUMENTS
TABLE 1 8-iso-PGF2α Level and Inflammatory Markers
| No AF (n = 103) | AF (n = 117) | p-value | |
| 8-iso-PGF2α, pg/mL | 47.55 ± 39.38 | 72.62 ± 46.29 | 0.00004 |
| WBC counts, ×103/ml | 6.27 ± 1.80 | 6.96 ± 2.05 | 0.009 |
| Neutrophil counts, ×103/ml | 3.52 ± 1.30 | 4.21 ± 2.00 | 0.003 |
| NLR | 1.89 ± 0.89 | 2.28 ± 1.83 | 0.048 |
| hs-CRP, mg/dl | 0.18 ± 0.30 | 0.18 ± 0.29 | 0.960 |
Abbreviations: 8-iso-PGF2α, 8-iso-prostaglandin F2α; hs-CRP, high sensitivity C-reactive protein; NLR, neutrophil to lymphocyte ratio; WBC, white blood cell.
TABLE 2 Factors associated with 8-iso-PGF2α
| Variable | Univariate | Multivariate | ||
| β ± SE | p-value | β ± SE | p-value | |
| Age, year | −0.166 ± 0.290 | 0.567 | ||
| AF | 25.075 ± 5.974 | <0.001 | 22.635 ± 6.696 | 0.001 |
| AF duration, month | −0.013 ± 0.102 | 0.895 | ||
| BMI, kg/m2 | 1.590 ± 0.873 | 0.070 | ||
| Smoking | 0.798 ± 7.543 | 0.916 | ||
| DM | 7.283 ± 8.745 | 0.406 | ||
| CHA2DS2VASc | −3.221 ± 2.583 | 0.214 | ||
| Hb, g/dl | 3.775 ± 2.039 | 0.066 | ||
| TG, mg/dl | 0.079 ± 0.036 | 0.031 | 0.073 ± 0.037 | 0.051 |
| hs-CRP, mg/dl | 3.244 ± 10.495 | 0.758 | ||
| NT-proBNP, pg/ml | 0.000 ± 0.005 | 0.948 | ||
| LA AP diameter, mm | 1.403 ± 0.542 | 0.010 | ||
| Haplotype “CCGGT” | 18.799 ± 8.775 | 0.034 | 17.123 ± 8.641 | 0.049 |
Abbreviations: AF, atrial fibrillation; BMI, body mass index; DM, diabetes mellitus; Hb, hemoglobin; hs-CRP, high sensitivity C-reactive protein; LA AP, left atrial anteroposterior; NT-proBNP, N-terminal pro-B-type natriuretic peptide; TG, triglyceride.
FIGURE 1 Boxplot depicting the difference of the 8-iso-PGF2α level depending on the presence of a C-C-G-G-T haplotype in the non-AF and AF groups. 8-iso-PGF2α, 8-iso-prostaglandin F2α; AF, atrial fibrillation.
PP-076-2-AF The role of soluble ST 2 on the progression and therapeutic effect of atrial fibrillation Dr Hong-Ju Kim1, M.D, Ph.D. Dong-Gu Shin1 1Yeungnam University Medical Center, Daegu, South KoreaObjectives: Soluble ST2 acts as a decoy receptor and is known as a pathophysiological mediator of myocardial fibrosis. Soluble suppression of tumorigenicity 2 (sST2) is a strong risk predictor in patients with heart failure (HF) and provides additional prognostic value to NT-proBNP. This study aims to investigate the value of sST2 in atrial fibrillation (AF) patients.
Materials and Methods: A total of 628 consecutive patients were divided into two groups: 551 AF (192 paroxysmal AF and 358 persistent AF, 114 asymptomatic AF and 436 symptomatic AF), and 77 non-AF control groups. The propensity score matching method was used to correct the difference in baseline characteristics between the groups.
Results: The mean sST2 value between the AF group and the control group were 28.41 ± 16.56 ng/ml and 22.53 ± 10.31 ng/ml, respectively (p = 0.010). The mean sST2 value in patients with persistent AF was higher than in patients with paroxysmal AF (34.66 ± 28.79 ng/ml vs. 28.66 ± 16.83 ng/ml, p = 0.013). In the symptomatic AF group, the mean sST2 value was higher than in the non-symptomatic AF group, but there was no statistically significant difference (33.13 ± 21.27 ng/ml vs. 31.16 ± 22.18, p = 0.493). The mean sST 2 value of the pre-ablation group was higher than that of the post-ablation group (48.20 ± 43.22 ng/ml vs. 24.85 ± 11.39 ng/ml, p = 0.000).
Conclusion: Mean sST2 was higher in AF, persistent AF, and symptomatic AF patients and decreased after ablation. anST2 is an effective biomarker that can predict the progression and therapeutic effectiveness of AF.
SUPPORTING DOCUMENTS
FIGURE 1
| Variables | Total population | PS matched population | ||||
| PaAF (n = 192) | PeAF (n = 358) | p-value | PaAF (n = 192) | PeAF (n = 192) | p-value | |
| Soluble ST2 (sST2) | 28.66 ± 16.83 | 35.83 ± 27.65 | 0.001 | 28.66 ± 16.83 | 34.66 ± 28.79 | 0.013 |
Soluble ST2 level was significantly higher in AF than the control group in the total population, and PS matched population.
FIGURE 2
| Variables | Total population | PS matched population | ||||
| PaAF (n = 192) | PeAF (n = 358) | p-value | PaAF (n = 192) | PeAF (n = 192) | p-value | |
| Soluble ST2 (sST2) | 28.66 ± 16.83 | 35.83 ± 27.65 | 0.001 | 28.66 ± 16.83 | 34.66 ± 28.79 | 0.013 |
FIGURE 3
| Variables | Total population | PS matched population | ||||
| PaAF (n = 192) | PeAF (n = 358) | p-value | PaAF (n = 192) | PeAF (n = 192) | p-value | |
| Soluble ST2 (sST2) | 28.66 ± 16.83 | 35.83 ± 27.65 | 0.001 | 28.66 ± 16.83 | 34.66 ± 28.79 | 0.013 |
The soluble ST2 level in symptomatic AF was higher, but there was no statistically significant difference.
FIGURE 4
| Variables | Total population | ||
| Before RFA (n = 96) | After RFA (n = 96) | p-value | |
| Soluble ST2 (sST2) | 48.20 ± 43.22 | 24.85 ± 11.39 | 0.000 |
The soluble ST2 level decreased significantly after RF ablation.
PP-078-2-AF Omnipolar Electrograms are more consistent and improve substrate characterization in human atrial flutter Dr Dimitrios Panagopoulos1, Dr Bradley Porter1, Mr Steven Kim3, Dr Nick Linton2, Dr Fu Siong Ng2, Dr Lousia Malcolm-Lawes1, Professor Prapakaran Kanagaratnam2, Professor Nicholas S Peters2, Dr Phang Boon Lim1, Dr Norman Qureshi1 1Imperial College London Healthcare NHS Trust, London, UK, 2Imperial College London, London, UK, 3Abbott, St Paul, USAObjectives: To investigate the difference between peak-to-peak voltage of omnipolar and bipolar electrograms in atrial flutter (AFL).
Materials and Methods: This study has been approved by an ethical committee. We recruited 18 patients with typical AFL. 10 s segments were recorded in areas of the Right Atrium using the HD Grid catheter and Precision. Beat-to-beat correlation curves were calculated as a surrogate for catheter stability (Figure 1A) and only highly stable (Pearson's r > 0.7) segments were analysed. Omnipolar (OPV) and the maximum (maxBPV) voltage on the vertical (Along—AL) or horizontal (Across—AC) bipolar pairs were compared (Figure 1B).
Results: OPV mean was 0.25 mV higher than the maxBPV mean and 0.69 mV higher than the overall BPV mean (p < 0.001). This difference was observed along all segments (Figure 2C).
OPV highly correlated (mean Pearson's r: 0.98) with maxBPV for each bipolar pair and was always higher (OPV: 2.41 ± 2.88 mV vs. maxBPV: 2.16 ± 2.55 mV, p < 0.001) (Figure 2B). OPV was more consistent on a beat-to-beat basis than either AL or AC BPV individually (Coefficient of Variation: OTV 0.34 ± 0.2 vs. AC 0.58 ± 0.57 and AL 0.43 ± 0.24, p < 0.001) (Figure 2A).
Conclusion: The ability of Omnipolar electrograms to record maximum voltage irrespective of current direction increases the sensitivity of detecting healthy tissue. Higher beat by beat consistency increases confidence in the fidelity of the maps created. Omnipolar mapping has the potential to improve detection of scar border zones which may serve as isthmuses for arrhythmia maintenance and therefore improve ablation outcomes.
SUPPORTING DOCUMENTS
PP-079-2-AF Role of low voltage region ablation in the treatment of persistent atrial fibrillation Dr Dimitrios Panagopoulos1, Dr Szabolcs Nagy1, Mr Steven Kim3, Ms Smaragda Lampridou1, Dr Fu Siong Ng1, Dr MIchael Koa-Wing1, Professor Prapakaran Kanagaratnam2, Professor Nick S Peters2, Dr Phang Boon Lim1, Dr Norman Qureshi1 1Imperial College London Healthcare NHS Trust, London, UK, 2Imperial College London, London, UK, 3Abbott Inc., St Paul, USA
Objective: To evaluate the clinical efficacy of additional ablation of low voltage regions, mapped in AF, in conjunction with pulmonary vein isolation (PVI).
Materials and Methods: This study has been approved by an ethics committee. We compared the effectiveness of additional radiofrequency ablation of low voltage regions in AF (<0.35 mV) to PVI.
Results: We have complete follow-up in 22 patients (median: 24 m, IQR: 9 m). All patients are at least 12 months after their procedure. Fifteen patients remain in SR (68%) with seven recurrences when compared to 59% of a historical control (p = 0.63) (Figure 2). Twelve patients remain in SR off antiarrhythmics (54.5%).
Conclusion: Ablation of low voltage areas in addition to PVI appears to offer an incremental benefit for the PsAF population. Although not statistically significant there is a trend of curve separation. Further randomized studies are needed to better assess this effect.
SUPPORTING DOCUMENTS
Twenty-two PsAF patients undergoing PVI were recruited. Voltage maps were created using 8 s segments of AF with the AFOCUSII catheter and Precision (Figure 1B). Standard PVI was performed in all patients, followed by scar-based ablation in the form of scar homogenization, transection or “boxing” of the low voltage areas (Figure 1A), anchoring to points of non-conductive tissue.Patients were followed up with a clinic review in 3 and 12 and Holter in 3, 6 and 12 months. We defined as recurrence, any atrial arrhythmia lasting more than 30 s, after a blanking period of 3 months. Results were compared to a contemporary historical control.
PP-080-2-AF Resting heart rate and cardiovascular outcomes in patients with atrial fibrillation: CODE-AF Registry Dr Hanjin Park1, Prof Hee Yu1, Prof Tae-Hoon Kim1, Prof Junbeom Park2, Prof Jin-Kyu Park3, Prof Ki-Woon Kang4, Prof Jaemin Shim5, Prof Jin-Bae Kim6, Prof Jun Kim7, Prof Eue-Keun Choi8, Prof Hyung Wook Park9, Prof Young Soo Lee10, Prof Boyoung Joung1 1Yonsei University, College Of Medicine, Seoul, South Korea, 2Ewha Womans University, School of Medicine, Seoul, South Korea, 3Hanyang University Seoul Hospital, Seoul, South Korea, 4Eulji University Hospital, Seoul, South Korea, 5Korea University Medical Center, Seoul, South Korea, 6Kyung Hee University School of Medicine, Seoul, South Korea, 7Ulsan University School of Medicine, Seoul, South Korea, 8Seoul National University Hospital, Seoul, South Korea, 9Chonnam National University Medical School, Chonnam, South Korea, 10Catholic University of Daegu School of Medicine, Daegu, South Korea
Objective: The prognostic significance of resting heart rate and its therapeutic target in atrial fibrillation (AF) is uncertain. We sought to investigate the relationship between resting heart rate and cardiovascular outcomes in patients with AF.
Methods: A total of 8886 patients with AF was included from the Comparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry. Patients were categorized according to baseline heart rate, and cardiovascular outcomes were accessed during a median follow-up of 30 months. The primary outcome was a composite of cardiovascular death, hospitalization due to heart failure, and myocardial infarction/critical limb ischemia.
Results: Compared to heart rate ≥ 100 beats per minute (bpm), heart rate 80–99 bpm was associated with the lowest risk of primary outcome (adjusted hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40–0.79, p = 0.001). In subgroup of patients with heart failure with preserved ejection fraction (HFpEF), heart rate between 80 and 99 bpm was associated with reduced risk of primary outcome compared to heart rate ≥ 100 bpm (HR 0.40, 95% CI 0.16–0.98, p = 0.045). However, in patients with heart failure with reduced ejection fraction (HFrEF), there was no association between resting heart rate and cardiovascular outcomes (p for interaction 0.001).
Conclusion: Resting heart rate was associated with cardiovascular outcomes in patients with AF, and those with resting heart rate between 80 and 99 bpm had the lowest risk of adverse events. The impact of resting heart rate on adverse events persisted in patients with concomitant HFpEF but was not apparent in those with concomitant HFrEF.
SUPPORTING DOCUMENTS
PP-081-2-AF Oral anticoagulation therapy in atrial fibrillation patients with advanced chronic kidney disease: CODE-AF Registry Dr Hanjin Park1, Prof Hee Tae Yu1, Prof Tae-Hoon Kim1, Prof Junbeom Park2, Prof Jin-Kyu Park3, Prof Ki-Woon Kang4, Prof Jaemin Shim5, Prof Jin-Bae Kim6, Prof Jun Kim7, Prof Eue-Keun Choi8, Prof HyungWook Park9, Prof Young-Soo Lee10, Prof Boyoung Joung1 1Yonsei University, College Of Medicine, Seoul, South Korea, 2Ewha Womans University, School of Medicine, Seoul, South Korea, 3Hanyang University Seoul Hospital, Seoul, South Korea, 4Eulji University Hospital, Seoul, South Korea, 5Korea University Medical Center, Seoul, South Korea, 6Kyung Hee University School of Medicine, Seoul, South Korea, 7Ulsan University School of Medicine, Seoul, South Korea, 8Seoul National University Hospital, Seoul, South Korea, 9Chonnam National University Medical School, Chonnam, South Korea, 10Catholic University of Daegu School of Medicine, Daegu, South Korea
Objectives: Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no OAC among AF patients with advanced CKD or ESRD on dialysis.
Methods: Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] <30 ml/min per 1.73/m2) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC group, and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed.
Results: During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.05 to 0.95, p = 0.042). In addition, the risk of composite adverse clinical outcome (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.32, 95% CI 0.11 to 0.96, p = 0.043).
Conclusion: Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcome compared to no OAC.
PP-083A-2-AF Association of obesity with incident atrial fibrillation in Korea and the United Kingdom Dr Sung Hwa Choi1, Dr Pil-Sung Yang2, Asst Prof Daehoon Kim1, Dr Jung-Hoon Sung2, MS Eunsun Jang1, Asst Prof Hee Tae Yu1, Asst Prof Tae-Hoon Kim1, Prof Hui-Nam Pak1, Prof Moon-Hyoung Lee1, Dr Gregory Y.H Lip3, Prof Boyoung Joung1 1Yonsei University Health System, Seoul, South Korea, 2CHA Bundang Medical Center, Bundang, South Korea, 3University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UKObjective: Obesity has been linked to atrial fibrillation (AF) burden and severity, and epidemiological studies suggest that AF is more prevalent in whites than Asian or Afro-Caribbean populations. We aimed to investigate whether obesity mediates associations with AF in Europe and Asia using patient-level data comparisons of two cohort studies.
Methods and Methods: Using Korean National Health Insurance Service's Health Screening (NHIS-HealS) and U.K. Biobank data, we included 401,206 Korean and 477,926 British aged 40–70 years without previous AF who received check-ups. The incidence and risk of AF were evaluated regarding different body mass index (BMI) values.
Results: The obese proportion (BMI ≥30.0 kg/m2, 2.8% vs. 24.3%, p < 0.001) was higher in the United Kingdom than the Korean. In the Korean and the UK cohort, the age- and sex-adjusted incidence rates of AF were 3.52 and 3.95 per 1000 person-years among overweight individuals (BMI, 25 to <30 kg/m2), and 4.97 and 6.54 per 1000 person-years among obese individuals, respectively. Compared to Koreans, the risk of AF was higher in the British population, with adjusted hazard ratios of 1.16 (95% CI, 1.11–1.22) and 1.11 (95% confidence interval [CI], 1.04–1.19) in overweight participants and 1.69 (95% CI, 1.57–1.83) and 1.45 (95% CI, 1.30–1.62) in obese participants, respectively (p for interaction <0.05).
Conclusions: Obesity was associated with AF in both populations. British subjects had a greater incidence of AF related to the high proportion of obese individuals, but the risk of AF was also increased when separating participants into overweight and obese categories.
SUPPORTING DOCUMENTS
PP-083B-2-AF Clinical characteristics and mechanisms of very late recurrence of atrial fibrillation 5 years after catheter ablation. Dr Sung Hwa Choi1, Asst Prof Daehoon Kim1, Asst Prof Je-Wook Park1, Asst Prof Hee-Tae Yu1, Asst Prof Tae-Hoon Kim1, Assoc Prof Jae-Sun Uhm1, Prof Boyoung Joung1, Prof Moon-Hyoung Lee1, Prof Hui-Nam Pak1 1Yonsei University Health System, Seoul, South Korea
Background: Atrial fibrillation (AF) is a chronic progressive disease that recurs continuously even after successful AF catheter ablation (AFCA).
Objective: We explored the mechanism of this long-term recurrence by comparing the patient characteristics and redo-ablation findings.
Methods: Among 4248 patients who underwent a de novo AFCA and protocol-based rhythm follow-up at single centers, we enrolled 1417 patients (71.7% male, age 60.0 [52.0–67.0] years, 57.9% paroxysmal AF) who experienced clinical recurrences (CRs) of the disease, and divided them according to the period of recurrence: within 1 year (n = 645), 1–2 years (n = 339), 2–5 years (n = 308), and after 5 years (CR >5 years, n = 125). We also compared the redo-mapping and ablation outcomes in 198 patients.
Results: In patients with a CR >5 years, the proportion of paroxysmal AF was higher (p = 0.014); however, the left atrial (LA) volume (computed tomography, p = 0.003), LA voltage (p = 0.003), frequency of early recurrence (p < 0.001), and use of anti-arrhythmic drugs (p < 0.001) were lower. A CR >5 years was independently associated with the low LA volume (odds ratio [OR] 0.99 [0.99–1.00], p = 0.019), low LA voltage (OR 0.62 [0.41–0.95], p = 0.030), and lower early recurrence (OR 0.39 [0.23–0.64], p < 0.001). Extra-pulmonary vein (PV) triggers (p for trend 0.003) during repeat procedures were significantly greater in patients with a CR >5 years, despite no difference in the de novo protocol. The rhythm outcome of repeat ablation procedures did not differ with the timing of the CR (log-rank p = 0.330).
Conclusions: Patients with a later CR showed a smaller LA volume, lower LA voltage, and higher extra-PV triggers during the repeat procedure, suggesting progression of AF.
SUPPORTING DOCUMENTS
PP-084-V-AF Impact on Marshall vein of pulmonary vein isolation using cryoballoon ablation Dr Yasunori Hiranuma1, Dr Taiki Shiba1, Dr Junya Harada1, Dr Kousei Tanaga1, Dr Toshihisa Inoue, Dr Yoshitake Nakamura1 1Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
Objective: The effect of pulmonary vein isolation using cryoballoon on the Marshall vein is unknown.
Materials and Methods: A case report of a 74-year-old man who underwent pulmonary vein isolation using a cryoballoon for paroxysmal atrial fibrillation. A 2-F 8-pole electrode catheter was placed in the Marshall vein using a SL0 and 5-F multipurpose catheter to confirm the effect of cryo application to the left pulmonary vein on the potential of the Marshall vein preceding pulmonary vein isolation.
Pulmonary vein isolation was performed starting from the left pulmonary vein, sequentially cryo applicating and isolating the left superior pulmonary vein and the left inferior pulmonary vein.
Result: Marshall vein potential could not be identified during or after isolation of the left superior pulmonary vein, but during isolation of the left inferior pulmonary vein, an isolated potential that appeared to be Marshall vein potential appeared at 110 s (−40°C) after the start of cryo application, delayed from the atrial potential. The potential was further delayed by continued application and disappeared at 220 s after the start of application (minimum temperature −46°C).
Conclusion: It is suggested that cryoballoon ablation to the left pulmonary vein created a conduction block in part of the Marshall vein tract, which is a potential additional benefit to atrial fibrillation ablation with cryoballoon.
SUPPORTING DOCUMENTS
PP-085-V-AF Prolonged sinus pause on termination of atrial fibrillation after catheter ablation: A reversible phenomenon Dr Yi Guo1, Dr Hongwu Chen1, Dr Weizhu Ju1, Dr Gang Yang1, Dr Kai Gu1, Dr Zidun Wang1, Dr Hailei Liu1, Dr Jiaojiao Shi1, Dr Mingfang Li1, Dr Minglong Chen1 1Division Of Cardiology, The First Affiliated Hospital Of Nanjing Medical University, Nanjing, 中国
Objectives: We studied the time-related features of prolonged sinus pause (PSP) on termination of atrial fibrillation (AF) and the necessity of pacemaker implantation (PMI) in patients with this phenomenon post-radiofrequency catheter ablation (RFCA) for AF in the blanking period and the 1-year follow-up duration.
Materials and Methods: This prospective observational study included consecutive patients with PSP ≥3 s on termination of AF during hospitalization after RFCA for AF at our center between October 2020 and June 2022. After ablation, 24-h Holter monitoring was performed at 1 and 3 months, and 7-day Holter monitoring was performed at 6 and 12 months after RFCA in all patients.
Results: Eleven patients (mean age 63.2 ± 2.0 years, six female, and nine paroxysmal AF) were included. PSP ≥3 s on termination of AF initiated on 2.0 (IQR: 1.0–4.0) days and the longest PSP appeared on 3.0 (IQR: 1.0–5.0) days after ablation. PSP ≥3 s vanished on 6.5 (IQR: 3.8–8.3) days after ablation. One patient received permanent PMI during hospitalization. Two patients had temporary pacemaker implanted and removed before discharge, and no further PMI was needed. One patient was rehospitalized for permanent PMI in the blanking period, and an additional one patient had a single episode of PSP of 3 s on termination of AF during the 1-year follow-up.
Conclusion: PSP ≥3 s on termination of AF after RFCA could be reversible. This condition could be treated with cessation of anti-arrhythmic drugs or bridging with temporary PMI. Permanent PMI may be necessary in some circumstances.
PP-086-V-AF Real-world clinical outcomes of Oral anticoagulants among Japanese atrial fibrillation patients with coronary artery disease Ms Yijiao Chen1, Dr Gong Anne1, Mr Haikun Bao2 1Boehringer Ingelheim, Shanghai, China, 2Boehringer Ingelheim Pharmaceuticals, Inc., USAObjectives: Stroke prevention is complicated in patients with atrial fibrillation (AF) and coronary artery disease (CAD). We compared the risk of major bleeding among Japanese AF patients with CAD commencing warfarin, dabigatran or rivaroxaban.
Materials and Methods: This study included AF adults with CAD who were newly prescribed dabigatran, rivaroxaban (non-vitamin K antagonist oral anticoagulants [NOACs]) or warfarin, registered between 18 April 2011 and 31 December 2020 in the Medical Data Vision hospital-based clinical database (ClinicalTrials.gov: NCT05051904). Primary outcome was major bleeding. Secondary outcome was the composite of stroke/systemic embolism/myocardial infarction/all-cause inpatient mortality/major bleeding/major gastrointestinal bleeding/intracerebral brain hemorrhage. Cox proportional hazard models with stabilized inverse probability treatment weighting were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) via a two-step approach; first between warfarin and each NOAC, and then within NOACs if sample size conditions were met.
Results: Dabigatran, rivaroxaban and warfarin groups included 6712, 20,329, and 12,316 patients, respectively. Risks of major bleeding was lower in the NOAC versus warfarin treatment groups (dabigatran: HR 0.50, 95% CI: 0.40–0.62; rivaroxaban: HR 0.78, 95% CI: 0.69–0.90); this risk was lower with dabigatran when compared with rivaroxaban (HR 0.64, 95% CI: 0.51─0.79). The net clinical benefit was observed to be superior in both NOAC groups (dabigatran: HR 0.78, 95% CI: 0.71–0.85; rivaroxaban: HR 0.83, 95% CI: 0.78–0.88) compared with warfarin (Figure).
Conclusion: Among real-world Japanese AF patients with CAD, NOACs were associated with better clinical outcomes than warfarin. Dabigatran presented a lower risk of major bleeding than rivaroxaban.
SUPPORTING DOCUMENTS
PP-087-V-AF Dementia risk factors in patients with atrial fibrillation: A Nationwide cohort study Dr Yushan Huang1, PhD Yun-Yu Chen1, Dr Yenn-Jiang Lin1, Dr Fa-Po Chung1, Dr Yu-Cheng Hsieh2, Dr Kuo-Liong Chien3, Dr Shih-Ann Chen2 1Taipei Veteran General Hospital, Taipei, Taiwan, 2Taichung Veterans General Hospital, Taichung, Taiwan, 3National Taiwan University, Taipei, Taiwan
Objectives: The risk factors of dementia in patients with atrial fibrillation (AF) are not well understood. During long-term follow-up, this study examined risk factors associated with new-onset dementia risk in Asian patients with AF.
Methods: A total of 68,387 AF patients over the age of 18 years without prior history of dementia were identified from the Taiwan's National Health Insurance Research Database (NHIRD, 2013–2014), 2.3% AF patients had ablation therapy (N = 1561; Table 1). New onset of dementia of each subject was identified by ICD-9-CM (290.0–290.4, 294.1–294.2, 331.0)/ICD-10-CM (F01-F03, G30) codes. The Cox proportional hazards model was used to determine the hazard ratios (HRs) for events. C-index was calculated for comparing the prediction performance of 5-year dementia.
Results: During a median follow-up of 6.78 (IQR: 6.09–6.98) years, a total of 8704 new-onset dementia events occurred (avg 1.87% per patient-year). After multivariable adjustment, higher age (HR: 1.091, 95% CI: 1.089–1.094), male gender (HR: 1.25, 95% CI: 1.19–1.30), sleep apnea (HR: 1.13, 95% CI: 1.07–1.38), and prior stroke (HR: 1.26, 95% CI: 1.19–1.34) were associated with incidence of 5-years risk of dementia (Table 2). Both CHA2DS2-VASc and AF-CA-Stroke scores are significant risk factors for 5-year dementia. In contrast, dementia risk significantly decreased in AF patients who received ablation (HR: 0.74, 95% CI: 0.58–0.94; Table 1).
Conclusion: In a long-term follow-up study based on a national survey, we found that certain risk factors predicted the onset of new-onset dementia in patients with AF. Long-term new-onset dementia was reduced by rhythm control of catheter ablation.
SUPPORTING DOCUMENTS
FIGURE 1 Study flow chart.
TABLE 1 Baseline characteristics after propensity-score matching
| Variables | AF cohort (N = 68,387) | Gp 0: AF—No ablation (N = 66,826) | Gp 1: AF—ablation (N = 1561) | p-value |
| Age (years) | 66.8 ± 11.8 | 67.4 ± 11.7 | 56.4 ± 10.8 | <0.001 |
| Male gender (n, %) | 36,313 (53.1%) | 35,241 (52.7%) | 1072 (68.7%) | <0.001 |
| CHA2DS2-VASc | 1.78 ± 1.18 | 1.97 ± 1.18 | 1.18 ± 1.03 | <0.001 |
| AF-CA-Stroke | 8.47 ± 2.08 | 8.59 ± 1.92 | 3.11 ± 1.54 | <0.001 |
| Underlying diseases (n, %) | ||||
| Hypertension | 28,048 (41.0%) | 27,436 (41.1%) | 612 (39.2%) | <0.001 |
| Congestive heart failure | 12,767 (18.7%) | 12,621 (18.9%) | 146 (9.35%) | <0.001 |
| Diabetes mellitus | 8726 (12.8%) | 8595 (12.9%) | 131 (8.39%) | <0.001 |
| Hyperlipidemia | 7421 (10.9%) | 7165 (10.7%) | 256 (16.4%) | <0.001 |
| Hyperuricemia | 1305 (1.91%) | 1286 (1.92%) | 19 (1.22%) | 0.13 |
| Chronic kidney disease | 2466 (3.61%) | 2436 (3.65%) | 30 (1.92%) | <0.001 |
| Chronic liver disease | 741 (1.08%) | 724 (1.08%) | 17 (1.09%) | <0.001 |
| Chronic obstructive pulmonary disease | 3514 (5.14%) | 3480 (5.21%) | 34 (2.18%) | <0.001 |
| Thyroid disease | 1641 (2.40%) | 1590 (2.38%) | 51 (3.27%) | <0.001 |
| Sleep apnea | 1727 (2.53%) | 1664 (2.49%) | 63 (4.04%) | <0.001 |
| Prior stroke | 8523 (12.5%) | 8445 (12.6%) | 78 (5.00%) | <0.001 |
| Peripheral vascular disease | 964 (1.41%) | 953 (1.43%) | 11 (0.70%) | <0.001 |
| Coronary artery disease | 1226 (1.79%) | 1205 (1.80%) | 21 (1.35%) | <0.001 |
| Cardiomyopathy | 1010 (1.48%) | 977 (1.46%) | 33 (2.11%) | <0.001 |
| Rheumatic heart disease | 3542 (5.18%) | 3501 (5.24%) | 41 (2.63%) | <0.001 |
| Amyloidosis | 4 (0.01%) | 4 (0.01%) | 0 (0.00%) | 0.64 |
| Atrial flutter | 518 (0.76%) | 412 (0.62%) | 106 (6.79%) | <0.001 |
| Paroxysmal supraventricular tachycardia | 3831 (5.60%) | 3593 (5.38%) | 238 (15.3%) | <0.001 |
| Ventricular tachycardia | 310 (0.45%) | 287 (0.43%) | 23 (1.47%) | <0.001 |
Abbreviation: AF, atrial fibrillation.
TABLE 2 Risk factors of dementia risk in patients with atrial fibrillation
| Variables | Uni-variable model: Hazard ration (95% CI) | p-value | Multi-variable model: Hazard ration (95% CI) | p-value |
| Age (years) | 1.094 (1.092–1.097) | <0.001 | 1.091 (1.089–1.094) | <0.001 |
| Male gender (n, %) | 1.75 (1.68–1.83) | <0.001 | 1.25 (1.19–1.30) | <0.001 |
| Receiving AF ablation | 0.30 (0.24–0.39) | <0.001 | 0.74 (0.58–0.94) | 0.015 |
| Underlying diseases (n, %) | ||||
| Hypertension | 1.14 (1.10–1.19) | <0.001 | 1.007 (0.96–1.05) | 0.74 |
| Congestive heart failure | 1.05 (0.995–1.11) | 0.08 | N/A | N/A |
| Diabetes mellitus | 1.11 (1.05–1.18) | 0.001 | 1.05 (0.99–1.12) | 0.12 |
| Hyperlipidemia | 0.82 (0.76–0.88) | <0.001 | 1.02 (0.95–1.10) | 0.55 |
| Hyperuricemia | 0.88 (0.74–1.03) | 0.11 | N/A | N/A |
| Chronic kidney disease | 1.10 (0.98–1.23) | 0.11 | N/A | N/A |
| Chronic liver disease | 0.75 (0.60–0.95) | 0.016 | 1.001 (0.79–1.27) | >0.99 |
| Chronic obstructive pulmonary disease | 1.28 (1.17–1.39) | <0.001 | 0.93 (0.85–1.02) | 0.10 |
| Sleep apnea | 1.19 (1.05–1.34) | 0.007 | 1.13 (1.07–1.38) | 0.002 |
| Prior stroke | 1.58 (1.49–1.67) | <0.001 | 1.26 (1.19–1.34) | <0.001 |
| Peripheral vascular disease | 1.51 (1.30–1.75) | <0.001 | 1.06 (0.85–1.31) | 0.62 |
| Coronary artery disease | 1.06 (0.91–1.24) | 0.48 | N/A | N/A |
| Cardiomyopathy | 0.57 (0.46–0.72) | <0.001 | 0.91 (0.73–1.15) | 0.44 |
| Atrial flutter | 0.53 (0.39–0.74) | <0.001 | 0.92 (0.67–1.27) | 0.60 |
| Paroxysmal supraventricular tachycardia | 0.81 (0.74–0.90) | <0.001 | 1.08 (0.98–1.20) | 0.13 |
| Ventricular tachycardia | 0.74 (0.52–1.05) | 0.09 | N/A | N/A |
| Prediction performance | p-value for comparison | p-value | ||
| CHA2DS2-VASc | 0.588 (0.581–0.594) | <0.001 | 1.27 (1.25–1.29) | <0.001 |
| AF-CA-Stroke | 0.690 (0.686–0.695) | 1.29 (1.28–1.30) | <0.001 | |
Note: A p-value <0.05 in the uni-variable model were selected into multi-variable model.
CHA2DS2-VASc:
Congestive heart failure (point = 1), hypertension (point = 1), age ≥ 65 years (point = 1), age ≥ 75 years (point = 2), diabetes mellitus (point = 1), stroke (point = 2), vascular diseases (point = 1), female (point = 1).
AF-CA-Stroke:
Age (maximal point = 5), not receiving ablation of atrial fibrillation (point = 4), prior history of stroke (point = 4), chronic kidney disease (point = 2), diabetes mellitus (point = 1), and congestive heart failure (point = 1).
Abbreviations: CI, confidence interval; N/A, not available.
PP-088-V-AF Safety and efficacy of Oral anticoagulants use in atrial fibrillation patients after catheter ablation Dr Hao Huang1, Dr Chi Cai1, Dr Wei Hua1 1Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Beijing, ChinaObjectives: Given the lack of evidence on the safety and efficacy of warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) in Asian patients with atrial fibrillation (AF) after catheter ablation (CA), We made a comprehensive evaluation in a Chinese real-world cohort.
Materials and Methods: Nine hundred and forty-two AF patients receiving oral anticoagulation therapy for 3 months after CA were included. Perioperative OACs use and adverse events related to thromboembolism and bleeding were evaluated.
Results: 50.7% of AF patients eligible for CA did not take oral anticoagulants before the procedure. Rivaroxaban and dabigatran were the most prescribed anticoagulants after the procedure. The real-world data showed no significant difference in the incidence of major bleeding events (0.8% vs. 0.0% vs. 0.2%, p = 0.138) and thromboembolic events (0.8% vs. 0.9% vs. 1.3%, p = 0.908) among warfarin, dabigatran and rivaroxaban groups. Dabigatran group experienced less periprocedural bleeding (4.2% vs. 9.0%, p = 0.008), procedure-unrelated bleeding (3.9% vs. 8.7%, p = 0.008) and minor bleeding (4.2% vs. 9.0%, p = 0.008) than rivaroxaban, which was consistent in a propensity score-matched cohort and 11 subgroups. Mitral regurgitation was associated with bleeding risk in multivariable logistic regression analysis (OR = 1.557, 95% CI: 1.099–2.204, p = 0.013), the effect of which is more significant in the rivaroxaban group (p = 0.032).
Conclusion: No statistically significant difference was found in the risk of thromboembolic events and major bleeding events among several OACs in AF patients undergoing catheter ablation, while rivaroxaban was associated with a significantly higher risk of minor bleeding compared with dabigatran. Mitral regurgitation was another independent risk factor for preprocedural bleeding.
SUPPORTING DOCUMENTS
FIGURE 1 Pairwise comparisons of outcomes among different OACs.
FIGURE 2 Incidence of bleeding events in Dabigatran and Rivaroxaban groups with different levels of mitral regurgitation. PP-089-V-AF Perspectives of Chinese nurse from tertiary hospital on the Management of Atrial Fibrillation Dr Hao Wang1, Dr Yutao Guo2, Ms Lina Ren2, Ms Zifang Yin2, Ms Haiyan Li3 1Department of Cardiology, The Second Medical Centre, Chinese Pla General Hospital, Beijing, China, 2Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China, 3Department of Cardiology, The First Medical Centre, Chinese Pla General Hospital, Beijing, China
Objective: To understand the perceptions of Chinese nurses from tertiary hospitals regarding their role in the AF care pathway and any barriers or facilitators to optimal AF management in China.
Research Design and Methods: Three focus groups with nurses on the management of AF were conducted in Chinese PLA General between January 2020 and June 2021. Focus groups were facilitated by a topic guide based on literature review and experts' opinions.
Results: Our study demonstrated that the nurses from tertiary hospital of China were lacking of knowledge about AF management. Nurses expressed their limitation of knowledge concerning AF risk stratification (symptoms, stroke, and bleeding), choosing of appropriate anticoagulants, monitoring of drug's side effects, and nursing follow-up of AF patients. The nurses were keen to get access to training and education materials as well as developing useful tools aiding their management of AF patients. They also expressed concerns about nurses' career planning, lacking of personnel, respect (from doctors, patients, and public), and safety issue in medical environment.
Conclusion: Chinese nurses from tertiary hospital showed insufficient knowledge of AF management, which suggests that an educational materials and tools for AF might be beneficial to promote and support nurses in the China.
PP-090-1-BS Next generation sequencing mitochondrial DNA analysis in atrial fibrillation Assoc Prof Hsiang Chun Lee1, Dr. Yi-Hsiung Lin2 1Kaohsiung Medical University, Kaohsiung, Taiwan, 2Kaohsiung Medical University Hospital, Kaohsiung, TaiwanObjective: The mitochondrial function determines cardiac function and also affects arrhythmogenesis. Mitochondrial DNA (mtDNA) damage is linked to aging. We hypothesize that mtDNA changes are present in atrial myopathy and atrial fibrillation (AF).
Materials and Methods: This study prospectively had enrolled patients receiving elective coronary bypass grafting and/or valve surgery and subjects were divided into three groups: normal sinus (NS, n = 50), postoperative AF (POAF, n = 50), and chronic AF (CAF, n = 17). Small pieces of the right atrial appendage and blood samples were collected during the surgery before initiating the cardiopulmonary bypass. Buffy coat and tissues were frozen stored until the extraction of mtDNA. The mitoRNA-seq approach, which enriches full length mtDNA and minimizes contamination from the nuclear-encoded mtDNA sequences. The cutoff for missing data is of a site <30 mapped reads.
Results: Common single nucleotide variants (SNVs), POAF-specific and CAF-specific nucleotide changes were identified according to the MITOMAP database. Atrial mtDNA non-synonymous mutations and identified SNVs were shown to be highly correlated with POAF and CAF. In addition, nucleotide transition variants were found, including m.16A>T, m.189A>T (H-strand origins), m.310Cins (H-strand replication origin), and m.16304T>C in the D-loop control region of the mtDNA in the atrial tissues of CAF and POAF groups.
Conclusion: Several nucleotide changes of mtDNA in the atrial tissues were associated with POAF and CAF. Alterations in frequency of D-loop SNVs of mtDNA in peripheral leukocytes and atrial tissue were correlated with persistence of AF. This study provides new insights into the role of mtDNA nucleotide changes in AF.
PP-091-1-BS The evaluating lesion characteristics on high-power short duration in radiofrequency catheter ablation using simulation model Dr Keijiro Nakamura1, Mr Yao Sun2, Dr Yoshinari Enomoto1, Dr Yasutake Toyoda1, Dr Hidehiko Hara1, Dr Kaoru Sugi3, Dr Masao Moroi1, Dr Masato Nakamura1, Dr Xin Zhu2 1Toho University Ohashi Hospital, Meguro, Japan, 2University of Aizu, Aizu, Japan, 3Odawara Cardiovascular Hospital, Odawara, JapanIntroduction: There is increased interest in creating high-power short duration (HPSD) ablation lesions in the field of atrial fibrillation (AF), one of new technology in radiofrequency ablation (RFA), because it reduces procedure duration. However, the achieving durable lesion or improving safety are not well evaluated. We evaluated the lesion characteristics and potential complications produced by computer simulation model with multi-hole open-irrigated catheter.
Methods and Results: Total of four RFA setting including conventional setting (20 W and 35 W) and HPSD (50 W and 90 W) were tested using simulation system. And we also evaluate the effect of impedance in RFA lesion. Although the lesion volume was similar, the 90 W in RFA creates wider lesions compared to 50 W (Figure 1). In all four settings, there was an inverse relationship between the increase in Imp at the start of ablation and lesion size, with a tendency for lesions to become smaller as Imp increased. Furthermore, when ablation time exceeded 3 s, the ablation layer with a deep temperature of 100°C or higher increased linearly and significantly compared to the 50 W setting (Table 1).
Conclusion: The assessment of computer simulation maximizes clinical benefit in optimum power and duration in RFA application maximizes clinical benefit and may help to avoid complications.
SUPPORTING DOCUMENTS
PP-092-1-BS Antiarrhythmic effects of exosome extracted from atrial fibrillation patients by inhibiting HDAC6 Dr Hyoeun Kim1, Dr Dasom Mun1, Dr Ji-Young Kang1, Research Professor Nuri Yun2, Professor Boyoung Joung1 1Yonsei University Of Medicine, South Korea, 2Yonsei University, South Korea
Objective: This study evaluated the effect of exosome from AF patients on electrical characteristics, Ca2+ release, histone deacetylases 6 (HDAC6) of HL-1 cells using tachypacing model.
Methods: Exosome was isolated from peripheral blood of AF (AF-Exo) and healthy control patients (Con-Exo) by Exo-quick. We were analyzed contents of miRNA, which were derived exosomes, using the Affymetrix GeneChip miRNA 3.0 array. The effects of AF-Exo and Con-Exo on tachypacing (5 Hz) model of HL-1 atrial cardiomyocytes were examined using a confocal microscopy.
Results: In tachypacing model of HL-1 atrial cardiomyocytes, Ca2+ wave frequency were increased and amplitude were decreased. In contrast, AF-Exo reduced Ca2+ wave frequency (53%, p = 0.015) and recovery of Ca2+ transient amplitude (41%, p = 0.021). However, Con-Exo had no effect. Tachypacing induced contractile dysfunction was prevented by AF-Exo, but not by Con-Exo. The depolymerization of microtubules through Histone Deacetylase-6 (HDAC-6) were increased by the duration of tachypacing. The increase in depolymerization of microtubules was prevented by AF-Exo, but not by Con-Exo. In HL-1 tachypacing model, total CaMKIIδ (T-CaMKII) and phosphorylated CaMKIIδ (P-CaMKII) protein expression were significantly increased but AF-Exo reduced the ratio of T-CaMKII and P-CaMKII (42%, p = 0.001). Finally, the level of miR-548az-5p, which is related with HDAC6 and CaMKII was significantly increased in AF-Exo.
Conclusions: Exosome was isolated from peripheral blood of AF but not control patients protects against AF-related atrial remodeling, by reducing HDAC6. Inhibition of HDAC6 with exosome from AF patients protects against AF remodeling, indicating exosome delivery as an effective therapeutic target in clinical AF.
PP-093-1-BS PITX2c impairment electrical remodeling increases susceptibility to atrial fibrillation Ms Dasom Mun1, Ms Ji-Young Kang1, Ms Yumin Chun1, Ms Da-Seul Park, Ms Hyoeun Kim1, Mr Nuri Yun2, Mr Boyoung Joung1 1Yonsei University College of Medicine, South Korea, 2Yonsei University, South KoreaObjectives: Functional mutations in the PITX2 (paired-like homeodomain transcription factor 2) gene have been shown to cause genetically inherited atrial fibrillation (AF). However, the mechanisms of pathogenesis remain poorly understood. Here, we aimed to develop PITX2c knock-out human iPSC atrial cardiomyocytes (hiPSC-atrial CMs) and understand the mechanism of PITX2 insufficiency leading to AF.
Materials and Methods: Generated a PITX2 knock-out iPSC line using CRISPR/Cas9-based genome editing system. hiPSCs were electroporated with Cas9/sgRNA ribonucleoprotein (RNP) complexes. hiPSC-CMs were differentiated into atrial CMs by treatment of retinoic acid (1 μM). For the 3D culture model, cells were plated at 250,000 cells/well in the spherical plate 5D. Electrophysiological properties and oxidative stress were assessed in PITX2c-deficient cardiomyocytes. Proarrhythmic effects of the PITX2c knock-out were quantified with AP morphology, AP duration (APD) restitution, wavelength (WL), and conduction velocity (CV) restitution using microelectrode arrays (MEA).
Results: PITX2c knock-out hiPSC-CMs differentiated into atrial cardiomyocytes, based on the manipulation of retinoic acid signaling. We demonstrated that atrial-specific differentiated hiPSC-CMs expressed atrial-specific genes and the properties of action potentials were like those of human atrial cardiomyocytes. Both 2D and 3D PITX2c knock-out atrial hiPSC-CMs showed signs of APD shortening and reduced WL and increased CV restitution. In addition, a functional assessment of calcium homeostasis has shown that PITX2c causes atrial arrhythmias by impairing calcium handling genes.
Conclusion: This study provides an understanding of electrical remodeling by PITX2c loss-of-function mutations, leading to an understanding of the development of arrhythmias.
PP-094-1-BS Engineered exosomes with cardiac targeting peptide for treatment of cardiac hypertrophy Dr Ji-Young Kang1, Dr Dasom Mun1, Dr Hyoeun Kim1, Dr Nuri Yun2, Prof Boyoung Joung1, Yumin Chun1, Da-seul Park1 1Yonsei University College Of Medicine, Seoul, South Korea, 2Yonsei University, Seoul, South KoreaObjectives: Exosomes have gained attention as nanocarrier; however, the poor targeting ability after systemic administration restrict exosomes' clinical application. Therefore, this study aimed to develop exosomes endowed with heart-targeting properties to serve as a promising therapeutic tool for cardiac hypertrophy.
Materials and methods: We firstly generated heart-targeted delivery system (CTP-Exo) by engineering the surface of exosomes with cardiac targeting peptide (CTP) using genetic modification. Next, we loaded siRNA into CTP-Exo, and siRNA-mediated cardioprotective effects were examined in angiotensin II (Ang II)-treated human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) and mice.
Results: We confirmed that generated cell line released exosomes (CTP-Exo), which highly express CTP on their surface. Isolated CTP-Exo had typical exosome properties, such as ~150 nm rounded or cup-shaped morphology, and the presence of marker proteins. Compared with unmodified-Exo, CTP-Exo specifically accumulated in the heart (p < 0.05). In addition, siRNA-loaded CTP-Exo (siRNA/CTP-Exo) exerted strong cardioprotective effects with excellent heart-targeting ability. In Ang II-treated iPSC-CMs, siRNA/CTP-Exo exhibited the decreased ROS production; the decreased cell surface area; and the upregulation of the hypertrophic markers (ANP, BNP, and b-MHC). After intravenous injection of siRNA/CTP-Exo in Ang II-treated mice, there was a significant improvement in cardiac function with reduced cardiomyocyte cross-sectional areas (p < 0.05).
Conclusion: Taken together, our results suggest that CTP-Exo function as efficient vehicles for heart-targeted delivery of siRNA, which in turn may potentially be used for the treatment of cardiac hypertrophy.
PP-095-1-BS Lamp2Y228* knock-in mouse models successfully simulated clinical manifestations of patient with Danon disease Dr. Wei Lai1,2, Ms Dandan Zhang1,2, Dr. Rong Wan2, Mr Yuhao Su1,2, Ms Yang Liu1,2, Dr. Qinmei Xiong1, Dr. Juxiang Li1, Dr. Yang Shen2,3, Dr. Ali J Marian4, Dr. Kui Hong1,2,3 1Department Of Cardiovascular Medicine, The Second Affiliated Hospital Of Nanchang University, Nanchang, China, 2Jiangxi Key Laboratory of Molecular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China, 3Department of Genetics Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Nanchang, China, 4Center for Cardiovascular Genetics, Institute of Molecular Medicine, The University of Texas Health Science Center-Houston, Houston, USAObjectives: Danon disease (DD) is a rare X-linked lysosomal storage disorder caused by mutations in the gene encoding the lysosome-associated membrane protein 2 (LAMP2). It is characterized by glycogen accumulation, cardiac and skeletal myopathy, and intellectual disability. LAMP2 is a key mediator of the lysosome-mediated autophagy degradation pathway, which is required for lysosome biogenesis. Although abnormal macroautophagy has been implicated in the pathogenesis of DD, its pathogenesis has remained largely unknown.
Materials and methods: DNA samples from a young patient with DD and his family members were analyzed by whole-exome sequencing and the key findings were confirmed by Sanger sequencing. A knock-in mouse model carrying the homologous Lamp2-Y228* was generated.
Results: The proband was a 17-year-old boy presenting with severe left ventricular hypertrophy, heart failure, and skeletal myopathy. A c.669T>G de novo nonsense variant in the LAMP2 gene, which generated a premature stop codon (p. Tyr223Ter). Knock-in of the mutation into the mouse Lamp2 gene (Lamp2Y228*) led to a phenotype resembling the typical DD, including the short PR interval, pre-excitation pattern on electrocardiogram, a smaller body size, lower body weight, and higher mortality. Transmission electron microscopy and immunofluorescence assay showed an aberrant accumulation of autophagolysosome and glycogen in the heart tissue.
Conclusion: Our findings suggest that Lamp2-Y228* mouse models successfully reproduce clinical manifestations of patient with Danon disease, which will further be used to explore the exact role of LAMP2 in an impaired autophagy causing Danon disease.
PP-096-1-BS Myocardial injury, inflammation and pro-thrombotic response after pulsed-field ablation in animal models Dr Suraya Hani Kamsani1, Dr Mehrdad Emami1, Mr Darius Chapman2, Mr Twins Yiu3, Mr Milanjot Assi3, Mr Stephen Walsh3, Mr Ian Fong3, Prof Prashanthan Sanders1 1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia, 2Flinders University, Adelaide, Australia, 3CathRx, Rydalmere, AustraliaBackground: Radiofrequency ablation is known to cause significant myocardial injury as well as a substantial increase in various inflammation markers. The effect of pulsed-field ablation (PFA) on these parameters in animal studies is unclear.
Objectives: We aimed to evaluate the immediate extent of myocardial injury, inflammation and pro-thrombotic response occurring during PFA procedure in porcine models.
Materials and Methods: Eleven healthy swine underwent pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) line ablation using an integrated prototype PFA system with three different voltage protocols (1800, 2300 and 2800 V). Levels of C-reactive protein (CRP), Troponin-T, D-dimer, along with white cell counts (WCC) were measured pre and post-ablation.
Results: Mean number of PFA applications per animal was 26 ± 7.2. There was no significant difference between the levels of CRP (p = 0.5) and D-dimer (p = 0.09) before and after ablation. On the other hand, Troponin-T levels increased significantly from a median of 16–399 ng/L (p < 0.05). There was also a significant increase in WCC from a mean of 14.4 ± 2.9 (×109/L) to 17.9 ± 3.7 (×109/L) (p < 0.05) along with neutrophil counts from 5.0 ± 1.8 to 14.4 ± 2.9 ng/L (p < 0.05). None of the animals had any intraprocedural complications.
Conclusion: This acute animal model showed that there was significant myocardial injury and some inflammation response without pro-thrombotic response immediately after pulsed-field ablation. Further data are needed to assess the significance of these findings.
PP-097-2-BS Renal denervation ameliorates the activated inflammatory response through JAK2-STAT3 pathway in a COSA animal model Ms Yu-Hui Chou1,2, Dr Li-Wei Lo1,2, Ph.D Ya-Wen Hsiao1, Ph.D Wei-Lun Lin1,2,5, Dr Shin-Huei Liu1,2, Dr Shih-Ann Chen1,2,3,4 1Taipei Veterans General Hospital, Taipei, Taiwan, 2National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Taichung Veterans General Hospital, Taichung, Taiwan, 4National Chung Hsing University, Taichung, Taiwan, 5Mackay Medical College, New Taipei City, TaiwanObjective: The role of STAT3 in the chronic obstructive sleep apnea (COSA) remains unclear. The main objective of the study was to explore the possible mechanisms in rabbit model with COSA and its change after renal artery sympathetic denervation (RDN).
Materials and Methods: Eighteen rabbits were injected at the tongue base under endoscopic guidance with normal saline (sham control) or liquid silicone (COSA and COSA-RDN) 1 month prior to the experiment, respectively. Combined surgical and chemical RDNs were approached through bilateral retroperitoneal flank incisions in COSA-RDN 2 months prior to the experiment. Immunoblots and real time PCR were evaluated after experiment.
Results: The expression of p-JAK2 and p-STAT3 was decreased significantly in OSA compared to sham control and the phosphorylation of JAK2 and STAT3 was up-regulated after RDN treatment compared to COSA group. The activation of NF-kB was up-regulated in OSA rabbit model compared to sham control, and after RDN treatment, the expression of NF-kB was reduced and there was no difference between control.
Conclusions: The phosphorylation of both JAK2 and STAT3 decreased in COSA, but up-regulated after RDN in COSA rabbits, suggesting the inflammatory response in sleep disordered breathing is prevented by RDN through the JAK2-STAT3 signaling pathway.
PP-098-2-BS Renal sympathetic denervation downregulates the inflammatory response elicited by chronic obstructive sleep apnea Dr Ya-Wen Hsiao1, Dr Li-Wei Lo1, Mrs Yu-Hui Chou1, Dr Wei-Lun Lin1, Dr Shin-Huei Liu1, Dr Shih-Ann Chen2 1Taipei Veterans General Hospital. Heart Rhythm Center And Division Of Cardiology, Department Of Medicine, Taipei, Taiwan, 2Taichung Veterans General Hospital, Taichung, TaiwanObjective: The inflammatory markers associated with cardiovascular risk have been reported as elevated in patients with chronic obstructive sleep apnea (COSA). The main objective of the study was to explore the effects of RDN on inflammatory factors in an animal model of COSA.
Materials and Methods: Eighteen rabbits were injected at the tongue base under endoscopic guidance with normal saline (sham control) or liquid silicone (COSA and COSA-RDN). Combined surgical and chemical RDNs were approached through bilateral retroperitoneal flank incisions. H&E stain, real time PCR and ELISA were evaluated after experiment.
Results: The immune cell infiltration was found in COSA when compared to control, and it decreased after RDN treatment. The level of anti-inflammatory cytokine (IL-10) was decreased significantly in COSA (13.82 ± 6.56), when compared to sham control (33.12 ± 13.81, p < 0.01), and it up-regulated after RDN (26.47 ± 9.46) treatment, when compared to COSA. The level of pro-inflammatory cytokine IL-6 and TNF-α were increased significantly in OSA (IL-6:46.62 ± 16.7, TNF-α: 30.8 ± 6.14) compared to sham control (IL-6: 22.71 ± 6.4, TNF-α 17.6 ± 4.62, p < 0.01), respectively, those mediates were down-regulated after RDN (IL-6:37.12 ± 10.39, TNF-α 23.4 ± 4.35) treatment, when compared to COSA (p < 0.05).
Conclusions: Sleep disordered breathing significantly increased the pro-inflammatory cytokines and lead to an inflammatory reaction in atrium and ventricle, and it can be prevented by RDN by decreasing of those inflammatory mediators.
PP-099-2-BS In silico population modelling implicates reduced INaL in abnormal QT adaptation in a LQT2 patient Dr Nicholas Kerr1, Dr Chai Ng2, Dr Bruce Walker2, A/Prof Rajesh Subbiah1, Dr Adam Hill2, Prof Jamie Vandenberg2 1Cardiology Department, St Vincent's Hospital, Sydney, Australia, 2Victor Chang Cardiac Research Institute, Sydney, AustraliaObjective: QT adaptation, the heart-rate dependence of ventricular repolarization, has important implications for both diagnosis of LQTS and development of arrhythmia in response to triggers, for example, the alarm clock response. We report a case of a 28-year-old female who presented with recurrent syncope and cardiac arrest post-partum who displayed markedly abnormal QT adaptation on standing ECG. A variant was found in KCNH2 which resulted in 51% loss of hERG current measured in vitro. To investigate possible mechanisms underlying failure of QT adaptation in this patient we used an in silico population modelling approach.
Methods: Populations of models were generated by randomly varying the levels of expression of ion channels in the Tomek model of the human ventricular myocyte. Ramp rate simulations started at a cycle length of 1500 ms and decreased in 50 ms increments to 700 ms.
Results: The APD decrease during the ramp protocol varied from 15.9 to 32.8 ms for models with moderately prolonged baseline APD. The subgroup of models that showed the least APD adaptation were those with lowest late sodium current expression. Hypokalaemia exacerbated the baseline APD prolongation across the entire population. In the presence of hypokalaemia, the low INaL subgroup still showed the least APD adaptation.
Conclusions: Individuals with LQT2 and low expression of INaL may be more susceptible to QT prolongation during sudden heart rate acceleration, such as occurs in the alarm clock response. Population in silico modelling is an efficient way to identify subgroups of patients susceptible to different arrhythmogenic triggers.
PP-100-2-BS Potential role of aquaporin 4 channel regulation related to atrial remodeling in atrial fibrillation Dr Hyewon Park1, Dr Yeji Kim1, Dr Hyelim Park2, Pf Junbeom Park1 1Ewha Womans University, Seoul, South Korea, 2Inha University School of Medicine, Incheon, South KoreaObjective: Atrial fibrillation (AF) is the most common persistent arrhythmia in clinical practice. Aquaporins (AQPs) are a family of small membrane proteins that transport water and have been implicated in cardiovascular disease. They also found a relation between AQP4 and cardiac edema from increased AQP4 in patients with preserved ejection heart failure. The purpose of this study is to find the relationship between AF and AQP4 expression at in vitro levels, and to investigate the potential of AQP4 as a therapeutic target in AF.
Materials and Methods: The experiment used HL-1 Cell, and each cells were classified control, AF induced group by treated angiotensin II (Ang II), and Ang II + AQP4 blocker (TGN-020) group (AQP4-B).
Results: In AQP4-B group, the fibrosis marker (Col Iα, Col IIIα, TGF- β1) increased (1 ± 0.1 vs. 3.8 ± 0.3, 1 ± 0.1 vs. 2.1 ± 0.2, 1 ± 0.1 vs. 2.4 ± 0.2, p < 0.001), and CaMKII and RyR2 decreased (1 ± 0.1 vs. 2.8 ± 0.1, 1 ± 0.1 vs. 2.2 ± 0.1, p < 0.001) whereas SERCA2a increased. In calcium Release image, it was observed that the AQP4-B group had a low regular intensity. Connexin mRNA expression went down in the Ang II group compared to the control group and recovered in the AQP4-B group. The expression patterns of fibrosis marker, calcium-handling proteins and Connexin 40 and 43 were confirmed by quantitative real-time PCR, respectively.
Conclusions: The findings highlight the importance of calcium handling protein phosphorylation changes in fibrosis-induced AF and support miR-423 detection in human urine as a potential novel approach of AF diagnosis.
PP-101-2-BS Effect of macrophage migration inhibitory factor on pulmonary vein arrhythmogenesis through late sodium current Dr Chye Gen Chin1, Dr Yao-Chang Chen2, Dr Yi-Jen Chen1 1Wanfang Hospital, Taiwan, 2National Defense Medical Center, TaiwanObjectives: Macrophage migration inhibitory factor (MIF), a pleiotropic inflammatory cytokine, is highly expressed in patients with atrial fibrillation (AF). Inflammation increases the risk of AF and is primarily triggered by pulmonary vein (PV) arrhythmogenesis. This study investigated whether MIF can modulate the electrical activity of the PV and examined the underlying mechanisms of MIF.
Methods: A conventional microelectrode, a whole-cell patch clamp, Western blotting, and immunofluorescent confocal microscopy were used to investigate electrical activity, calcium (Ca2+) regulation, ionic currents, and cytosolic reactive oxygen species (ROS) in rabbit PV tissue and isolated single cardiomyocytes with and without MIF incubation (100 ng/ml, treated for 6 h).
Results: The MIF-treated PV tissue (n = 8) demonstrated a faster beating rate, higher incidence of triggered activity, and premature atrial beat than the control PV tissue. Compared with the control PV cardiomyocytes, MIF-treated single PV cardiomyocytes had larger Ca2+ transients, sarcoplasmic reticulum Ca2+ content, and cytosolic ROS. Moreover, MIF-treated PV cardiomyocytes exhibited larger late sodium currents (INa-Late¬), L-type Ca2+ currents, and Na+/Ca2+ exchanger currents than the control PV cardiomyocytes. KN93, ranolazine and N-MPG reduced the beating rates and the incidence of triggered activity and premature captures in the MIF-treated PV tissue.
Conclusions: MIF increased PV arrhythmogenesis through Na+ and Ca2+ dysregulation through the ROS activation of CaMKII signaling, which may contribute to the genesis of AF during inflammation. Anti-CaMKII treatment may reverse PV arrhythmogenesis. Our results clearly reveal a key link between MIF and AF and offer a viable therapeutic target for AF treatment.
SUPPORTING DOCUMENTS
PP-103-2-BS Irisin modulates electrical activity and calcium homeostasis in left atrial cardiomyocytes Dr Yuan Hung1, Professor Yao-Chang Chen1, Professor Wei-Shiang Lin1 1National Defense Medical Center, Taipei City, Taiwan
Objectives: Irisin is an exercise-induced metabolic hormone secreted primarily by skeletal and cardiac muscle cells. Small amounts of this myokine have been detected in adipose tissue, brain, subcutaneous glands, liver, stomach, spleen, and testis. Several studies demonstrated three therapeutic potentials of irisin, including anti-inflammatory, anti-oxidative, and anti-apoptotic effects. The purpose of the present study was to investigate whether irisin could modulate the left atrium (LA) cardiomyocyte electrical activity and study potential mechanisms.
Materials and Methods: Conventional microelectrode and whole-cell patch clamp were used to investigate the action potentials and ionic currents in isolated rabbit LA tissue preparations or single cardiomyocytes before and after irisin treatment. Calcium transients were used to study intracellular calcium dynamics.
Results: Irisin significantly reduced LA tissue resting membrane potential, action potential duration (APD)20, and APD50 in a dose-dependent response. Acute application of irisin could suppress trigger activities induced by isoproterenol (1 μM) in LA. In whole-cell patch clamp examinations, irisin (10 ng/ml) significantly decreased late sodium currents (INa-late), L-type calcium currents (ICa-L), and sodium-calcium exchanger currents (INCX). Calcium transients were significantly lower in LA treated with irisin (10 ng/ml) than control (0.61 ± 0.08 vs. 1.07 ± 0.13, p < 0.001).
Conclusion: Irisin reduced LA arrhythmogenesis through its inhibitory effects on ICa-L, INa-late, and INCX currents, which regulate intracellular calcium homeostasis. Irisin suppressed isoproterenol-induced trigger activities in LA and may provide a novel therapeutic strategy for atrial arrhythmogenesis.
PP-104-V-BS LIGHT promote the atrial fibrosis and AF inducibility by promoting macrophages TGFβ1 secretion MD Yirong Wu1, Prof Yizhou Xu1, MS Siyao Zhan1 1Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, HangZhou, ChinaObjectives: To illustrate the underlying mechanism of LIGHT (TNF superfamily member 14, TNFSF14) promote the atrial fibrosis and AF inducibility.
Methods: The mRNA level of PBMCs in AF patients and healthy controls was detected by PCR array. ELISA and flow cytometry were used to detect protein level of LIGHT and corresponding receptor HVEM (herpesvirus entry mediator) in peripheral blood CD3+ and CD14+ cells respectively. Detecting the morphological, functional, and electrophysiological changes in heart followed by tail intravenous injection of rLIGHT in mice. rLIGHT were used to stimulate BMDMs to prepare the macrophages conditioned medium (MCM), then MCMs were used to culture mice atrial fibroblasts.
Results: The PBMCs in AF patients (n = 5) have higher mRNA level of LIGHT (Foldchange = 8.96, p = 0.0017) and TNFRSF14 (Foldchange = 4.98, p = 0.0089). LIGHT are mainly expressed by CD3+ cells while HVEM expressed by CD14+ cells. The protein level of LIGHT and TNFRSF14 in AF patients (n = 34) was higher than that of healthy controls (n = 19) and closely correlated with left atrial reverse remodeling. In vivo study demonstrated that rLIGHT injection promoted systemic immune responses and increased T cells and macrophages infiltration in heart (atrial and ventricle). Moreover, rLIGHT injection also promoted atrial fibrosis and AF inducibility detected by MASSON staining and atrial burst pacing. In vitro study demonstrated that MCM rather than rLIGHT alone increased fibroblasts proliferation, collagen synthesis and differentiation into myofibroblasts by promoting macrophages TGBβ1 secretion.
Conclusion: LIGHT promote the atrial fibrosis and AF inducibility by promoting macrophages TGFβ1 secretion.
PP-105-1-CIED Night-to-night variability of sleep disturbance indexes impedes accurate assessment of the sleep apnea severity Assoc Prof Seung-Jung Park1, Ass Prof Hye Bin Gwag2 1Sungkyunkwan University School Of Medicine, Samsung Medical Center, South Korea, 2Sungkyunkwan University School Of Medicine, Samsung Changwon Hospital, South KoreaObjective: Sleep-disordered breathing (SDB), one of the most common comorbidities in cardiac electronic implantable device (CIED) patients, is frequently under-diagnosed. A special diagnostic function of CIED can facilitate SDB detection by continuous monitoring. The DEDiCATES study prospectively enrolled patients with CIED possessing this function to evaluate the association between device-detected SDB and cardiovascular risk.
Materials and Methods: Baseline severity of SDB was analyzed using the first device interrogation data in 539 patients. Daily respiratory disturbance index (RDI) values, which represents the average number of sleep disturbance events per night, were manually verified and collected.
Results: At the first device interrogation (91 ± 20 days), daily RDI values were always below 30/h in 23 (4.3%) patients (non-severe SDB group), and the remaining 516 patients (95.7%) were classified into the severe SDB group based on the conventional categorical criteria (RDI ≥30/h for at least one night). However, only 50 (9.7%) of 516 patients in the severe SDB group always exhibited RDIs ≥30/h (52.5 ± 8.6/h). Therefore, 466 (86.5%) of 539 patients showed RDI values compatible to both severe (≥30/h) and non-severe (<30/h) SDB criteria. The degree of alteration in RDI values, for example, minimum to maximum RDI values, was significantly greater in the severe SDB than the non-severe SDB group (37.7 ± 12.3/h vs. 12.7 ± 8.4/h, p < 0.001).
Conclusions:
Majority of CIED patients revealed RDI values compatible to both severe and non-severe SDB criteria. Therefore, discriminating power of single night polysomnography for the presence of severe SDB may be significantly limited.
PP-106-1-CIED Relationship between lateral tine engagement and non-septal implantation of leadless pacemaker confirmed by computed tomography Dr Akira Mizukami1, Dr. Ryo Nakada1, Dr. Shota Miyakuni1, Dr. Jiro Hiroki1, Dr. Shu Yamashita1, Dr. Maki Ono1, Dr. Daisuke Ueshima1, Dr. Akihiko Matsumura1, Dr. Masahiko Goya2, Dr. Tetsuo Sasano2 1Kameda Medical Center, Kamogawa, Japan, 2Tokyo Medical and Dental University, Bunkyo-ku, JapanObjective: Implantations of leadless pacemakers in the septum lower the risk of cardiac perforation. However, unexpected non-septal implantation is not uncommon. The locations and numbers of the engaged tines may be affected by the implantation site, but the relationship has not been investigated.
Materials and Methods: A total of 67 patients who underwent leadless pacemaker implantation with postprocedural computed tomography (CT) between September 2017 and November 2020 were enrolled. The actual implantation site was assessed by CT. During the pull-and-hold test, the engagement of all tines was assessed. Tines were categorized into four locations: septal, lateral, superior, and inferior by RAO and LAO fluoroscopic image.
Results: There were 28 septal and 39 non-septal implantations. Implantation to the anterior/posterior edge of septum were included in the non-septal group. The rate of engagement of the lateral tines were significantly higher in the non-septal group compared with septal group (82.1% vs. 39.3%, p < 0.001). However, there were no significant differences in other tine locations between the two groups. The number of engaged tines were significantly higher in the non-septal group compared with septal group (3.2 ± 0.8 vs. 2.8 ± 0.8, p = 0.02). Cardiac injuries including hematoma, pericardial effusion and cardiac tamponade were observed in four patients, which were all in the non-septal group with engagement of the lateral tines.
Conclusion: The engagement of the lateral tines was significantly more frequently observed in non-septal implantation and may provide a clue in prediction of actual implantation site of leadless pacemaker.
PP-107-1-CIED Cavo-tricuspid isthmus: An alternative Lead implantation site in sinus node dysfunction due to pulmonary hypertension Ms Theresia Sri Rezeki Sembiring1,2, Mr Dony Yugo Hermanto1,2, Mr Sunu Budhi Raharjo1,2, Mr Dicky Armein Hanafy1,2, Mr Yoga Yuniadi1,2 1National Cardiovascular Centre Harapan Kita, Jakarta Barat, Indonesia, 2Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta Barat, IndonesiaObjectives: To report cavo-tricuspid isthmus (CTI) as an alternative atrial pacing site in patient with sinus node dysfunction (SND) complicated with idiopathic pulmonary arterial hypertension (IPAH).
Case Illustration and Discussion: A-59-year-old female came with signs and symptoms of right heart failure (RHF) accompanied by junctional bradycardia, hyperkalemia and metabolic acidosis. Despite well-treated congestion and fully corrected metabolic problem, her junctional bradycardia did not spontaneously resolve. In fact, alternating episodes of tachycardia and bradycardia were found from her 24-h-Holter monitoring accompanied by symptoms. We decided to implant PPM AAIR, but we did not find pacing site with acceptable threshold as we positioned the atrial lead in right atrial appendage (RAA), inter-atrial septum (IAS) and lower atrial septum (LAS) even with a very high output setting. Eventually, a good atrial capture threshold was found at CTI with threshold of 0.8 V at 0.50 ms and impedance of 613 Ω at 5.0 V. Her ECG showed atrial pacing with QRS rate of 60 bpm and QRS duration of 100 ms. Upon clinical follow-up, she was clinically stable and finally discharged with furosemide 40 mg o.d., ramipril 5 mg o.d., and warfarin 1 mg o.d. SND in patients with IPAH might occur due to chronic inflammation and interstitial fibrosis across the entire right atrium. Not only in sinus node, it also occurs in RA causing atrial myopathy and subsequently failure to yield appropriate atrial pacing.
Conclusion: In patients with SND and atrial myopathy due to IPAH, CTI might be an alternative atrial pacing site.
PP-108-1-CIED Device malfunction or normal behaviour? Dr Wei Shen Chee1, Dr Abd Ghani Abd Raqib1, Dr Gian Singh Sathvinder Singh1, Dr Mat Daud Aimaduddin1, Dr Chin Yung Chea1, Dr Habizal Nor Halwani1, Dr Mohd Yusof Hartini1, Dr Selvaraj Kamaraj1, Dr Abdullah Ramaiah Asri Ranga1, Dr Abd Ghapar Abd Kahar1 1Department Of Cardiology, Serdang Hospital, MalaysiaObjective: Aim to demonstrate Left Ventricle Upper Rate Interval lock-in in Cardiac Resynchronization Therapy rather than device malfunction in a patient with 97 % of Biventricular pacing.
Materials and Methods: During routine interrogation for his CRTD which was implanted in 2018 for Non Ischemic Dilated Cardiomyopathy we noted loss of biventricular pacing that is followed by RV sensing and then LV sensing after a Premature Ventricular Contraction. With the LV maximal trigger rate (MTR) set as 130 bpm (461 ms), it inhibits the LV pacing as the LVs to RVp is 400 ms which causes the LVURI lock in and thus causing the desynchrony rather than device malfunction.
Results: We increased the upper rate to 130 bpm and AMS rate to 160 bpm to prevent pacemaker wenkebach. When the UTR increased to 130 bpm the LV MTR increased to 150 bpm and thus preventing the lock in. With remote home monitoring, his latest biventricular pacing has increased to 99%.
Conclusions: For those patients with CRT we aim to achieve as high percentage of Biventricular pacing as possible and for this gentleman (at least more than 98.5%) the LVURI lock in contributes to the less than optimal Biventricular pacing.
SUPPORTING DOCUMENTS
PP-109-1-CIED Out-smart the algorithm Dr Wei Shen Chee1, Dr Abd Ghani Abd Raqib1, Dr Yoon Kee Siow1, Dr Chin Yung Chea1, Dr Mat Daud Aimaduddin1, Dr Gian Singh Sathvinder Singh1, Dr Habizal Nor Halwani1, Dr Mohd Yusof Hartini1, Dr Selvaraj Kamaraj1, Dr Abdullah Ramaiah Asri Ranga1, Dr Abd Ghapar Abd Kahar1 1Department of Cardiology, Serdang Hospital, Malaysia
Objective: To demonstrate the potential limitation of SMART algorithm in differentiating supraventricular tachycardia (SVT) with aberrancy from ventricular tachycardia (VT) with 1:1 VA conduction.
Materials and Methods: Every implantable cardioverter-defibrillator (ICD) have their own algorithms to discriminate SVT from VT with the aim to detect and deliver appropriate therapy. Here we have a middle-aged gentleman with non-ischemic dilated cardiomyopathy (Ejection Fraction of 35%–40%), for whom single chamber ICD with atrial dipole was implanted for secondary prevention, noted 21 episodes of non-sustained tachycardia during device interrogation.
Result: Using the SMART algorithm, based on the tachycardia with VA 1:1 conduction with relatively stable A and V, the device will detect the tachycardia as SVT rather than VT. With the obvious change in morphology in the Far Field, we decided to turn off the SMART algorithm to enable the morphology match for better VT discrimination.
Conclusion: Every devices will have their own VT discriminator and is of paramount significance to know the differences for each devices to aid us in discriminating VT from SVT for better detection and delivery of appropriate therapy.
SUPPORTING DOCUMENTS
PP-110-1-CIED Optimal duration of temporary pacing in acute myocardial infarction Asst Prof Hyung Ki Jeong1, Doctor Sung Sik Oh2, Professor Sung Soo Kim3 1Wonkwang University Hospital, Iksan, South Korea, 2Presbyterian medical center, Jeonju, South Korea, 3Chosun university hospital, Gwangju, South Korea
Objectives: It is not uncommon to require a temporary pacemaker (TPM) for bradyarrhythmia during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). There have been few studies about temporary pacing in the era of PCI.
Materials and Methods: Among 8274 patients of AMI, 368 patients who had been inserted temporary pacemaker during PCI were enrolled from January 2010 to December 2019. Among them, 253 patients (68.8%) recovered the rhythm just after reperfusion. One hundred and fifteen patients (31.2%) needed TPM until their rhythm restored after procedure. We analyzed the duration of maintaining TPM and the descriptive factors.
Results: ST-elevation MI (STEMI) patients were 73 and non-ST-elevation MI (NSTEMI) patients were 42. The median duration from TPM insertion to rhythm recovery time was 35.3 h. The most common target lesion was the right coronary artery (n = 80, 69.6%) and the most common indication for permanent pacemaker (PPM) implantation was complete AVB (n = 64, 55.7%). There was no significant difference in rhythm recovery time between STEMI and NSTEMI (31.6 [17.2–47.7] vs. 49.5 [10.7–132.5], p = 0.168). There was no significant difference in rhythm recovery time according to each target coronary artery. Most of STEMI patients except two patients (2.7%), the rhythm was finally recovered, meanwhile, nine (21.4%) NSTEMI patients needed permanent pacemaker.
Conclusion: It took 35.3 h to recover self-rhythm in AMI patients who needed a TPM. Most of STEMI patients recovered cardiac electrical conduction. Our center usually waited for 1 week to decide whether to implant a permanent pacemaker or not.
SUPPORTING DOCUMENTS
TABLE 1 Baseline characteristics of study populations
| All patients (N = 115) | STEMI (N = 73) | NSTEMI (N = 42) | p value | |
| Age | 77.36 ± 11.2 | 75.57 ± 12.4 | 80.48 ± 7.8 | 0.011 |
| Sex (Male) | 75 (65.2%) | 51 (64.6%) | 28 (35.4%) | 0.842 |
| Sx to ER arrival time (Hours) | 41.15 ± 65.2 | 32.66 ± 61.0 | 55.90 ± 70.3 | 0.066 |
| ER door to reperfusion time (Hours) | 6.42 ± 16.1 | 1.46 ± 1.7 | 15.62 ± 25.0 | 0.002 |
| Past medical History | ||||
| HTN | 82 (71.3%) | 52 (71.2%) | 30 (71.4%) | 0.982 |
| DM | 42 (36.5%) | 22 (30.1%) | 20 (47.6%) | 0.061 |
| DL | 11 (9.6%) | 4 (5.5%) | 7 (16.7%) | 0.050 |
| Smoking | 49 (42.6%) | 33 (45.2%) | 16 (38.1%) | 0.458 |
| MI | 4 (3.5%) | 1 (1.3%) | 3 (7.1%) | 0.104 |
| Angina | 8 (7.0%) | 1 (1.3%) | 7 (16.7%) | 0.002 |
| CVA | 7 (6.1%) | 5 (6.8%) | 2 (4.8%) | 0.652 |
| CKD/ESRD | 15 (13.0%) | 6 (8.2%) | 9 (21.4%) | 0.043 |
| Target lesion | ||||
| LAD | 10 (8.7%) | 6 (8.2%) | 4 (9.5%) | 0.811 |
| LCX | 8 (7.0%), | 2 (2.7%) | 6 (14.3%) | 0.019 |
| RCA | 80 (69.6%) | 59 (80.8%) | 21 (50.0%) | <0.001 |
| LM | 1 (0.9%) | 0 (0.0%) | 1 (2.4%) | 0.185 |
| Multivessel | 16 (13.9%) | 6 (8.2%) | 10 (23.8%) | 0.020 |
| Successful PCI/PTCA | 104 (90.4%) | 69 (94.5%) | 35 (83.3%) | 0.050 |
| CABG | 2 (1.7%) | 0 (0%) | 2 (4.8%) | 0.131 |
| Ejection Fraction (%) | 54.34 ± 10.5 | 53.11 ± 10.9 | 56.66 ± 10.3 | 0.096 |
| Significant stenosis at index procedure | ||||
| LAD | 52 (45.2%) | 32 (43.8%) | 20 (47.6%) | 0.695 |
| LCX | 44 (38.3%) | 26 (35.6%) | 18 (42.9%) | 0.442 |
| RCA | 79 (68.7%) | 51 (69.9%) | 28 (66.7%) | 0.722 |
| LM | 5 (4.3%) | 2 (2.7%) | 3 (7.1%) | 0.265 |
Abbreviations: CABG, coronary artery bypass graft; CKD, Chronic kidney disease; CVA, cerebrovascular accident; DL, dyslipidemia; DM, diabetes mellitus; ER, emergency room; ESRD, end-stage renal disease; HTN, hypertension; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LM, left main coronary artery; MI, myocardial infarction; NSTEMI, non ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; PTCA, percutaneous transcatheter angioplasty; RCA, right coronary artery; STEMI, ST-segment elevation myocardial infarction; Sx, symptom.
TABLE 2 Annual number of temporary and permanent pacemaker implantation during AMI procedure
| Year | Total TPM | TPM after procedure | PPM | Total MI | STEMI | NSTEMI |
| 2010 | 32 | 9 | 1 | 704 | 334 | 370 |
| 2011 | 41 | 14 | 0 | 740 | 349 | 391 |
| 2012 | 48 | 15 | 1 | 784 | 332 | 452 |
| 2013 | 43 | 15 | 0 | 767 | 320 | 447 |
| 2014 | 29 | 10 | 1 | 905 | 364 | 541 |
| 2015 | 29 | 11 | 2 | 853 | 344 | 509 |
| 2016 | 26 | 2 | 0 | 940 | 404 | 536 |
| 2017 | 43 | 12 | 4 | 821 | 354 | 467 |
| 2018 | 39 | 13 | 1 | 885 | 335 | 550 |
| 2019 | 37 | 14 | 1 | 875 | 335 | 540 |
Abbreviations: MI, myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; PPM, permanent pacemaker; STEMI, ST-segment elevation myocardial infarction; TPM, temporary pacemaker.
TABLE 3 Temporary pacing indication in the percutaneous coronary intervention in acute myocardial infarction
| TPM indication | All patients (N = 115) | STEMI (N = 73) | NSTEMI (N = 42) | p value |
| Sinus dysfunction | 39 (33.9%) | 25 (34.2%) | 14 (33.3%) | 0.921 |
| Second degree AVB | 2 (1.7%) | 0 (0.0%) | 2 (4.8%) | 0.131 |
| 2:1 AVB | 8 (7.0%) | 4 (5.5%) | 4 (9.5%) | 0.412 |
| High grade AVB | 2 (1.7%) | 2 (2.7%) | (0.0%) | 0.279 |
| CAVB | 64 (55.7%) | 42 (57.5%) | 22 (52.4%) | 0.592 |
Abbreviations: AVB, atrioventricular block; CAVB, complete atrioventricular block; MI, myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; PPM, permanent pacemaker; STEMI, ST-segment elevation myocardial infarction; TPM, temporary pacemaker.
TABLE 3 Average self-rhythm recovery time as the target coronary lesion
| LAD (N = 10) | LCX (N = 8) | RCA (N = 80) | LM (N = 1) | Multivessel (N = 16) | p value | |
| Insertion to recovery hours | 45.72 ± 26.3 | 23.83 ± 17.4 | 35.10 ± 30.0 | 91.18 | 55.53 ± 59.6 | 0.280 |
Abbreviations: LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LM, left main coronary artery; RCA, right coronary artery.
TABLE 4 The patients who were implanted permanent pacemaker
| No. | Sex | Age | Sx to ER arrival (hours) | Door to reperfusion (hours) | Failed PCI | TPM to PPM (hours) | EF (%) | Diagnosis | Target lesion | TPM indication |
| 1 | Male | 90 | 1 | 26 | 130 | 61.6 | NSTEMI | LAD | 2nd AVB | |
| 2 | Male | 89 | 6 | 2 | 179 | 42 | NSTEMI | LAD | 2:1 AVB | |
| 3 | Female | 87 | 72 | Failed | 133 | 56.3 | NSTEMI | RCA | CAVB | |
| 4 | Female | 92 | 168 | 73 | 268 | 40 | NSTEMI | LCX | CAVB | |
| 5 | Male | 65 | 192 | Failed | 123 | 30 | STEMI | RCA | CAVB | |
| 6 | Male | 88 | 7 | 1 | 146 | 66.5 | NSTEMI | LCX | Sinus dysfunction | |
| 7 | Male | 75 | 11 | 127 | 181 | 60.8 | NSTEMI | LAD, LCX | CAVB | |
| 8 | Male | 84 | 24 | 12 | 159 | 63.75 | NSTEMI | RCA | CAVB | |
| 9 | Male | 89 | 168 | Failed | 144 | 70.8 | NSTEMI | LAD | CAVB | |
| 10 | Female | 92 | 24 | 1 | 146 | 69 | STEMI | RCA | CAVB | |
| 11 | Male | 85 | 1 | 14 | 187 | 40.8 | NSTEMI | LAD, LCX | CAVB | |
| Average | 163.3 h | 54.7(%) |
Abbreviations: AVB, atrioventricular block; CAVB, complete atrioventricular block; Door to Reperfusion, time interval from arrival of emergent room to the moment of coronary reperfusion; EF, ejection fraction; ER, emergency room; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LM, left main coronary artery; NSTEMI, non ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; PPM, permanent pacemaker; RCA, right coronary artery; STEMI, ST-segment elevation myocardial infarction; Sx to ER arrival, time interval from symptom onset to arrival of emergency room; Sx, symptom; TPM to PPM, time interval from temporary pacemaker insertion to permanent pacemaker; TPM, temporary pacemaker.
PP-111-1-CIED Impact of diastolic dysfunction in patients with preserved ejection fraction undergoing permanent cardiac pacemaker placement Asst Prof Kim Sung Soo1, Asst Prof Jeong Hyung Ki2 1Chosun University Hospital, South Korea, 2Wonkwang University Medical School, South KoreaBackground: Chronic right-ventricular (RV) pacing can exacerbate heart failure in patients with a low ejection fraction (EF). There is little information on the effects of diastolic dysfunction (DD) in patients with preserved EF undergoing permanent pacemaker (PPM) placement. We aimed to investigate the clinical outcomes in these patients.
Methods: This multicenter, retrospective analysis of PPM use in Chonnam, South Korea, included all patients with preserved EF undergoing transvenous PPM implantation for atrioventricular blockage from 2017 to 2019. Patients were divided into two groups according to DD. Clinical characteristics, 12-lead electrocardiograms, echocardiography, and laboratory parameters were evaluated. Composite outcomes were defined as (1) hospitalization, and (2) cardiac death by heart failure during the 15-month follow-up period.
Results: One hundred sixty-seven patients (66 men; overall mean age, 75.3 ± 11.9 years) were divided into two groups: 125 normal versus 42 DD. Compared with normal subjects, the DD group included older patients (mean age, 79.1 ± 9.9 vs. 74.0 ± 12.3; p = 0.016), and had longer paced QTc interval (pQTc, 168.5 ± 20.1 vs. 159.1 ± 16.3 ms; p < 0.001). Fifteen patients were hospitalized and two died. In a Cox proportional regression analysis, DD (hazard ratio [HR], 7.343; 95% confidence interval [CI], 2.035–26.494; p = 0.002) and pQRSd (HR, 1.046; 95% CI, 1.004–1.091; p = 0.033) were independent predictors of composite outcomes.
Conclusions: In patients with DD, RV pacing raised the risk of pacing-induced heart failure despite preserved left-ventricular function. Thus, patients with DD should be monitored intensively.
SUPPORTING DOCUMENTS
PP-112-1-CIED Possibility to achieve successful VDD pacing during high atrial rate in patients with leadless pacemaker Dr Yuta Sudo1, Dr Hiroyuki Okada1, Dr Hiroshi Inagaki1 1Soka Municipal Hospital, Soka-shi, Japan
Objective: A leadless pacemaker capable of atrioventricular (AV) synchronous pacing is a relatively new cardiac implantable electronic device with the unique feature that it lacks leads but allows for AV synchrony. However, AV synchrony of AV-synchronous leadless pacemakers is somewhat inferior to that of transvenous pacemakers, and this disadvantage is particularly apparent in case of high atrial rate. We report a case with high atrial rate (around 100 beats per minute) but with AV synchrony close to 100% thanks to the ingenious use of settings.
Materials and Methods: An 82-year-old woman with complete AV block received an AV-synchronous leadless pacemaker. After implantation, the pacemaker was programmed to VDD mode and atrial sensing was adjusted. The preoperative atrial rate was just under 100 beats per minute. A high atrial rate persisted thereafter, and the percentage of atrial mechanical sensed-ventricular pacing (AM-VP) was 66.5% at follow-up device interrogation 3 days after implantation.
Result: After adjusting the A3 window end interval and the A4 threshold and turning off rate smoothing, the percentage of AM-VP has remained above 97% for more than a few months despite of sustained high atrial rate. The ECG also showed appropriate AV synchrony.
Conclusion: AV-synchronous leadless pacemakers can achieve adequate AV synchrony with appropriate adjustments even when atrial rate is high in some patients.
PP-113-1-CIED Incidence, risk factors, and characteristics of stress induced cardiomyopathy after permanent pacemaker implantation Dr Minsoo Kim1, Dr Sung-yun Jung1, Dr Yun Seok Song1, Dr Jin Sung Lee1, Dr HyongJun Kim1 1Dongkang hospital, Ulsan, KoreaObjectives: We aimed to identify the incidence, risk factors, and characteristics of stress-induced cardiomyopathy (SCMP) after permanent pacemaker (PPM) implantation.
Materials and methods: Data on 39 consecutive patients with PPM implantation at Dongkang hospital from 2021 to 2022 were retrospectively analyzed. Echocardiography was routinely performed before and after the procedure. Post-procedural echocardiography was performed a day after the procedure. SCMP was diagnosed on the basis of echocardiography and coronary angiography. Baseline, procedural, and echocardiographic characteristics were analyzed.
Results: The incidence of SCMP after PPM implantation was 7.7%. Risk factors for SCMP after PPM implantation were intensive care unit (ICU) stay before procedure, diastolic dysfunction, and high peak systolic pressure gradient of tricuspid valve. Among three patients with SCMP, two patients were older than 85 years old with ICU stay before the procedure. Another patient with SCMP was relatively younger age (59 years old), however, she had same day revision of atrial lead because of lead dislodgement. Worsening of ventricular lead measurement was observed in one patient. In this patient, even echocardiography improved a week after the diagnosis of SCMP, ventricular lead measurement improved 2 months after the diagnosis of SCMP.
Conclusion: Incidence of SCMP after PPM implantation can be relatively high, and it can cause temporary worsening of ventricular lead measurements. Risk factors for SCMP after PPM can be old age with prior ICU stay or lead revision, however, it needs further study.
SUPPORTING DOCUMENTS
TABLE 1 Baseline, procedural, and echocardiographic (pre-procedural) characteristics of patients with and without stress-induced cardiomyopathy after permanent pacemaker implantation
| Stress-induced cardiomyopathy | No (N = 36) | Yes (N = 3) | p-value |
| Age (years) | 75.2 ± 9.3 | 77.7 ± 16.2 | 0.673 |
| Sex (male) | 9 (25.0%) | 1 (33.3%) | 1 |
| BMI (kg/m2) | 23.5 ± 3.4 | 22.7 ± 2.9 | 0.671 |
| Diagnosis | 0.614 | ||
| SSS | 14 (38.9%) | 2 (66.7%) | |
| AVB | 19 (52.8%) | 1 (33.3%) | |
| AF SVR | 3 (8.3%) | 0 (0.0%) | |
| Hypertension | 23 (63.9%) | 2 (66.7%) | 1 |
| Diabetes | 17 (47.2%) | 0 (0.0%) | 0.328 |
| Atrial fibrillation | 12 (33.3%) | 1 (33.3%) | 1 |
| History of MI | 0 (0.0%) | 0 (0.0%) | N-S |
| PCI | 6 (16.7%) | 0 (0.0%) | 1 |
| Heart failure | 0 (0.0%) | 0 (0.0%) | N-S |
| History of stroke | 7 (19.4%) | 0 (0.0%) | 0.952 |
| Open heart surgery | 2 (5.6%) | 0 (0.0%) | 1 |
| Chronic lung disease | 0 (0.0%) | 1 (33.3%) | 0.108 |
| Chronic liver disease | 0 (0.0%) | 0 (0.0%) | N-S |
| Hemodialysis | 2 (5.6%) | 0 (0.0%) | 1 |
| Creatinine (mg/dL) | 1.2 ± 1.2 | 0.9 ± 0.0 | 0.227 |
| ICU stay before procedure | 1 (2.8%) | 2 (66.7%) | 0.004 |
| Temporary pacemaker | 4 (11.1%) | 0 (0.0%) | 1 |
| Number of leads | 1 | ||
| Single chamber | 3 (8.3%) | 0 (0.0%) | |
| Dual chamber | 33 (91.7%) | 3 (100.0%) | |
| Procedure time (min) | 66.2 ± 20.2 | 50.3 ± 8.0 | 0.189 |
| Pocket hematoma | 1 (2.8%) | 0 (0.0%) | 1 |
| Lead revision | 1 (2.8%) | 1 (33.3%) | 0.346 |
| Ejection fraction (%) | 63.1 ± 4.6 | 59.7 ± 6.4 | 0.236 |
| LV end-diastolic dimension (mm) | 48.9 ± 4.0 | 50.3 ± 3.2 | 0.548 |
| E/E' | 15.6 ± 5.9 | 25.2 ± 6.8 | 0.037 |
| LA diameter (mm) | 40.3 ± 7.6 | 42.0 ± 7.2 | 0.712 |
| LAVI (ml/m2) | 52.7 ± 16.9 | 68.1 ± 24.6 | 0.157 |
| Any valvular diseasea | 12 (33.3%) | 0 (0.0%) | 0.582 |
| TRPG (mmHg) | 34.6 ± 10.0 | 49.8 ± 19.1 | 0.025 |
Note: Data are reported as mean ± standard deviation, medians (interquartile range), or numbers (n).
Abbreviations: AF SVR, atrial fibrillation slow ventricular response; AVB, atrioventricular block; BMI, body mass index; ICU, intensive care unit; LA, left atrium; LAVI, left atrial volume index; LV, left ventricle; MI, myocardial infarction; N-S, non-specified; PCI, percutaneous coronary intervention; SSS, sick sinus syndrome; TRPG, peak systolic pressure gradient of tricuspid valve.
aAny valvular disease = moderate to severe stenosis or regurgitation at any valve.
FIGURE 1 Impedance and threshold of ventricular lead after stress-induced cardiomyopathy. In this patient, left ventricular ejection fraction (LVEF) and regional wall motion abnormality (RWMA) improved a week after the diagnosis of stress-induced cardiomyopathy. However, improvement of ventricular lead measurements was slower than improvement of LVEF and RWMA.
PP-114-1-CIED The effect of electrode location on battery longevity during leadless LV endocardial pacing Dr Mark Elliott1,2, Dr Nadeev Wijesuriya1,2, Dr Vishal Mehta1,2, Dr Peggy Jacon3, Professor Steven Niederer1, Dr Jeffrey Alison4, Dr Olivier Piot5, Dr Paul Roberts6, Dr John Paisey6, Professor Pascal Defaye3, Professor Christopher Aldo Rinaldi1,2 1King's College London, London, UK, 2Guy's and St Thomas' NHS Foundation Trust, London, UK, 3Grenobles Alpes University Hospital, Grenobles, France, 4Monash Health, Melbourne, Australia, 5Centre Cardiologique du Nord, Paris, France, 6University Hospital Southampton NHS Foundation Trust, Southampton, UKObjective: The WiSE-CRT system (EBR Systems, CA, USA) delivers leadless LV endocardial pacing. The conventional location for the electrode is the lateral wall, however, a technique to implant on the LV septum has been recently described. In addition to the potential advantages of left bundle branch capture, a septal electrode is closer to the transmitter than a lateral wall electrode. We aimed to assess the differences in estimated battery longevity between a septal and lateral wall electrode location.
Materials and Methods: Eight patients underwent acoustic window screening prior to WiSE-CRT implantation. Target positions for the electrode (septum and lateral wall) were identified on transthoracic echocardiography with the probe positioned in the planned transmitter location. Anterior–posterior distance and angle between the provisional transmitter and electrode locations were measured. The effect of distance and angle on estimated energy requirements and battery longevity was modelled.
Results: The distance from the skin surface to the septum was significantly shorter than the distance to the lateral wall (6.2 ± 1.5 vs. 11.9 ± 1.5 cm; p < 0.001). There was no difference in angle between the two provisional electrode locations (17.5 ± 9.6 vs. 17.5 ± 4.6 degrees; p > 0.05). There was a reduced estimated pacing energy requirement for a septal versus lateral wall electrode location (5.56 ± 3.2 vs. 12.7 ± 1.6 dB; p = 0.001) (Figure 1), which would result in a predicted 2.7-fold increase in battery life.
Conclusion: A septal location for the WiSE-CRT electrode is associated with a longer estimated battery longevity compared to the conventional lateral wall location.
SUPPORTING DOCUMENTS
FIGURE 1
PP-115-1-CIED The incidence and outcomes of atrial high-rate episodes (AHRE) in a single tertiary center Dr Gurpreet Pal Singh Jugindar Singh1, Dr Hazleena Mohamed Hasnan1, Dr Yew Fung Kwan1, Dr Ramachandran Sathappan1, Dr Sabapathy Diagarajan1, Dr Mohd Ruslan Mustapa1, Dr Kengeswari Raja1, Dr Tai Meng Chen1, Dr Nor Hanim Mohd Amin1 1Hospital Raja Permaisuri Bainun, Ipoh, MalaysiaObjectives: Previous studies have shown that patients with AHRE have an elevated risk of stroke and thromboembolism. This study aims to observe the incidence and outcomes of AHRE in our cardiology clinic follow-up.
Materials and Methods: This is a retrospective, single-center study of patients who underwent a cardiovascular implantable electronic device (CIED) with atrial lead/sensing from January 2015 to March 2020. Among 413 of patients, 92 patients fulfilled the inclusion and exclusion criteria. Device electrogram and electrocardiography (ECG) of all eligible patients had been analyzed and their baseline characteristics had been obtained. Chi-squared and independent t-tests in SPSS version 21 had been used to analyze the categorical and quantitative variables, respectively.
Results: The mean duration of follow-up was 51.18 (SD 26.37) months. Out of 92 patients, 42 (45.7%) had AHRE. Among the AHRE cohort, 54.8% (n = 23) had subclinical atrial fibrillation (AF) and 45.2% (n = 19) had subclinical atrial flutter (AFL). AHRE more commonly seen in patients with sinus node dysfunction (63.3% vs. 36.7%, p value 0.02). There was increase in AHRE frequency per year but none of the patients developed clinical AF and AFL. There was no stroke reported but two major cardiovascular events (MACE) (4.75%, p value 0.46) occurred among AHRE patients.
Conclusion: In our study, the incidence of AHRE among CIED patients was 45.7%, which was similar to various previous publications. However, none of them developed stroke and the MACE were non-significant.
PP-116-1-CIED Real-world effectiveness of automated dynamic optimization and left ventricular-only pacing algorithm of cardiac resynchronization therapy Dr Su Hyun Lee1, Dr Hye Bin Gwag2, Dr Seung-Jung Park1 1Samsung Medical Center, Seoul, South Korea, 2Samsung Changwon hospital, Changwon, South KoreaObjectives: Cardiac resynchronization therapy (CRT) device-based algorithm adjusts the atrioventricular and ventriculo-ventricular delays according to dynamic changes of intrinsic conduction. Despite results from the clinical trial showed favorable outcomes of automated optimization algorithm, few real-world data exist. We investigated the efficacy of AdaptivCRT (aCRT) algorithm on clinical and echocardiographic outcomes using a retrospective multicenter registry in Korea.
Materials and Methods: Between September 2013 and March 2020, 515 patients implanted with CRT device possessing aCRT algorithm were identified from 25 tertiary hospitals. A total of 367 patients were included for the analysis after excluding those with replaced generator, persistent atrial fibrillation, narrow QRS duration, or follow-up loss. Patients were categorized into three groups according to the pacing mode; conventional biventricular pacing (BiV) (n = 122), aCRT with <50% left ventricular-only pacing (LVP) (n = 159), and aCRT with ≥50% LVP (n = 86). The primary outcome was a composite of all-cause death, heart failure hospitalization, and defibrillator therapy for ventricular tachyarrhythmia.
Results: During a median 28-month follow-up, the aCRT with ≥50% LVP group showed a significantly lower incidence of primary outcome (18.6%) compared to the other groups (37.7% in the BiV, and 32.7% in the aCRT with <50% LVP groups; p = 0.01).
Conclusion: Our largest Asian-Pacific real-world data showed that CRT with a higher LV-only pacing percentage (≥50%) showed better clinical outcomes compared to conventional BiV CRT.
SUPPORTING DOCUMENTS
TABLE 1 Baseline characteristics
| Variable | Conventional BiV (n = 122) | Adaptive CRT LVP <50% (n = 159) | Adaptive CRT LVP ≥50% (n = 86) | p value |
| Demographics | ||||
| Age | 65.1 ± 12.0 | 67.8 ± 12.4 | 65.8 ± 11.7 | 0.16 |
| Male | 79 (64.8) | 104 (65.4) | 43 (50.0) | 0.04 |
| BMI | 23.9 ± 3.6 | 23.7 ± 3.9 | 23.8 ± 3.9 | 0.95 |
| NYHA class | 24 (19.7) | 36 (22.9) | 21 (25.0) | 0.65 |
| II | 98 (80.3) | 119 (75.8) | 63 (75.0) | 0.58 |
| III + IV | 66 (54.1) | 98 (61.6) | 46 (53.5) | 0.33 |
| Hypertension | 46 (37.7) | 71 (44.7) | 46 (53.5) | 0.08 |
| Diabetes | 26 (21.3) | 40 (25.2) | 19 (22.1) | 0.72 |
| Chronic kidney disease | 10 (8.2) | 20 (12.6) | 6 (7.0) | 0.28 |
| Cerebrovascular disease | 17 (13.9) | 34 (21.4) | 16 (18.6) | 0.28 |
| Ischemic CMP | 23 (18.9) | 31 (19.5) | 4 (4.7) | 0.005 |
| Paroxysmal AF | ||||
| Medication | ||||
| Beta blocker | 100 (82.0) | 117 (73.6) | 68 (79.1) | 0.23 |
| RAS blocker | 101 (82.8) | 144 (90.6) | 74 (86.0) | 0.15 |
| Aldosterone antagonist | 86 (70.5) | 109 (68.6) | 63 (73.3) | 0.74 |
| Diuretics | 107 (87.7) | 139 (87.4) | 70 (81.4) | 0.35 |
| Echocardiographic findings | ||||
| LVEF, % | 24.8 ± 6.7 | 24.8 ± 5.8 | 24.1 ± 6.1 | 0.64 |
| LVEDD, mm | 66.6 ± 9.1 | 66.7 ± 8.4 | 66.7 ± 9.5 | 0.99 |
| LVESD, mm | 56.7 ± 10.3 | 57.2 ± 9.3 | 58.0 ± 10.6 | 0.62 |
| LVEDV, ml | 209.3 ± 75.6 | 202.3 ± 75.3 | 213.2 ± 85.7 | 0.63 |
| LVESV, ml | 158.0 ± 69.4 | 152.8 ± 63.2 | 159.5 ± 69.3 | 0.77 |
| Electrocardiographic findings | ||||
| LBBB | 102 (83.6) | 123 (77.4) | 84 (97.7) | <0.001 |
| Heart rate, bpm | 74 ± 18 | 72 ± 16 | 73 ± 13 | 0.59 |
| PR interval, ms | 193.1 ± 40.8 | 198.6 ± 43.6 | 182.7 ± 28.7 | 0.02 |
| QRS duration, ms | 169.7 ± 23.2 | 167.1 ± 23.0 | 163.3 ± 19.1 | 0.12 |
| Indication for CRT | ||||
| De novo | 93 (76.2) | 127 (79.9) | 84 (97.7) | <0.001 |
| Upgrade | 29 (23.8) | 32 (20.1) | 2 (2.3) | |
| Type of CRT | ||||
| CRT-D | 120 (98.4) | 153 (96.2) | 85 (98.8) | 0.35 |
| CRT-P | 2 (1.6) | 6 (3.8) | 1 (1.2) | |
| LV leads (RAO) | ||||
| Non-apical | 118 (96.7) | 147 (92.5) | 84 (97.7) | 0.12 |
| LV leads (LAO) | 122 (100.0) | 153 (96.2) | 84 (97.7) | 0.1 |
| Lateral | ||||
| CRT pacing, % | 98.9 ± 5.5 | 99.4 ± 1.7 | 99.8 ± 0.3 | 0.15 |
| Follow-up duration, months | 37.7 ± 20.6 | 33.1 ± 21.7 | 32.9 ± 20.0 | 0.13 |
Note: Values are presented as mean ± SD or number (percentage). p value refers to the difference among the three groups by ANOVA test or chi-squared test.
PP-117-1-CIED Post-procedural complete heart block and left bundle branch area pacing after transcatheter aortic valve implantation Ms Andini Wardhani1,2, Mr Dony Yugo Hermanto1,2, Dr Dicky Armein Hanafy1,2, Dr Sunu Budhi Raharjo1,2, Prof Yoga Yuniadi1,2 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, West Jakarta, Indonesia, 2National Cardiovascular Centre Harapan Kita, West Jakarta, IndonesiaObjective: To report the single-center clinical experience of new-onset complete heart block (CHB) requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI).
Case Illustration: An ECG of 78-year-old man after TAVI procedure showed a CHB with LBBB ventricular escaped rhythm (QRSd of 153 ms). Patient previously had history of revascularized CAD but still having heart failure symptoms without any conduction abnormalities. Echocardiography showed severe aortic stenosis (AS) and decreased LVEF of 44%. A clinical CHB was manifested immediately after TAVI procedure. Dual-chambered PPI with left bundle branch area pacing was implanted successfully (corrected QRSd of 102 ms, LVAT 73 ms, and V1-V6 R-R interval of 33 ms), since infrahissian block was established. Early echocardiography evaluation evinced well-seated low gradient (17 mmHg) prosthetic valve and restoration of LVEF (49%). Patient was discharged with an improved symptom.
Conclusion: TAVI has become an accepted treatment option for patient with high-risk severe AS. New onset CHB due to mechanical compression of large prostheses after TAVI is not uncommon and associated with higher incidence of PPI. Decreased LVEF becomes consequence since this conduction abnormality leads to ventricular dyssynchrony and adverse cardiac remodeling. Although occurrence of new CHB was inevitable and remains a vexing issue, PPI showed good outcome with narrower QRSd and recover LVEF after procedure. PPI on CHB post-TAVI procedure could be an alternative to preserve functional physiological LV conduction.
SUPPORTING DOCUMENTS
PP-118-1-CIED Cardiac physiologist led Micra AV clinic—Experience from a tertiary hospital Mr David Yun1, Dr Elizabeth Woollard1, Dr Vincent Paul1 1Fiona Stanley Hospital, Perth, Australia
Objectives: Fiona Stanley Hospital is the only site in Australasia that is independent of industry support in the implantation of Micra Ventricular (VR) and Micra Atrio-ventricular (AV) devices. Ninety-three Micra devices have been implanted, including 76 VR and 17 AV devices. The Micra AV uses the mechanical activity of the atrium to determine AV synchrony (AVS) and poses unique challenges in programming. We report the experience of a dedicated cardiac physiologist (CP) led Micra AV clinic.
Materials and Methods: Standard outpatient pacemaker clinic setting in tertiary hospital for patients with Micra AV looking at programming issues and success in achieving AVS.
Results: For the AV devices, a median follow-up time of 12 months was observed (range: 1–26 months). AVS (>75%) was achieved by 1 month for all 17 patients. AVS was difficult in patients with marked first degree heart block and patients requiring intermittent pacing. This was able to be programmed around with manipulation of timing windows. AVS was lost in patients with a higher or lower sinus rate and the bradycardic events were able to be programmed around. A single patient did not have AVS at outset due, this improved over time as atrial function improved after valvular intervention.
Conclusion: Micra AV poses new challenges as it relies on both mechanical and electrical parameters. With advancing technology in leadless pacing, there is a growing potential for cardiac physiologists to broaden practice. Understanding the concepts and challenges has allowed us to achieve AVS in a high proportion of our patients.
PP-119-V-CIED Mortality outcomes, incidence of shocks in patients implanted with AICD: A single-center experience over two decades Dr Harsh Pandey1, Dr Narayanan Namboodiri1, Dr Krishna Kumar Mohanan Nair1, Dr Ajit Kumar VK1 1Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum India, Thiruvananthapuram, IndiaObjectives: To assess appropriate shock and inappropriate shocks in patients who underwent ICD therapy in primary and secondary prevention group.
Materials and Methods: This is a descriptive single-center study with retrospective case enrolment and prospective follow-up. Patients who underwent ICD/CRT-D implantation from January 1997 to June 2020 were identified by searching an institutional database. The study population was grouped by type of prevention (secondary or primary) for sudden cardiac death. Device interrogation was checked for appropriate and inappropriate shocks.
Results: A total of 428 (81% male, mean age 55 ± 11 years) ICD recipients were included. Of these, 290 (67.7%) patients received an ICD for secondary prevention of sudden cardiac death and 138 (32.3%) patients for primary prevention. During a 1913 patients year follow-up (mean of 4.4 ± 2.7 years), secondary prevention patients exhibited a 33% increased risk for an appropriate shock compared with primary prevention patients. The incidence of appropriate shock was 14% in the primary prevention group and 30% in the secondary prevention group. On multivariate analysis, LV dysfunction (<50%) was a significant predictor for appropriate shock.
Conclusion: During long-term follow-up, the secondary prevention AICD recipient group compared to the primary prevention group exhibited a higher risk of appropriate therapy. Both groups showed lower and similar occurrences of inappropriate shocks.
PP-120-1-CIED Low infection rate of 3-incision technique during long-term S-ICD follow-up Dr Robert Puchalski1, Dr Stuart Healy1, Dr David Adam1, Dr Logan Bittinger1, Dr Jeff Alison1, Dr Emily Kotschet1 1Monash Heart, Melbourne, AustraliaObjectives: To assess long-term complication rate, particularly infection, in consecutive patients at a single site, Monash Health.
Materials and Methods: We performed retrospective analysis of 33 consecutive S-ICD procedures performed at Monash Health from 31 August 2015 to 24 March 2022. All procedures were performed under general anaesthetic, using the 3-incision technique. All patients underwent peroxide pocket washout before closing. DFTs were performed at the conclusion of all cases. Follow-up analysis was performed by assessing procedural notes, device checks, and clinic letters. We collected information regarding indication and disease aetiology, infection, premature battery depletion, time-to-generator change, inappropriate shocks, lead failure, lead replacement, and requirement for trans-venous device.
Results: Follow-up was complete for 31/33 (94%) patients. Mean follow-up time was (3.3 years ± 1.8 years). Twenty-five (76%) patients were male. The indication was primary prevention in 11 patients (33%), and there were eight patients (24%) with HOCM. DFT was successful in 32/33 patients (97%), and only unsuccessful in one patient because VF could not be induced. There was one infection during follow-up (3%). This lead was extracted and replaced on right parasternal position. There were four premature battery depletions (12%), five patients (15%) suffered inappropriate shocks. There was one lead replacement for failure. One patient (3%) required the addition of a trans-venous system for a pacing indication.
Conclusion: S-ICD implantation can be performed with a low complication rate. Literature suggests up to 10% infection rate for 3-incision technique. Our infection rate compares favourably to published data.
PP-121-1-CIED Adopting ultrasound-guided axillary vein access for CIED Lead implantation Asst Prof Jongmin Hwang1, Associate Professor Hyoung-Seob Park1, Professor Seongwook Han1 1Keimyung University Dongsan Hospital, Daegu, South KoreaObjective: There are many reports that US-guided axillary vein access (U-AVA) is a safe and effective method. Nevertheless, U-AVA has not been adopted universally in cardiac implantable electronic devices (CIED) lead implantation procedures, especially in Korea.
Materials and Methods: This is a single center, prospective study of patients undergoing new CIED implantation from May 2021 to July 2022. Patients' baseline demographic and procedural data were collected, and it was compared with January 2019 to April 2021 fluoroscopy-guided axillary vein access (F-AVA) patients' data.
Results: Total 198 patients underwent the U-AVA and 230 patients underwent the F-AVA approach. The U-AVA was successful in 93.4% of patients (185/198) and the most common reason for failed U-AVA was ≥3 cm subcutaneous tissue thickness. Compared to conventional F-AVA procedure, U-AVA showed significantly shorter Air-Kerma, Dose-Area Product (9.96 ± 6.35 mGy vs. 17.0 ± 12.1 mGy, p = 0.037; 1.91 ± 1.02 Gy-cm2 vs. 2.95 ± 2.24 Gy-cm2, p = 0.014). There were no significant differences between the two groups in mean implant procedure time (57.54 ± 12.8 min vs. 65.91 ± 12.21 min, p = 0.89). However, complications related to axillary venous approach were dramatically decreased in U-AVA patients' group (one pneumothorax in U-AVA group vs. two pneumothorax, two severe hematoma due to axillary artery puncture).
Conclusion: The U-AVA for CIED lead implantation is a feasible and safe alternative approach and offers a significant reduction in radiation doses without increasing procedural time. Also, venous approach related complication was decreased.
SUPPORTING DOCUMENTS
PP-122-1-CIED Conduction system pacing in the post-AVR patients and atrioventricular conduction disturbance: A single-center experience Dr Anand Yadav Pasula1, Dr Anindya Ghosh1, Dr Ulhas M Pandurangi1 1The Madras Medical Mission, Chennai, India
Objectives: To study the feasibility and safety of conduction system pacing in patients with post-aortic valve replacement and high degree of atrioventricular conduction block.
Methods: Consecutive patients who qualify for pacemaker implantation post-aortic valve replacement either by transcatheter (TAVR) or surgical (SAVR) were enrolled. Procedural success and outcomes were assessed and analyzed. CSP was performed using the Select Secure (3830; Medtronic) pacing lead, delivered through a fixed curve (C315HIS: Medtronic).
Results: Total of 12 patients required permanent pacemaker after aortic valve replacement (age 64 + 7 years, 40% female, QRSd: 153 + 11 ms). Eleven patients (91%) successfully underwent CSP. Seven had surgical and four had a transcatheter aortic valve replacement. His bundle pacing (HBP) was achieved in five patients and six underwent left bundle branch area pacing (LBBAP). One patient in the HBP group had lead dislodgement and later lead was repositioned in the RV apex. Mean QRSd at baseline and post-procedure between HBP and LBBAP groups was not significantly different. Mean thresholds in HBP 2.5 + 0.8 V at 1.0 ms and LBBAP 1.3 + 0.6 V at 1.0 ms. R wave amplitude in HBP is 5.1 + 3.2 mV and LBBAP is 12.7 + 6 mV. During the 12-month follow-up one patient in the HBP group had increased thresholds and none in the LBBAP group.
Conclusions: Conduction system pacing in post-aortic valve replacement (TAVR/SAVR) patients with pacing requirements is feasible and safe. LBBAP had a higher implant success rate and stable lead parameters than HBP.
PP-123-1-CIED Conduction system pacing (CSP) feasibility in routine clinical practice: Experience from an Indian center Dr Basavaraj Sutar1, Dr Daljeet kaur, Dr Sridevi C, Dr Sachin Yalagudri, Dr Muthaiah Subramanium, Dr Calambur Narasimhan 1Aig Hospital, Hyderabad, IndiaObjectives: To assess the feasibility and outcomes of CSP in patients eligible for cardiac resynchronization therapy (CRT) and pacing indication.
Methods: CSP has been attempted in patients with left ventricular ejection fraction <50% and indications for CRT or pacing. Procedural outcomes, His bundle or left bundle branch capture, NYHA class, QRS duration, and echocardiographic data were recorded. Clinical and echocardiographic responses were assessed.
Results: CSP was attempted in 189 patients and failed in 10 cases. LBBAP was attempted in 137 patients and his bundle pacing in 42 patients. CSP was attempted in 68% of patients with bradyarrhythmia and SSS patients. In HBP, selective HBP was achieved in 14 patients, there was a significant improvement in LVEF (49.3 ± 9.3 vs. 36.7 ± 9.2) in the LV dysfunction subgroup. Out of 137 LBBA pacing, selective LBB pacing was achieved in 18 patients. LBBAP threshold and R-wave amplitudes were 0.7 ± 0.3 V at 0.6 ms and 10.6 ± 6 mV at implantation and remained stable during a mean follow-up of 6 ± 5 months. LBBAP resulted in significant QRS narrowing from 148 ± 19 to 123 ± 14 ms (p < 0.01) in CRT indication patient. LVEF improved from 36 ± 11% to 48 ± 9% (p < 0.01) in LV dysfunction group. Clinical and echocardiographic responses were observed in 85% of CRT indication patients.
Conclusions: Conduction system pacing is feasible and safe and provides an alternative option for CRT and bradyarrhythmia. LBBAP provides remarkably low and stable pacing thresholds.
PP-124-1-CIED Electrical synchrony improvement with a programmable dynamic atrioventricular delay algorithm Dr. Bernard Thibault2, Dr. Anthony Chow3, Mr Jan Mangual1, Dr. Nima Badie1, Dr. Peter Waddingham3, Dr Luke McSpadden1, Dr Tim Betts4, Dr Leonardo Calo5, Dr. Francisco Leyva6 1Abbott, Sylmar, USA, 2Montreal Heart Institute, Montreal, Canada, 3Barts Heart Centre, London, UK, 4Oxford University, UK, 5Policlinico Casilino, Italy, 6Aston Medical School, UKIntroduction: Dynamic atrioventricular delay (AVD) with SyncAV have been shown to improve electrical synchrony with biventricular (BiV) and left ventricular (LV) only pacing. However, it is unknown if algorithms with fixed AV offsets provide the same benefit as a dynamic algorithm with programmable offsets.
Objective: Compare QRS duration (QRSd) reduction of LV-only pacing with dynamic AVD fixed at 70% of the intrinsic AV interval versus dynamic AVD with a patient-tailored AV offset (SyncAV).
Method: CRT implants (LBBB, QRSd ≥150 ms) were prospectively enrolled. Blinded QRSd was measured from 12-lead ECG during intrinsic, LV-only pacing 70% AVD, and BiV and LV-only pacing with SyncAV enabled and optimized (10%–70% offset) to minimize QRSd.
Results: 50 patients were evaluated (66.6 years, 41.9% male, 18.9% ischemic, 26.0% EF, 163.7 ms intrinsic QRSd). LV-only 70% AVD reduced QRSd by 17.4% vs. intrinsic to 137.2 ms (p < 0.005 vs. intrinsic). LV-only with optimal SyncAV offset reduced QRSd by 22.0% vs. intrinsic to 129.4 ms (p < 0.005 vs. intrinsic and LV-only 70% AVD). In this cohort, activating BiV pacing with optimal SyncAV programming resulted in a further narrowing of QRSd (25.3%) vs. intrinsic to 124.5 ms (p < 0.005 vs. intrinsic, LV-only 70% AVD, and LV-only SyncAV). BiV with SyncAV resulted in narrower QRSd compared to LV-only SyncAV in 70% (35/50) of patients.
Conclusion: LV-only pacing with optimized dynamic AVD offset with SyncAV yielded a narrower QRSd compared to fixed 70% AVD. BiV pacing with SyncAV resulted in a greater reduction of QRSd than LV-only in the majority of patients.
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PP-125-1-CIED QRS duration after biventricular pacemaker implantation—Whether there is any impact of electrical Axis Dr Rahul Singhal1 1Fortis Heart Institute Jaipur Rajasthan, Jaipur, India
Background: Common indication for Biventricular (BiV) pacing is treating HF with interventricular or intraventricular dyssynchrony and LBBB. Clinical improvements are expected with shortening of QRS duration after BiV. I aimed at observing differences in changes of QRS morphology, duration, electrical axis before and during simultaneous, LV and RV pacing.
Objective: Study was initiated to ascertain correlation between these parameters.
Methods: Fifty-three patients with mean age 51 years with 67% males were studied. Correlation was evaluated between axis and duration of QRS complex by calculating electrical axis of the heart (QRS vector) using mathematical formula tanθ = (I + 2III)/(I√3) before BiV implantation, during LV, RV and simultaneous BiV pacing.
Results: Duration of QRS complex changed in all but seven patients with statistically significant (p < 0.01) mean difference 38.7 ± 9.1 ms. Our study found correlation between QRS complex duration during BiV pacing and following parameters: (1) Electrical axis of preoperative QRS complex (correlation coefficient was −0.76), (2) Preoperative duration of QRS complex (correlation coefficient was +0.98), (3) Duration of QRS complex during LV pacing (correlation coefficient was +0.96). Best results (narrowing of QRS) were achieved when QRS axis before implantation was between 66° and 86° normal or slightly to the right axis (42.5% of patients) then the QRS with LBBB and left axis deviation.
Conclusion: This study indicates that LBBB morphology and normal axis of preoperative QRS complex showed greater predisposition for narrowing of QRS after implantation of biventricular pacemaker. Duration of preoperative and LV pacing QRS depends on ventricular conduction properties and has influence for postoperative QRS duration.
PP-126-1-CIED MICRA implantation via the right internal jugular vein access in a young patient: Case report Dr Muhammad Izzad Johari1, Dr Rohith Stanislus1, Zunida Ali1, Noor Asyikin Sahat1, Amirzua Ahmad Said1, Azlina Daud1, Gina Dayang Manit1, Mohamad Halmy Aziman1, Dr Low Ming Yoong1, Dr Suraya Hani Kamsani1, Dr Surinder Kaur Khelae Atma Singh1, Dr Azlan Hussin1 1National Heart Institute, Jalan Tun Razak, MalaysiaObjective: To report safety and feasibility of MICRA implantation via right internal jugular vein (IJV).
Materials and Methods: We report the successful implantation of MicraTM TPS via right IJV in a young patient who required a leadless pacing system as a bridge due to a transvenous pacemaker infection.
Result: A 15-year-old male patient was referred for an infected transvenous pacemaker 6 months after he was implanted with a dual chamber pacemaker for symptomatic congenital complete heart block. Blood culture grew Staphylococcus Aureus. The transvenous pacemaker system was subsequently explanted. A temporary wire was inserted. As the infection was systemic, the patient was young and dependent on pacing, a decision to implant a leadless pacemaker system as a bridge was made. Femoral angiograms showed that the calibre of the femoral veins were small. Right internal jugular vein was angiographically able to accommodate the size of the sheath.
The right internal jugular vein was accessed with ultrasound guidance and 8F dilator was inserted. Right jugular vein was successively dilated before the insertion of the 27F leadless pacemaker sheath. The sheath was advanced with into the mid right atrium. The Micra pacemaker delivery catheter was advanced where it was then deployed at the mid right ventricle. Parameters were within acceptable parameters. The sheaths were then removed, and the skin was closed. Pacing parameter tested the next day and on 1 month follow-up demonstrated stable electrical pacing parameters.
Conclusion: MICRA implantation via the right IJV is a safe and feasible alternative.
PP-127-1-CIED MICRA AV leadless pacemaker: Real world experience of 100 consecutive patients in national heart institute Dr Muhammad Izzad Johari1, Dr Suraya Hani Kamsani1, Dr Rohith Stanislus1, Zunida Ali1, Noor Asyikin Sahat1, Amirzua Ahmad Said1, Azlina Daud1, Gina Dayang Manit1, Mohamad Halmy Aziman1, Low Ming Yong1, Dr Surinder Kaur Khelae Atma Singh1, Dr Azlan Hussin1 1National Heart Institute, Jalan Tun Razak, MalaysiaBackground: MICRA have been shown to be safe and effective. Recently, a new leadless pacemaker capable of maintaining atrioventricular synchronous pacing, the MICRA AV, was introduced. We report our clinical experience using the MICRA AV Transcatheter Pacing System (Medtronic, Minneapolis, MN, USA) in 100 patients over a period of 2 years.
Methods: A retrospective review of all MICRA AV implanted between July 2020 and July 2022 was performed. Patients' demographic data, indication for pacing, pacing parameter performance up to a median follow-up period of 2 years follow-up were analysed.
Results: A total of 101 patients who underwent the MICRA AV implantation were analyzed. Sixty patients (60%) were male, and the mean age of the patients were 72 years old (range 35–92 years) The MICRATM AV were successfully implanted in all of the patients (100%). The mean P and R wave was 3.0 and 10.1 mV respectively. The mean capture threshold at implant was 0.57 [email protected] ms (0.24–1.63 [email protected] ms) and the implanting impedance were 610 ohms (430–1350 ohms). The P and R wave sensing, thresholds and impedances were noted to be stable at intermediate and long-term follow-up. There was no cardiac perforation, device dislodgement, infection or need for re-intervention immediate post-implant or during the follow-up period of 2 years.
Conclusion: The MICRA AV implantation is safe and effective in a wide cohort of patient with an AV block pacing indication. The leadless pacemakers' clinical performances were stable during a median follow-up of 2 years.
PP-128-2-CIED Implantation of a leadless pacemaker in a patient with an inferior vena cava filter Dr Rohith Stanislaus1, Dr Suraya Kamsani1, Dr Jayakanthan Kolanthai Velu1, Dr Yee Sin Tey1, Dr Azlan Hussin1, Dr. Surinder Kaur Khelae1, Dr Muhammad Izzad Johari1, Amirzua Ahmad Said1, Azlina Daud1, Mohd Halmy Aziman1, Gina Dayang Manit1, Zunida Ali1, Noor Asyikin Sahat1 1National Heart Institute, Kuala Lumpur, MalaysiaObjective: To demonstrate the feasibility of implanting a leadless pacemaker in the setting of a IVC filter in a patient with vascular access issues.
Material/Methods: An 80-year old female with ESRF and CHB was implanted with a conventional dual-chamber pacemaker 2 months prior. Recent admission for sepsis, intracranial/GIT bleed. During her recovery period, she developed a Left Common Femoral DVT. In view of her risk of Pulmonary Embolism an IVC filter was implanted. 2 weeks post-IVC filter, she developed a PPM pocket infection necessitating explantation of the device. However, she was on dialysis via a Right IJV, an AVF had not been created yet. Her Right IJV catheter was exchanged with an 11F sheath, a 9F retrieval sheath with a 20 mm loop snare was inserted and hooked onto the IVC, the sheath was advanced and the filter was partially collapsed. This assembly was left in-situ while a second operator obtained right transfemoral venous access for the leadless pacemaker delivery sheath insertion. The delivery sheath successfully negotiated past the partially captured/collapsed IVC filter. A MICRA was then deployed as per standard procedure at right ventricular septal location. Device parameter were all within limits (R-wave 6.5 mV, Impedance 560 ohms, Threshold 0.38 mV at 0.4 ms). The IVC filter was then re-deployed with femoral venogram guidance. The patient was stable throughout the procedure.
Conclusion: This case demonstrated that a leadless pacemaker implantation is feasible and safe in the presence of an IVC filter, without the risk of potentially damaging/compromising the IVC filter or pacemaker.
PP-129-2-CIED Clinical implication of fat biopsy among patients with requiring cardiac implantable electronic devices Assoc Prof Jin-Kyu Park1, Songyi Han1, Asso Prof Ki-Seok Jang 1Hanyang University, Seoul, South KoreaObjective: Transthyretin amyloidosis is an under-recognized cause of cardiomyopathy which associated cardiac arrhythmia and heart failure. Fat biopsy is one of supportive method to diagnosis of cardiac amyloidosis. We aimed to assess the clinical implication of amyloid deposit via fat biopsy in subjects with cardiac arrhythmia and heart failure.
Materials and Methods: We enrolled consecutive patients requiring cardiac implantable electronic devices during 2 years in single center. Thoracic subcutaneous fat was obtained during procedures and stained with Congo Red. Congo red staining was analyzed by two pathologists. 99mTc-3,3-disphosphono-1,2-propanodicarboxylic acid scintigraphy (99mTc-DPD) scintigraphy was also performed.
Results: Among total 73 patients (50.6% male), 58 (79.4%) patients received procedures of permanent pacemaker and 15 (20.6) patients did procedure of implantable cardioverter defibrillator and cardiac resynchronization therapy. Congo red was positive in 17 (23.3%) patients (16 bradyarrhythmia and 1 heart failure). In findings of 99mTc-DPD scintigraphy, there were positive in five (6.8%) patients (three bradyarrhythmia and two heart failure). Only one case was finally diagnosed as hereditary cardiac amyloidosis. No serious complication was noticed in pocket site.
Conclusion: Fat biopsy with Congo red during procedure for cardiac implantable electronic device was suboptimal as first-screening tool for cardiac amyloidosis. However, this can be useful and safe method in case of clinically suspected cardiac amyloidosis.
PP-130-2-CIED Leadless pacemaker implantation with absent right superior vena cava Dr Mitsuhiro Kunimoto1, Dr Kikuo Isoda1, Dr Haruna Tabuchi1 1Juntendo Nerima hospital, Nerima-ku, JapanObjective: To report a successful leadless (LP) pacemaker implantation in patient who had been implanted with an atrial single-chamber (AAI) pacemaker lead through persistent left superior vena cava (PLSVC).
Materials and Methods: In our case, a 75-year-old man underwent pacemaker implantation because of symptomatic sick sinus syndrome (SSS). Preoperative venography confirmed an absent right superior vena cava (ARSVC) and a PLSVC. Right ventricular pacing was considered difficult, and he was implanted with an atrial single-chamber (AAI) pacemaker lead through PLSVC for SSS. Two years after operation, he was admitted to our hospital for symptomatic complete atrioventricular block (c-AVB). Three-dimensional CT scan also revealed an ARSVC (Panel A) and a PLSVC and we implanted a LP in right ventricle via the right femoral vein (Panel B, arrow).
Result: LP could follow not only the autologous atrial wave, but also the wave triggered by atrial pacing, indicating combination of AAI pacemaker and LP can work as dual chamber pacing system in our patient (Panel C).
Conclusion: We reported a rare case in which c-AVB was detected in a patient with PLSVC who had been implanted with an atrial single chamber pacemaker lead. We managed a patient successfully by implantation of an LP.
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PP-131-2-CIED Learning curve for physiological pacing Dr Friska Anggraini Helena Silitonga1, Dr Muhammad Yamin1, Dr Simon Salim1, Dr Angga Pramudita1, Dr Rubiana Sukardi2, Ms Catur Wulanningsari2, Mr Rohmad Widiyanto2 1Division Of Cardiology, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, 2Integrated Cardiac Centre—Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Objectives: Physiological pacing has been found to have many advantages because this procedure can mimic human physiology so that it will be very beneficial for the patient. His bundle pacing (HBP) and Left bundle branch pacing (LBBP) are physiological pacing techniques that aim to capture the His bundle-Purkinje system or the left bundle branch area and synchronously activate both ventricles. We present our initial experience and learning curve with physiological pacing procedure.
Materials and Methods: This study is a retrospective observational study of patients undergoing physiological pacing. Pacing indication, fluoroscopy time, pacing capture thresholds, sensing and impedance were recorded.
Results: HBP and LBBP was attempted in a total of 39 patients, during the study period (2019–2022). Permanent Physiologic pacing was successfully achieved in 33 of these patients. Failure to implant occur in about 20% of patients. In patients whose physiologic pacing has failed, the RV lead is placed in the RV septal. A high threshold can be seen in about 10% of patients, especially in the first 10 cases. Over time, the fluoroscopy duration shortened, almost the same as the conventional non-physiological pacing.
Conclusion: HBP and LBBP are pacing techniques that are feasible and have the potential to overcome non-physiologic RV pacing limits with a high success rate. In this study we showed that there was evidence of a learning curve, although not statistically significant, there was a decrease in the duration of fluoroscopy and pacing capture threshold. The learning curve is quick, and the uptake is fast.
PP-132-2-CIED Impact of atrial fibrillation detected by cardiac implantable electronic devices on stroke in cancer patients Dr Miyo Nakano1, Assoc Prof Yusuke Kondo1, Asst Prof Masahiro Nakano2, Asst Prof Takatsugu Kajiyama2, Dr Ryo Ito1, Dr Mari Kitagawa1, Dr Masafumi Sugawara1, Dr Toshinori Chiba1, Dr Satoko Ryuzaki1, Dr Yutaka Yoshino1, Prof Yoshio Kobayashi1 1Department Of Cardiovascular Medicine, Chiba University Graduate School Of Medicine, Chiba, Japan, 2Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine, Chiba, JapanBackground and Objective: Cancer may increase the risk of embolic stroke events. Little is known about the incidence of atrial fibrillation (AF) and embolic stroke events, in cancer patients with cardiac implantable electronic devices (CIEDs) in Asia, and the appropriate treatment guideline in cancer patients with AF has not established yet. The purpose of this study is to identify the incidence of embolic stroke events in cancer patients with CIEDs and to examine the risk factors of embolic stroke events.
Methods: We retrospectively analyzed the database of our CIEDs clinic. We examined the characteristics and incidence of embolic stroke events and investigated the relationship between new-onset AF detected by CIEDs and the incidence of embolic stroke events.
Results: We enrolled 138 consecutive cancer patients with CIEDs who had no prior AF and took no anticoagulant in this study (follow-up period, 76 ± 58 months; age, 73 ± 16 years; male, 76%; defibrillator, 48%). The mean CHA₂DS₂-VASc and HAS-BLED scores were 3.2 ± 1.5 points and 2.3 ± 1.6 points, respectively. During the follow-up period, 13 patients (9.4%) had embolic stroke events. In the multivariate logistic regression analysis, independent predictors for embolic stroke events were new-onset AF episode ≥20 s (odd ratio [OR] 4.2, 95% confidence interval [CI] 2.1–9.5, p = 0.0082) and an enlarged left atrium ≥40 mm (OR 3.3, 95% CI 1.2–8.2, p = 0.018).
Conclusions: AF episodes lasting for ≥20 s and enlarged left atrium were risk factors of embolic stroke events. We should examine AF burden carefully in this population.
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PP-133-2-CIED Acute success, stability and safety of LBBP with Agilis Hispro steerable catheter: Single Centre experience Dr Shonda Ng1, Dr Kenny Wee Kian Tan1, Dr Kevin Ming Wei Leong2, Dr Pow-Li Chia1, Dr David Chee Guan Foo1 1Tan Tock Seng Hospital, Singapore, 2Woodlands Health Campus, Singapore
Objectives: His-bundle pacing adverse sequelae includes lead dislodgement and elevated pacing thresholds. Left bundle branch pacing (LBBP) is an alternative for conduction system pacing. We aim to study acute success rates, short-term stability and safety of LBBP with Agilis HisPro steerable catheter and extendable-retractable stylet-based (SB) leads.
Materials and Methods: Thirty-one patients who underwent LBBP with HisPro catheter and SB leads were included in this series. Patients' demographics, pacing indications, baseline QRS morphologies and duration and left ventricular ejection fraction (LVEF) were analyzed. Acute success was defined as achieving stimulation to LV activation time (Stim-LVAT) ≤75 ms or incomplete right bundle branch paced morphology in V1. We also reported LBB potential (if present) and V6-V1 interpeak interval. All lead parameters and complications in the immediate (1 day) and short-term (1 week and 3–6 months) timeframe were evaluated.
Results: Thirty-one patients (mean age 73), gender (female 55%), and LVEF (mean 47%) were analyzed. Pacing indications included sinus nodal dysfunction (26%), atrioventricular block (71%) and heart failure (3%). We achieved an acute success rate of 87% (6.5% with LVSP, 6.5% converted to CRT). Forty-four percent of successful LBBP patients had LBB potential and/or interpeak interval > 33 ms. Immediate and short-term lead parameters were stable and acceptable in all cases. There were no complications (such as lead dislodgement) reported during the acute and short-term follow-up.
Conclusion: LBBP is successful in 87% of cases with HisPro catheter and extendable-retractable SB leads and proven to be safe and feasible. Incremental experience with delivery tools will improve success implantation.
PP-134-1-CIED Cross-cultural validation into Filipino of the Aquarel questionnaire among post-pacemaker patients in UST Hospital Dr Patricia Camille Badion1, Dr Marcellus Francis Ramirez1 1University of Santo Tomas Hospital, Sampaloc, PhilippinesArrhythmias have greatly contributed to most of the total morbidity and mortality of cases worldwide. With this, the advent of pacemaker devices greatly influenced its treatment. Having implanted devices demands lifelong therapy and aims to offer better quality of life. The Assessment of QUAlity of life and RELated events (AQUAREL) questionnaire was developed as the first disease-specific tool to measure quality of life in these patients; however, it is only available in English. To measure quality of life among Filipinos who have undergone pacemaker insertion, a culturally appropriate version should be validated. A five-step cross-cultural validation study was done to create a Filipino version of the AQUAREL questionnaire. Forward translation, back translation and panel reconciliation were done by language experts. Pretesting and content validation were done with the help of field experts in Cardiology. Field testing involved 31 post-pacemaker patients who completed the 24-item questionnaire. All items were retained with minimal modifications and yielded an item constant validity index (I-CVI) of 1.00. Descriptive statistics and Bland–Altman plots of the items exhibited good linguistic equivalence. Correlation coefficients of both versions were ≥0.30 indicating good conceptual equivalence. The Cronbach's alpha values for both Filipino and English versions were 0.775 and 0.771 showing good internal consistency. Thus, the Filipino version of the AQUAREL questionnaire is a valid and culturally appropriate instrument in measuring quality of life among Filipino patients after pacemaker insertion.
PP-135-2-CIED The impact of shorter duration intravenous antibiotic following cardiac implantable electronic devices (CIED) implantation Dr Fera Hidayati1, Dr Erika Maharani1 1Department of Cardiology & Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada/Sardjito Hospital Yogyakarta, Sleman, IndonesiaObjectives: Intravenous (IV) antibiotics before and a few days after cardiac implantable electronic device (CIED) implantation are generally administered in our hospital resulting in an extended hospital stay. This study investigates the effects of a shorter duration of IV antibiotics after CIED implantation.
Materials and Methods: An observational retrospective study was conducted using CIED registry in Sardjito General Hospital, Yogyakarta, Indonesia, between Jan 2017 to Aug 2021. Adults with CIED implantation who fulfilled the inclusion and exclusion criteria were recruited. All subjects received 1.5-g Ampicillin-Sulbactam IV before the procedure. There were two groups of subjects: Group 1 obtained IV Ampicillin-Sulbactam bid ≥4–6 times and Group 2 received IV Ampicillin-Sulbactam bid two times after the implantation. Follow-up of CIED infection was done a minimum of 6 months after implantation.
Results: A total of 453 patients were included in this study, 153 and 300 in group 1 and 2, respectively. The mean age was 65.8 ± 13.2 yo and 67.1 ± 13.1 yo in group 1 and 2. A permanent pacemaker (PPM) was the most common CIED type implanted in both groups (97.3% and 98%). The atrioventricular node dysfunction was the most frequent indication for PPM procedure (58.6% and 61.4%). The rate of CIED-related infections was 4.6% (7) and 1.0% (3) in group 1 and 2, respectively (p = 0.02). The median length of stay (LOS) in group 1 and 2 were 7 and 4 days, respectively (p = 0.000).
Conclusion: The CIED-related infection and LOS were significantly lower in the group with a shorter duration of antibiotic administration.
PP-136-2-CIED Case series of late permanent pacemaker pocket infection Dr Samuel Wowor1,2, Dr Ifan Citra1,2, Dr Theovano Oktavio1,2, Dr Benny Setiadi1,2 1Department of Cardiology and Vascular Medicine, Sam Ratulangi University, Manado, Indonesia, 2Prof. Dr. R. D. Kandou Hospital, Manado, IndonesiaObjective: To demonstrate characteristics of patients with late PPM pocket infections in our center.
Materials and Methods: The data in this case series were obtained retrospectively from medical records. There was a total of three patients with late PPM pocket infection with illustration of each case.
Results: All three patients presented with late onset of local inflammation at the pocket surface without fever. Blood culture samples in case 2 and 3 patients were drawn after antibiotics were administered. The third patient's blood culture result was positive for MRSA. Pocket swab and tissue culture results were negative in all patients.
In terms of host-related risk factors, the second patient had undiagnosed diabetes with history of previous CIED related infections. The first patient also had previous CIED related infections and were only treated conservatively. The third patient had chronic renal insufficiency. There was no procedure related or device characteristic risk factors in all patients. All patients received empirical antibiotics, complete PPM explantation. One patient underwent reimplantation.
Conclusion: CIED infections could be localized or systemic. Late onset of local inflammatory changes at generator pocket site is most likely a pocket infection, and could supported by culture, commonly caused by Streptococcus. Negative culture often found in late pocket infections as in the two patients. It is important to screen for risk factors after implantation. Two patients had previous CIED infections which should have had the PPM removed in the first place. The treatment to CIED infections is antibiotics, explantation and reimplantation of a new device.
SUPPORTING DOCUMENTS
Case Illustration
Case 1
Seventy-seven-year-old male presented to cardiology clinic complained about a lump appeared on skin over the PPM implantation site with tenderness and slightly erythematous skin for the past 1 week. Two months prior, patient had similar complaints and was treated in hospital with antibiotics. Patient had history of total AV block, for which the PPM was implanted 11 months prior, and history of coronary angioplasty and hypertension. There were no systemic signs of infection including fever, and complete blood count results came out within normal range. The lump was aspirated, and the sample was sent to laboratory for culture with blood culture samples, and antibiotics (cefazoline and clindamycin) were administered empirically upon admission. Echocardiography study showed no signs of vegetations on the lead as well as the valves. We decided to remove the PPM and its lead and do debridement of the PPM generator pocket on the next day. After PPM extraction, holter ECG was done to decide whether it was necessary to implant another PPM. The holter result was second degree type 1 AV block, so we decided to withhold PPM reimplantation in this admission. The blood and pus culture results came out negative. Patient was discharged after completed antibiotic treatment.
Case 2 Sixty-seven-year-old female patient presented to cardiology clinic with complaints of pus discharge from the skin surface of the generator pocket site for the last 2 days, with red discoloration, tenderness, and being warm on palpation. There were no systemic symptoms including fever. Patient had history of PPM implantation procedure 2 years prior, and 2 months after the initial implantation, patient had similar complaints but was only treated with antibiotics. Patient denied history of diabetes mellitus or routine use of antidiabetic agents. On physical examinations, the skin surrounding the incision site was slightly erythematous, a small erosion wound just under the incision site with pus discharge. Late pacemaker pocket infection was then suspected, and patient was admitted to the hospital. Pus discharge sample was sent to the lab for culture. Echocardiography evaluation showed no signs of vegetations on lead or heart valves. Laboratory test results showed no elevated white blood cells, 218 mg/dl of random blood glucose, HbA1c was 11.1%. Antibiotics were administered empirically (ceftriaxone and clindamycin), and insulin therapy was given along with patient's routine medications. Blood sample was taken for microbiological culture, which unfortunately was taken after administration of antibiotics. Patient underwent generator pocket debridement and extraction of PPM lead and generator, and temporary pacemaker was placed. Pocket and device swab, as well as pocket tissue samples were taken for microbiological culture, which all came out negative. Patient then underwent reimplantation of PPM at the opposite site after completed the antibiotics therapy.
FIGURE 1 Pacemaker site case 2.
Case 3 Eighty-one-year-old male presented to cardiology emergency department with skin lesion and tenderness at the PPM implantation site for the last 1 week followed by pus discharge at the PPM pocket skin surface for the past 3 months. Patient has dextrocardia and had PPM implanted 3 years prior. Physical examination on admission showed red discoloration with pus discharge on the PPM implantation site, patient was also icteric. On laboratory findings, WBC was 12,200/μl, hemoglobin 14.0 g/dl, platelet count 244,000/μl, ureum 81 mg/dl, creatinine 2.0 mg/dl, SGOT 58 U/L, other laboratory findings were unremarkable. Patient was suspected to have late pacemaker pocket infection, and antibiotic (cefazoline) was administered. Echocardiography study showed no signs of vegetation on lead and heart valves. Blood and pus culture were taken the next day. Patient underwent complete explantation of the PPM unit and generator pocket debridement. Tissue sample and pocket swab sample were sent to the laboratory for culture. During hospital admission, patient developed fever and abdominal tenderness. Laboratory results were WBC 22,800/μl, SGOT 33 U/L, ureum 98 mg/dl, creatinine 1.9 mg/dl, total bilirubin 6.37 mg/dl, direct bilirubin 6.12 mg/dl, SGOT 107 U/L, SGPT 33 U/L. Patient was then diagnosed with acute cholangitis. Antibiotic was switched to a broader spectrum (vancomycin). The blood culture result came out methicillin-resistant Staphylococcus aureus (MRSA) sensitive to vancomycin, therefore the antibiotic treatment was continued. The tissue and pocket swab culture on the other hand came out negative. Patient was then discharged and was planned for reimplantation later.
FIGURE 2 Pacemaker site case 3.
Discussion
Permanent pacemaker implantation is relatively safe with minimal risk of complications. However, there is a risk of infections with incidence about <2%.1 Early infections usually are caused by wound contamination during surgery, while late infections usually are secondary infections due to bloodstream infections. This case series demonstrated late infections in PPM pocket with successful management by antibiotic administration, complete removal of PPM and debridement.
All three patients presented with signs of local inflammation at the generator pocket site late after initial implantations, with the third case being the most obvious one with clear erosion and purulent discharge. In late presentation of local inflammatory changes at generator pocket site, the diagnosis would almost be certain of pocket infections. If the onset of inflammatory changes was early, it is important to distinguish between superficial skin infections, or allergic reactions to the device or dressing and pocket infections.3 There was no fever observed in any of these patients at initial presentation, which is common in CIED related infections, the third case patient developed fever later during admission, due to acute cholangitis.
Although it is recommended to draw blood samples before starting antibiotics, the blood culture samples in case 2 and 3 patients were drawn after antibiotics were administered, which could had interfered the negative results of second patient. The decision to start the antibiotics before blood culture samples were drawn in these patients was unfortunately solely due to our center's limitations. Our laboratory does not provide blood culture samples processing outside of office hours, making it difficult to draw blood culture samples after office hours. Therefore, it was more appropriate to start antibiotics as soon as possible rather than delaying it for the next day. The third patient's blood culture result was positive for MRSA. The majority pathogen causing CIED related infection is Staphylococcus, and MRSA was responsible in about one third of CIED related infections. Positive blood cultures due to Staphylococcus is highly suggestive that the clinical syndrome is due to CIED infection. Bloodstream infections from remote source could potentially cause pocket infections. However, this patient developed acute cholangitis during hospital admission, and the pathogen causing acute cholangitis are usually gram-negative and anaerobic organisms, therefore it was unlikely that this pocket infection was due to remote source bloodstream infections, and these two conditions could be unrelated.4 In terms of pocket swab and tissue culture, all results came out negative. Previous study reported culture negative CIED related infections found in 13.2%, and were more likely seen in late pocket infections.5
Several risk factors have been attributed to CIED related infections including host-related, procedure-related and device characteristics. In a meta-analysis, diabetes mellitus, renal disease, COPD, corticosteroid use, malignancy, heart failure, and anticoagulant use are the most significant host-related risk factors.6 The second patient denied history of diabetes but was diagnosed during hospital admission with high level of HbA1C, meaning the patient had undiagnosed diabetes with poor glycemic control. Patient with diabetes were two times more likely to get CIED related infections.6 This patient also had similar symptoms previously about 2 months after the initial implantation. Whilst it was unclear whether that was just a superficial skin infection or just irritation or allergic reaction to the dressings or topical antibiotics because the onset was still considered early. However, previous device infections could possibly be a contributing risk factor in this patient. The first patient also had similar symptoms just 2 months before presenting at the cardiology clinic and was treated with antibiotics before. Unlike the second patient, the first symptoms that appeared 2 months prior were highly suggestive of PPM pocket infection due to its late onset, but conservative approach was taken without long-term suppressive antibiotics which eventually led to recurrency. Conservative approach to salvage the device is recommended only if the device removal is not possible, and should be followed by long-term suppressive antibiotic therapy.7 Patients with renal insufficiency are three times more likely prone to CIED related infections,6 and the third patient presented with elevated creatinine level suggesting chronic renal insufficiency. Regarding procedure related risk factors, all three patients seemed to have none. There was no recorded history of non-infectious post-operative complications especially hematoma or lead dislodgement, none of these patients underwent replacement/revision procedures before, and antibiotics prophylaxis have always been our standard care before PPM implantation. As to device characteristics, all patients used single chamber, and were all placed in pectoral pockets.
As recommended by consensus, antibiotics administration and complete removal of the device unit including the leads is the key to successful treatments of CIED related infections, whether it was just a localized pocket infections or systemic infections.7 All patients received empirical antibiotics, underwent complete PPM explantation procedure, followed by debridement of the PPM pocket.
REFERENCES
1. Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, et al. 16-Year Trends in the Infection Burden for Pacemakers and Implantable Cardioverter-Defibrillators in the United States. J Am Coll Cardiol. 2011 Aug;58(10):1001–6.
2. Han HC, Hawkins NM, Pearman CM, Birnie DH, Krahn AD. Epidemiology of cardiac implantable electronic device infections: incidence and risk factors. EP Eur. 2021 Jun 23;23(Supplement_4):iv3–10.
3. DeSimone DC, Sohail MR. Approach to Diagnosis of Cardiovascular Implantable-Electronic-Device Infection. Kraft CS, editor. J Clin Microbiol. 2018 Jul;56(7):e01683-17.
4. Jain MK, Jain R. Acute bacterial cholangitis. Curr Treat Options Gastroenterol. 2006 Apr;9(2):113–21.
5. Hussein AA, Baghdy Y, Wazni OM, Brunner MP, Kabbach G, Shao M, et al. Microbiology of Cardiac Implantable Electronic Device Infections. JACC Clin Electrophysiol. 2016 Aug;2(4):498–505.
6. Polyzos KA, Konstantelias AA, Falagas ME. Risk factors for cardiac implantable electronic device infection: a systematic review and meta-analysis. EP Eur. 2015 May;17(5):767–77.
7. Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, et al. European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections—endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). EP Eur. 2020 Apr 1;22(4):515–49.
PP-137-2-CIED Factors associated with pacemaker induced cardiomyopathy, a single-center experience Dr Pitawat Saesue1, RN Napawan Pornnimitthum2, Dr Arisara Suwanagool2 1Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 2Her Majesty's Cardiac Center Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, ThailandBackground: Some patients implanted with permanent pacemaker (PPM) developed LV dysfunction that will cause heart failure symptoms, indicating an upgrade to a cardiac resynchronization therapy (CRT).
Objective: To establish the predictors and associated factors of Pacemaker induced cardiomyopathy (PICM) in patient underwent pacemaker implantation.
Methods: We conducted a retrospective chart review of patients in cardiac device clinic who underwent pacemaker implantation then later upgraded to CRT at Siriraj Hospital, Thailand from January 2013 through December 2019. The patients were classified into PICM and non-PICM groups, each possible associated factor was analyzed. Patients who were implanted with CRT from other indications were excluded.
Results: Among 564 PPM patients, 43 (7.6%) were detected as PICM with a median onset of 6.68 ± 5.2 years post-implantation, mean post-PPM LVEF 34.94 ± 7.67%, mean change in LVEF 30.64 ± 11.25%. We found these factors include ventricular pacing (VP) >70% (p = 0.003), younger age at implantation (Mean age of PICM compared to non-PICM 60-year-old vs. 70-year-old, p = 0.002) were significantly showed association with PICM. Other factors included baseline characteristics, baseline ECG (rhythm, QRS morphology, and duration), and lead position showed statistically nonsignificant between two groups.
Conclusions: Patients who underwent PPM implantation and required ventricular pacing >70% or younger age group at implantation are at a higher risk of developing pacemaker-induced cardiomyopathy.
PP-138-2-CIED The usefulness of a 20-degree caudal view to guide axillary venous access during device implantation Dr Soorampally Vijay1 1Manipal Hospital, Banglore, IndiaBackground: For cardiovascular implantable electronic device implantation, axillary venous access is recommended. The procedure is often done in an anteroposterior (A-P) view under fluoroscopic guidance. However, this view lacks the depth of perception with a fear of creating complications. To alleviate this problem, caudal fluoroscopy (adding 20° caudal angulation to the A-P view) has been proposed.
Objectives: This study's objective was to elucidate the benefits and safety of caudal fluoroscopy (adding 20° caudal angulation to A-P view) in guiding axillary venous access.
Materials and Methods: The fluoroscopic images and contrast venograms were acquired in the A-P and 20° caudal views. The described technique has been a routine practice for operators at our center. In the period from 2020 to 2022, there were 410 cases requiring central venous access: 230 pacemaker implants, 64 CRTs, 109 implantable cardioverter defibrillators, and 7 lead revisions/device upgrades. The caudal view was used in 95% of cases, the cephalic vein cut down in 3% of cases, and standard A-P fluoroscopy in 2% of cases. There was no pneumothorax or hemothorax in our data set.
Conclusion: Combining A-P and caudal fluoroscopic views while obtaining venous access for the cardiovascular electronic device was associated with high safety.
PP-139-2-CIED A challenging case of contralateral pneumothorax after Dual-Chamber permanent pacemaker implantation MD Sermsuke Ruengwittayawong1, MD, CEPS Wipat Phanthawimol1, MD Jirayu Sutasanasuang2, MD Thossapoom Phubangkertphon2, MD Weeraya Noisiri3, MD Peerapat Katekangplu11Cardiac Electrophysiology Unit, Department of Cardiology, Central Chest Institute Of Thailand, Nonthaburi, Thailand, 2Department of Cardiology, Central Chest Institute Of Thailand, Nonthaburi, Thailand, 3Department of Radiology, Central Chest Institute Of Thailand, Nonthaburi, Thailand
Objective: We report a case of right-sided pneumothorax after dual-chamber permanent pacemaker implantation via a left subclavian vein approach.
Materials and Methods: A 77-year-old woman without history of lung disease was referred to our institution for complete atrioventricular block (Figure 1). Left subclavian venous access was done under fluoroscopic guidance using contrast venogram on the ipsilateral arm. There was no air leak during an attempt to gain vascular entry. Active fixation leads were successfully implanted at the anterolateral wall of the right atrium and right ventricular apical septum with optimal pacing threshold, sensing and impedance. Nine hours after implantation, patient developed sudden onset of dyspnea. Chest radiograph revealed right-sided pneumothorax. Emergent pleural chest tube insertion was performed (Figure 2). Echocardiogram did not show pericardial effusion. Device interrogation yielded unchanged lead parameters. Complete resolution of pneumothorax was achieved in the next couple of days.
Results: Computed tomography revealed that atrial and ventricular leads were not perforated but the tip of atrial lead abutted anterolateral wall lying in close proximity to subpleural blebs in the right middle lobe (Figures 3 and 4). Anterolateral right atrial wall comprises pectinate muscle and the paper-thin part. Tip of the helical screw at this site possibly injured adjacent subpleural blebs causing rupture, resulting in pneumothorax.
Conclusion: Contralateral pneumothorax after dual-chamber permanent pacemaker implantation is extremely rare but possible, even without lead perforation. It can be prevented by avoiding atrial lead implantation at the anterolateral free wall especially in the patient with history of chronic lung disease.
SUPPORTING DOCUMENTS
FIGURE 1 12-lead electrocardiogram showed sinus tachycardia (cycle length = 560 ms) and narrow QRS complex junctional escape rhythm (cycle length = 1560 ms) with complete atrioventricular block.
FIGURE 2 Chest radiographs in anteroposterior view before device implantation (A). Moderate right-sided pneumothorax with right lung collapse 9 h after dual-chamber pacemaker implantation via left subclavian vein approach. No evidence of left-sided pneumothorax, tip of atrial and ventricular leads were placed at the anterolateral free wall of the right atrium and right ventricular apical septum respectively without lead dislodgement (B). Resolution of right-sided pneumothorax after emergent pleural chest tube insertion (C).
FIGURE 3 Computed tomography in coronal view demonstrated that tip of the atrial active fixation lead abutted anterolateral free wall of the right atrium (white arrow). There was 1 mm protrusion of the lead tip beyond outline of the atrial wall without evidence of lead perforation. Pericardial effusion or pneumopericardium was not seen.
FIGURE 4 Computed tomography in axial view lung window demonstrated paraseptal emphysema and small subpleural blebs in the right middle lobe (white circle dotted line) lying in close anatomical proximity to the tip of the atrial lead helical screw (yellow arrow).
PP-140-2-CIED Device-detected sleep-disordered breathing and risk of new-onset atrial fibrillation: Result of the DEDiCATES study Prof Hye Bin Gwag1, Associate Professor Seung-Jung Park2 1Sungkyunkwan University School Of Medicine, Samsung Changwon Hospital, South Korea, 2Sungkyunkwan University School Of Medicine, Samsung Medical Center, South KoreaObjective: Recent cardiac implantable electronic devices have diagnostic function to monitor sleep-disordered breathing (SDB) which is comparable to polysomnography. Patient enrollment is completed for the DEDiCATES study, a multicenter prospective study, aiming to evaluate the association between device-detected SDB and atrial fibrillation (AF).
Materials and Methods: Baseline characteristics and the first device interrogation data (post-implant 3 ± 1 months) were analyzed. Daily Respiratory Disturbance Index (RDI) values were collected to assess SDB burden. New-onset AF was defined as (1) no previous history of AF, and (2) atrial high-rate episodes with stored electrogram compatible with AF and cumulative duration ≥1 h/day.
Results: Among a total of 539 patients with available RDI reports during the first interrogation. The mean value of average, maximal, and minimal RDI of total patients was 32.9, 53.5, and 17.0, respectively, and 74 patients (13.7%) had previous AF. Patients with previous AF were older, more likely to be female, and had a lower prevalence of heart failure compared to those without, while average and maximal RDI values did not differ. Among 465 patients without previous AF, new-onset AF was detected in 39 (8.4%) patients. The mean average RDI was higher in patients with new-onset AF than those without (37.3 vs. 32.5, p = 0.01), and higher average RDI was associated with new-onset AF in multivariate analysis (OR 1.302, 95% CI 1.002–1.062, p = 0.04).
Conclusions: New-onset AF was associated with higher average RDI. Further analysis of longer-term data is needed to confirm the relationship between AF and SDB burden.
PP-141-2-CIED Incidence and prognosis of pacing induced cardiomyopathy in patients with pacemaker: A Nationwide study Asst Prof Young Jun Park1 1Wonju Severance Christian Hospital, Wonju, South KoreaObjective: Patients with pacemakers develop heart failure for various reasons. However, prognosis and incidence are unclear in patients with new-onset heart failure. Therefore, this study aimed to evaluate risk factors, and prognosis of PaHF using the Korean nationwide cohort database.
Methods: We aimed to evaluate the incidence and prognosis of new- onset heart failure in patient with permanent pacemaker (PPM) using a nationwide database from the Health Insurance Review and Assessment Service in South Korea.
Methods: A total of 21,545 participants who underwent PPM from 2010 to 2017 were included. Participants who were diagnosed with HF before the PPM implantation were excluded. New-onset heart failure is determined by one admission event due to heart failure by taking heart failure medication. The primary outcome was new-onset HF. Secondary outcomes were new-onset HF, cardiac resynchronization therapy (CRT), death.
Results: New-onset heart failure was developed in 6.59% (1446) of participants at baseline. Compared to the non-heart failure group, heart failure group was likely to be older and had higher comorbidities. The incidence of new- onset heart failure was similar in the sick sinus syndrome (SSS) group and AV block (AVB) group. After PS-matching, patients with PaHF had a higher risk of all-cause death than patients non-PaHF (HR 1.42 [95% CI, 1.20–1.69] [p < 0.001]). In PaHF patients, CRT upgrade patients showed better prognosis compared without CRT upgrade (HR 0.42 [95% CI, 0.38–1.69] [p < 0.001]).
Conclusion: New-onset heart failure is associated increased mortality. CRT upgrade is associated with lower mortality.
PP-142-2-CIED New Insight and Perspective of pediatric PPM implantation in CHD Prof Chandara Mam1 1Kantha Bopha Children's Hospital, Phnom Penh, CambodiaIntroduction: Pediatric PPM is underrated in postoperative CHD. In children, the cardiac output is mainly dependent to heart rate. That is why CHD with immediate postoperative bradyarrhythmia is very unstable. Moreover, most of postoperative CHBs are the consequence of procedures involving the closure of VSD. If CHB persists after at least 2 weeks of temporary pacing, permanent pacing is needed in order to improve the quality of life and avoid the risk of asystole or DCM.
Objectives: The aims of this study to show the importance of PPM implantation on morbidity, mortality of children with CHB (±postoperative).
Materials and Methods: Age under 15 years.
All CHBs.
The study population consists of 10 children with CHB diagnosed by pediatric cardiologist in Kantha Bopha Children's Hospital, Heart corner, Phnom Penh, Cambodia.
Results: The age is varied from 8 months to 14 years which two cases are 10 years. Six patients with postoperative CHD (60%), four patients with non-postoperative CHD (40%). Five cases are paced via transvenous (50%).
Conclusions: Pediatric PPM is very crucial either early or late postoperative CHB. The possibility of an associated myocarditis or congenital CHB cannot be over looked. Echocardiographic monitoring and pacemaker programming are also vital following implantation.
SUPPORTING DOCUMENTS
PP-143-V-CIED Substernal extravascular ICD system infection in large animals Ms Amy Thompson1, Ms Melissa Christie, Dr Linnea Lentz 1Medtronic, USA
Background: The extravascular ICD (EV ICD) with substernal lead placement may provide clinical advantages to transvenous and subcutaneous systems. An understanding of substernal infection manifestation and treatment is required.
Methods: The EV ICD system was implanted in 13 large animals (canine, porcine, ovine), and porcine were co-implanted with a transvenous CRT-D system. Animals were monitored for clinical presentation of infection over 12–18 weeks of follow-up, and cultures were collected to confirm infection. Treatment was bifurcated, with some animals receiving antibiotics while EV ICD leads remained in situ, and other animals treated with system removal and antibiotics. Histopathology was conducted at the end of study.
Results: Five infections were confirmed over the course of study, four of which involved infection of the EV ICD system and one of which involved infection of only the concomitantly implanted CRT-D system without infection of the EV ICD system. Two of the EV ICD-related infections were treated with system removal and antibiotic course, and both infections resolved. Two additional EV ICD-related infections were treated with antibiotics alone without explant of the EV ICD leads; histology showed that neither infection resolved. The transvenous CRT-D system infection progressed to septicemia and endocarditis, requiring early study end. No EV ICD-related infection progressed to blood stream infection, and the sternal bone did not become infected when infection was present in the substernal tissues.
Conclusions: Study findings suggest that EV ICD-related infections are treatable with system removal and antibiotic therapy.
PP-144-2-CIED Left bundle branch area pacing in patients with CRT indication: Short-term results and 1-year follow-up Dr Vikas Kataria1, Ms Ishita Yaduvanshi, Dr. Mohit Bhagwati1, Dr. Amitabh Yaduvanshi1 1Holy Family Hospital, New Delhi, IndiaBackground: Cardiac resynchronization therapy (CRT) using bi-ventricular pacing is class I recommendation for symptomatic patients with heart failure (LVEF ≤35%), QRS duration ≥150 ms and LBBB QRS morphology. Left bundle branch area pacing (LBBAP) has been reported as an alternative option for CRT.
Objectives: The aim of this study was to assess the feasibility and outcomes of LBBAP in patients eligible for CRT.
Methods: Patients with CRT indications were subjected to LBBAP. Peri-procedural outcomes & QRS duration were recorded. Changes in New York Heart Association (NYHA) class, need for HF hospitalization, echocardiographic data, lead-device parameters were evaluated at follow-up. HF status was assessed by clinical (no HF hospitalization and improvement in NYHA class) and echocardiographic response (≥5% improvement in LVEF).
Results: LBBAP was attempted in 15 patients (mean age 68 ± 10 years, 38% women, ischemic cardiomyopathy in 47%). All patients had baseline LBB. LBBAP threshold and R-wave amplitudes were 0.8 ± 0.2 V at 0.5 ms and 11.4 ± 5 mV at implantation and remained stable during mean follow-up of 12 ± 4 months. LBBAP resulted in significant QRS narrowing from 154 ± 34 to 118 ± 34 ms (p < 0.01). LVEF improved from 33 ± 9% to 44 ± 12% (p < 0.01). Clinical and echocardiographic improvement was observed in 77% and 74% of patients, respectively.
Conclusions: LBBAP is feasible, safe and provides an alternative option for CRT. LBBAP provides low and stable pacing thresholds and is associated with improved clinical and echocardiographic outcomes.
PP-146-2-CIED Utilization of a three-dimensional accelerometer in medical devices for accurate physiologic state monitoring Prof Roy Gardner1, Prof TIm Betts, Prof Fabio Quartieri, Dr Paul Ryu, Dr Fady Dawoud, Dr John Gill, Prof Jag Singh 1Golden Jubilee National Hospital, Clydebank, Glasgow, UKObjectives: To demonstrate the feasibility of using 3D accelerometer (AXL) data to quantify activity, posture, and sleep duration.
Materials and Methods: A custom-made wearable-data-collection-system was used to collect 3-D AXL data for activity, posture, and sleep detection algorithm development. Activity data were collected while subjects underwent treadmill usage at speeds of 1/2/3/4/5 miles/h. Posture data were collected with subjects in supine, left-sided, right-sided, upright and reclined posture. Sleep data were collected while subjects wore the wearable system overnight. Activity monitoring algorithm development was based on determining the thresholds for 2 and 3 mph of treadmill speed to predict low (<2 mph), moderate (2–3 mph), and intense (>3 mph) activity zones. Posture detection algorithm was developed using the five postures, with data collected during supine and standing postures used for a calibration. Sleep detection used the output from both activity and posture algorithms to determine the duration of sleep.
Results: AXL data were collected from 9, 14, and 6 healthy subjects for activity, posture, and sleep feature development, respectively. Activity algorithm successfully predicted low, moderate, and intense activities with thresholds between 2 (± 0.2) mph and 3 (± 0.5) mph treadmill speeds. Posture algorithm demonstrated the accuracy of 99.4% with high correlation (R2 = 0.9991) in detecting five postures. For sleep detection, overnight activity and posture data led to 95% accuracy with when compared to the manually adjudicated sleep onset and offset from activity/posture trends.
Conclusion: Highly accurate physiologic state monitoring (i.e. sleep, activity and posture) is feasible from 3D-based AXL.
PP-147-2-CIED Long-Term effects of ventricular high septal pacing in pacemaker dependent patients Prof Lae-young Jung1, Dr Sanghyo Kim1, Dr Jihee Son1, Prof Kyoung-Suk Rhee1 1Jeonbuk National University Hospital, Jeonju, South KoreaBackground: Long-term RV apical pacing (RVAP) has been shown to have negative effects on ventricular function and hemodynamics as a result of ventricular dyssynchrony.
Objective: To evaluate whether high septal pacing (HSP) is superior to RVAP in preventing deterioration of left ventricular systolic function and cardiac remodeling in pacemaker dependent patients.
Method: A total of 407 patients with atrioventricular block and atrial fibrillation with slow ventricular response were included in the study. All patients received a permanent pacemaker and were assigned into two groups (RVAP: n = 288, HSP: n = 119). After implantation, patients underwent an echocardiographic study during 3 years. Left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), pro-BNP level and clinical data were analyzed retrospectively.
Result: Baseline LVEF, LVEDD and pro-BNP level were not different between two groups. At 36 months, the incidence of pacemaker induced cardiomyopathy was significantly lower in the HSP group than in the RVAP group (1.7% vs. 6.9%, p = 0.033). The mean LVEDD was significantly lower in the HSP group than in the RVAP group (50.2 ± 5.3 mm vs. 52.1 ± 6.1 mm, p = 0.025), whereas HSP group had a trend toward a better LVEF than RVAP group (54.2 ± 6.3% vs. 52.2 ± 9.3%, p = 0.076). Four patients in the RVAP group were hospitalization for heart failure (p = 0.196).
Conclusion: RV high septum can be an alternative pacing site to reduce deterioration of left ventricular systolic function and cardiac remodeling in pacemaker dependent patients.
SUPPORTING DOCUMENTS
PP-148-2-CIED Septal hematoma and coronary vein infringement during left bundle branch area pacing RN Hyeon-Jin Lee1, RN Hye-Min Park1, RN Chun-Ja Yoo1, Prof Lae-young Jung1 1Jeonbuk National University Hospital, Jeonju, South Korea
Objectives: While septal branch of coronary artery perforation has been previously reported during left bundle branch area pacing (LBBAP), septal hematoma and coronary venous infringement has not yet been well described. Here we describe two cases.
Case report
Case 1
LBBAP was performed for treatment of complete atrioventricular block (CAVB) in a 58-year-old male. The Selectra 3D 55-M curve (Biotronik) was utilized to support the Solia S 60 lead (Biotronik). From the right ventricle (RV), in a mid-septal area of the interventricular septum (IVS), the lead was inserted into the septum with 7–8 clockwise turns. After penetration of the lead, contrast was injected, filling the IVS and perforator branch vein, and the coronary sinus was visualized. The lead was removed with no complication and repositioned.
Case 2
LBBAP was performed for treatment of CAVB in a 51-year-old male. The Selectra 3D 65-M curve (Biotronik) was utilized to support the Solia S 60 lead (Biotronik). From the RV, in a mid-septal area of the IVS, the lead was inserted into the septum with five to six clockwise turns. After penetration of the lead, contrast was injected, filling the IVS and perforator branch vein, and the coronary sinus was visualized. The lead was removed with no complication and repositioned.
Conclusion: LBBAP is generally feasible and safe, but the incidence of the septal hematoma and coronary vein infringement may be underestimated. Although there are no established recommendations about the management, the replacement of the lead allowed with no complications in the follow-up.
SUPPORTING DOCUMENTS
PP-149-2-CIED A case of CRT optimization using SyncAVTM for Bifascicular blocks Dr Ryohei Miyamoto1, Dr Nobuhiro Nishiyama1, Dr Masahiro Morise1, Dr Takahide Kodama1 1Toranomon Hospital, Minato Ward, Japan
Objective: To optimize CRT setting using SyncAV™ for bifascicular blocks.
Materials and Methods: A 60 s man underwent CRT-D implantation for reduced left ventricular ejection fraction, chronic heart failure, non-sustained ventricular tachycardia, and bifascicular blocks (QRS 166 ms) which were right bundle branch block (RBBB) and left anterior hemiblock (LAH) associated with ischemic cardiomyopathy (post-CABG).
Result: The RA lead was implanted in the right atrial appendage, the RV lead in the right ventricular apex and the LV lead in the anterolateral branch of the coronary sinus because of LAH. The QRS during RV pacing was 206 ms and the longest RV pacing-LV sensing time was 201 ms in the LV lead proximal section. For CRT optimization, SyncAV™ Delta was adjusted under RV pacing only so that the QRS of the fusion waveform of RV pacing and RBBB self-conduction was narrowest which was 132 ms when SyncAV™ Delta was −80 ms. Next the VV interval was adjusted using QRS axis as a reference. Eventually, the QRS was narrowest at 122 ms when SyncAV™ Delta −80 ms and the VV interval 0 ms. Before and after CRT-D implantation, LVEDV went from 249 to 210 ml and LVESV went from 176 to 141 ml, resulting in a Volume Responder and no hospitalization for heart failure over the next 2 years.
Conclusion: This case shows a patient with RBBB who became a Responder by optimizing CRT settings using SyncAV™. We report this relatively simple adjustment method, which is useful for optimizing CRT in patients with RBBB.
PP-150-2-CIED Hypertrophic cardiomyopathy increases the risks of bradyarrhythmia and pacemaker implantation Dr Tsu-An Yang1, Dr Shang-Ju Wu1, Dr Cheng-Hung Li1,2, Dr Chi-Jen Weng1,2, Dr Jiunn-Cherng Lin1,2, Dr Yu-Shan Chien1,2, Dr Yi-Huei Chen3, Dr Ching-Heng Lin3, Prof Yu-Cheng Hsieh1,2, Dr Shih-Ann Chen Chen1,2,4 1Cardiovascular Center, Taichung Veterans General Hospital and Chiayi Branch, Taichung and Chiayi, Taiwan, 2Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, 3Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, 4Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, TaiwanObjective: Previous studies of bradycardia complicating hypertrophic cardiomyopathy (HCM) have reported rare patients. Whether HCM is associated with bradyarrhythmia, leading to permanent pacemaker (PPM) implantations remains unclear. This study was to explore the risks of brady-arrhythmia and subsequent PPM implantation in patients with HCM.
Method: Patients with newly diagnosed HCM were identified from the Taiwan National Health Insurance Research Database from 2012 to 2017. A control cohort was selected by matching age and gender in a 1:1 ratio to the study cohort. The primary outcomes were the occurrence of brady-arrhythmia or PPM implantation. A multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for outcomes.
Result: A total of 12,094 (n = 6047 in each group) patients with a mean age of 63.1 ± 14.8 years were analyzed. During the follow-up period, the percentage of patients with bradyarrhythmia was higher in the HCM group (3.3%) than that in the control group (0.5%) (p < 0.001). The percentage of patients receiving PPM implantation was also higher in the HCM group (4.6%) than that in the controls (0.3%) (p < 0.001). HCM was associated with increased risks of bradyarrhythmia (adjusted HR: 5.66, p < 0.001) and PPM implantation (adjusted HR: 15.06, p < 0.001). The presence of atrial fibrillation (AF) was independently associated with increased risks of bradyarrhythmia (adjusted HR: 1.64, p = 0.029) and PPM implantation (adjusted HR: 1.71, p = 0.008).
Conclusion: Patients with HCM was associated with increased risks of bradyarrhythmia and subsequent PPM implantation. The presence AF in patients with HCM increased the risks of bradyarrhythmia and PPM implantation.
PP-151-2-CIED Characteristics and clinical outcomes of patients who underwent CRT implantation in a New Zealand hospital Dr Clement Tan1, Mr Brian Shin2, Dr Janice Swampillai2, Dr Ali Al-Sinan1, Dr Daniel Garofalo1, Ms Anna Wilson1, Ms Victoria Day1, Associate Professor Martin Stiles1 1Te Whatu Ora Health NZ, Waikato, Hamilton, New Zealand, 2Waikato Clinical School, University of Auckland, Hamilton, New ZealandObjectives: Cardiac resynchronization therapy (CRT) is recommended for symptomatic patients with left bundle branch block and left ventricular (LV) ejection fraction (EF) <35% despite optimal medical therapy. We aimed to describe the characteristics and outcomes of CRT patients at Waikato Hospital, and evaluate potential predictors of clinical response.
Materials and methods: Of 183 patients (71% male) receiving CRT between 19/3/2004 and 27/10/2021, two-thirds had a defibrillation-capable device. Ethnicity was 74% European and 14% Maori. 72% of patients had a diagnosis of non-ischaemic cardiomyopathy (NICM).
Results: Post-implantation public cardiology follow-up occurred for 158 (86%) patients plus 4 patients had an echocardiogram. Of 162 patients who had cardiology follow-up and/or echocardiogram post-CRT, 118 (73%) and 116 (63%) patients recorded improvement in NYHA class or in EF post-CRT, respectively. Overall, 123 (67%) patients were classified as responders, 39 (21%) were non-responders and 21 (11%) unclear. Of these responders, 85 (69%) patients were male. Predictors associated with response were smaller pre-implant LV internal diastolic diameter (p = 0.038) and LV internal systolic diameter (p = 0.026) but not sex, non-ischaemic aetiology or ejection fraction.
Conclusion: Small LV dimensions were identified as predictors of favourable response to CRT. A significant proportion of patients did not receive public follow-up and repeat echocardiograms which has been identified as an area for improvement. Some patients are non-responders which underscores the importance of further research and patient selection.
PP-152-2-CIED His-bundle pacing experience targeting an RV his approach using a stylet-driven system in Non-EP laboratory Dr Andrew Leong1, Mr Guowei Zhuo1, Dr Derek Chin1 1Khoo Teck Puat Hospital, SingaporeObjectives: To review short to mid-term electrical lead performance of HBp (His-bundle pacing) with a stylet driven technique, aiming for an RV His approach.
Materials and Methods: All patients undergoing pacemaker implantation or His cardiac resynchronization therapy with a Biotronik system (Solia S leads/Selectra-3D 40, 55 and 65 catheters) at Khoo Teck Puat Hospital from 11/8/20 to 24/6/22 were evaluated.
Results: Permanent HBp was attempted in 70 cases, 53 cases were successful (75.7%). Indications for implant were: sinus node dysfunction (26), AV block (18), binodal disease (7) and His CRT-D (2).
Three cases required lead revision—two for dislodgements and one for inadvertent atrial pacing. One case lost His capture on the third month follow-up but maintained acceptable RV septal pacing (RVSP) thresholds. The average His threshold at implant was 1.82 V@1 ms, 1.73 V@1 ms at 3 months, 1.5 V@1 ms at 6 months and 1.88 V@1 ms at 12 months. Targeting a RV His lead position, good RVSP thresholds were achieved—average RVSP threshold at implant was 0.91 V@1 ms, 1.0 V@1 ms at 3 months, 1.1 V@1 ms at 6 months and 1.08 V@1 ms at 12 months.
Conclusion: HBp using a stylet-driven approach allows for greater precision in targeting an RV His position, this usually results in a nonselective HBp to RVSP to loss of capture transition sequence. Majority of the HBp leads implanted appeared to achieve a durable performance over 12 month. Good RVSP thresholds provide backup in cases of AV block with loss of His capture and remain stable over time.
PP-153-V-CIED Conduction system pacing after TAVR: A systematic review and meta-analysis Dr Sijing Cheng1, Dr Xi Liu1, Dr Yu Deng1, Dr Minsi Cai1, Dr Hao Huang1, Dr Yu Yu1, Dr Wei Hua1 1Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaObjectives: Roughly 15% of patients require permanent pacemaker implantation within 30 days following transcatheter aortic valve replacement (TAVR) due to complete heart block1. And His-Purkinje conduction system pacing (CSP) including his-bundle pacing (HBP) and left bundle branch pacing (LBBB) could establish normal myocardial activation. However, the feasibility of CSP in patients requiring pacemaker implantation after TAVR remains unclear. The aim of this study is to evaluate the feasibility of CSP in patients requiring pacemaker implantation after TAVR.
Materials and Methods: We searched the MEDLINE, Embase, Web of Science, and ClinicalTrials until March 5, 2022. The primary endpoint was the success rate of CSP. We used the fixed model to investigate the success rate in HBP and LBBP, respectively. And we reported the success rate of CSP using random-effect model. All statistics were performed using R 4.1.2.
Results: We included six studies with a total number of 162 patients. Among these, two studies included both HBP and LBBP after TAVR. Success rates ranged from 50% to 81% in HBP and 80% to 95% in LBBP. For patients requiring pacemaker implantation after TAVR, HBP was successful in 65% of patients (95% CI 54%–75%), while LBBP was successful in 92% of patients (95% CI 83%–95%). Overall, CSP could be achieved in 80% of patients (95% CI 65%–89%).
Conclusion: Our study demonstrated that CSP, especially LBBP was feasible in patients requiring pacemaker after TAVR. And LBBP had a higher success rate than HBP.
SUPPORTING DOCUMENTS
PP-154-V-CIED The prognostic value of albumin–bilirubin score in patients with CRT or CRTD Dr Sijing Cheng1, Dr Yu Deng1, Dr Xi Liu1, Dr Hao Huang1, Dr Yu Yu1, Dr Xuhua Chen1, Dr Hongxia Niu1, Dr Wei Hua1 1Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Objectives: The aim of this study was to investigate the prognostic value of the albumin-bilirubin (ALBI) score in patients with cardiac resynchronization therapy (CRT) with or without defibrillator (CRTD).
Materials and Methods: We retrospectively enrolled patients implanted CRT or CRTD between November 2008 and June 2021. ALBI score was calculated as the formula: log10 total bilirubin [μmol/L] × 0.66 + albumin [g/L] × −0.085. The primary endpoint was the composite of all-cause mortality and heart failure rehospitalization (HFH). Cox regression was adjusted for age, sex, BMI, Atrial fibrillation, CRTD, ischemia cardiomyopathy, baseline LVEF, NT-proBNP, creatinine, NYHA class, and use of medication.
Results: Nine hundred patients were included for analysis. During a median follow-up period of 866 days, 249 (27.7%) patients met the primary endpoint. In Cox-regression analysis, ALBI score was independently associated with the composite endpoint (HR 1.07 [1.03–1.11] per 0.1 increase; p = 0.001). Moreover, PRD was significantly associated with the composite endpoint in the CRTD group (HR 1.09 [1.03–1.14]; p = 0.001), but not in the CRT group (HR 1.04 [0.98–1.11]; p = 0.176), although there was only a trend for the interaction between the ALBI score and the effect of CRTD compared with CRT (p = 0.14).
Conclusion: Increased ALBI score was associated with risk of the composite of all-cause mortality and HFH. Large trials are warranted to investigate the value of ALBI score to identify CRTD responders compared with CRT.
PP-155-V-CIED Using insertable cardiac monitor signal processing as a surrogate marker for QT interval Dr. Antony Chu1, Mr Gautham Rajagopal2, Dr. Shantanu Sarkar2 1Brown University, Providence, USA, 2Medtronic, Mounds View, USAObjective: To evaluate the accuracy of QT intervals determined by insertable cardiac monitor (ICM) ECG-based automated QT detection software when compared with expert validated manually calculated QT intervals acquired by Holter ECGs in a dataset where surface ECG and ICM ECGs are obtained simultaneously.
Methods: We utilized a previously described QT detection algorithm optimized for T-wave sensing in ICMs to calculate a beat-by-beat QT interval. Continuously uplinked LINQ ICM ECG and 24-h Holter recordings utilizing 2-leads from 25 patients were analyzed. One-min ECG data of both Holter ECG and ICM were randomly extracted from each patient and manually annotated to determine QT for every beat. Statistical analysis was performed using Pearson's correlation coefficient.
Results: The data consisted of both surface ECG and ICM ECG for 25 patients, providing over 1500 beats for analysis. The manually annotated QT from surface ECG were highly correlated with the manually annotated QT from ICM ECG with a Pearson's correlation coefficient of 0.85 (p < 0.001). The mean of difference between manually annotated surface ECG and ICM ECG QT intervals was 6.3 ms. The algorithm QT were highly correlated with the manually annotated QT from ICM ECG (correlation coefficient of 0.96, p < 0.001; mean difference of 7.4 ms) as well as manually annotated QT from surface ECG (correlation coefficient of 0.71,p < 0.001; mean difference of 16.3 ms).
Conclusion: Absolute values of QT interval calculated by an automated algorithm designed for longitudinal long-term monitoring of QT interval in an ICM are accurate and highly correlative with manually annotated QT intervals.
PP-156-V-CIED Continuous long-term QT interval monitoring using insertable cardiac monitors for dynamic QT analytics Dr. Antony Chu1, Mr Gautham Rajagopal2, Dr. Shantanu Sarkar2 1Brown University, Providence, USA, 2Medtronic, Mounds View, USAObjective: To analyze proof of concept longitudinal QTc intervals in patients detected by a QT monitoring algorithm optimized for monitoring absolute and dynamic QT intervals on Insertable Cardiac Monitor (ICM) ECG data.
Methods: We developed a unique ICM QT detection algorithm based on T-wave signal processing. The algorithm determines the QT interval for every beat thus providing long-term QT trends. The QT algorithm was performed nightly and ICM ECG transmitted episodes were obtained from a de-identified Medtronic CareLink™ database. These data represent long-term QTc trends from real-world patients with a history of diabetes and long QT.
Results: Figures 1 and 2 include various examples of long-term QTc trends that were obtained by processing ICM ECG through the developed QT detection algorithm. The QT intervals were determined using ICM ECG transmitted nightly from patients with implanted ICM with both diabetes and long QT. The QTc intervals in Figure 1 show a lot of day-to-day variability with QTc intervals varying over 100 ms in these patients having both diabetes and long QT. Conversely, Figure 2a,b depict examples from patients showing lesser variability and a more stable QT over long-term. This type of long-term QT trends may be clinically essential in correlating QT changes with arrhythmias and adverse clinical events.
Conclusion: ICM QT monitoring performed utilizing a unique QT detection algorithm can provide longitudinal and long-term dynamic QT trends in patients implanted with ICM. Dynamic changes in continuously monitored QT may affect risk for arrhythmias or cardio-vascular hospitalizations and requires further investigation.
SUPPORTING DOCUMENTS
FIGURE 1 Examples of continuous long-term monitoring QTc trends in patients with (a) 714; (b) 423; (c) 399; (d) 330 days of nightly transmitted ICM ECG episodes. The red plot depicts the 10-day moving average QTc interval.
FIGURE 2 Examples of continuous long-term monitoring QTc trends in patients with (a) 313; (b) 329; (c) 283; (d) 381 days of nightly transmitted ICM ECG episodes. The red plot depicts the 10-day moving average QTc interval.
PP-157-V-CIED A new method for left ventricular Lead delivery: Side helix overcome the tortuous lateral vein Dr Makoto Takano1 1St. Mrianna University, Yokohama City, JapanThis study highlights the case of a 75-year-old man who presented with non-ischemic cardiomyopathy. Computed tomography coronary angiography revealed coronary artery stenosis and the presence of a lateral branch. Cardiac resynchronization therapy (CRT) was performed. We believe that our study makes a significant contribution to the literature because it presents a novel methodology of using an Attain Stability Quad 4798 (ASQ) with a side-helix to overcome the limitation of lead positioning in CRT. The study showed that ASQ lead overcame the anatomical disorder of the CS, enabling LV pacing from a more optimal site.
SUPPORTING DOCUMENTS
PP-158-V-CIED Year 4 and 5 extraction experience of a novel extravascular defibrillation Lead in sheep Mr Mark Marshall1, Dr Hector Mazzetti, Dr Sergio Ferraris, Mr Gonzalo Martinez 1Medtronic, Saint Paul, USA
Background: Extravascular (EV) ICDs are a valuable alternative to transvenous ICDs. A novel ICD system is in clinical study placing an EV lead under the sternum in the substernal space for defibrillation and ATP therapy. Chronic substernal lead removal is unknown.
Objective: Assess EV ICD lead removal in a sheep model out to 5 years.
Methods: Twenty-four sheep were implanted with two EV leads implanted via subxiphoid incision and tunneled cranially right and left of midline over the cardiac silhouette. Lead removal was performed using a direct traction protocol recording force applied, advancing to the use of extraction tools if unsuccessful.
Results: Three sheep were extracted at each of years 4 and 5. Traction alone succeeded in 0/6 leads at year 4 and 3/6 leads at 5 years. When extraction tool where used the Cook Medical (CM) Bulldog® lead extender (BDLE) was effective, two leads experienced slipping of the cable through the wire loop and cable breakage. CM SS Byrd® sheaths were effective at dissecting proximal scarring at the diaphragmatic attachments but too short for distal adhesions. The Evolution® was effective at removing scarred leads with both distal and proximal scar. One lead was abandoned due to cable breakage by the BDLE.
Conclusions: Chronic removal of EV ICD leads from the EV space was performed safely using traction and currently available extraction tools through 5 years of implant in sheep. Care must be taken when utilizing the CM BDLE to avoid cable breakage and slipping.
SUPPORTING DOCUMENTS
PP-159-V-CIED Insertable cardiac monitoring results in greater atrial fibrillation diagnosis and Oral anticoagulation after cryptogenic stroke Dr Giuseppe Boriani1, Dr Angelo Auricchio2, Dr Giovanni Luca Botto3, Prof Giuseppe Boriani4, Gregory Roberts5, Dr Andrea Grammatico6, Yelena Nabutovsky4, Dr Jonathan Piccini7 1Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy, 2Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland, 3Department of Cardiology—Electrophysiology, ASST Rhodense, Civile Hospital Rho and Salvini Hospital Garbagnate Milanese Hospital, Milan, Italy, 4Abbott, Santa Clara, USA, 5Abbott, Sylmar, USA, 6Abbott, Rome, Italy, 7Duke Clinical Research Institute, Duke University, Durham, USA
Objective: To compare the detection of atrial fibrillation (AF) and initiation of oral anticoagulation after cryptogenic stroke in those monitored with external cardiac monitors (ECM) versus insertable cardiac monitors (ICM; Confirm Rx™).
Materials and Methods: Using Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data, we identified patients hospitalized with a stroke in 2017–2019 who received an ICM or ECM within 3 months of stroke. Patients were included if in the year prior to cardiac monitoring (index), they had continuous FFS insurance and Part D prescription drug enrollment. Patients with a history of AF, atrial flutter, cardiac rhythm management devices, or OAC were excluded. The outcomes of interest were AF detection and OAC initiation. ICM and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. Kaplan–Meier and Cox Proportional Hazard regression analyses were used to compare outcomes between the groups.
Results: Prior to matching, patients with ICMs had higher rates of ischemic heart disease, patent foramen ovale, prior stroke, and longer stroke hospitalizations than patients with ECM only. After matching, all covariates were balanced (standardized mean difference <0.10). In the matched cohort, ICM patients had significantly higher probability of AF detection (hazard ratio (HR) 2.88, 95% confidence interval (CI) [2.31,3.59]) and OAC initiation (HR 1.90, 95% CI [1.52,2.37]) compared with ECM alone.
Conclusion: Patients with ICM were almost three times more likely to be diagnosed with AF and two times more likely to be prescribed OAC compared with patients who received ECM only.
SUPPORTING DOCUMENTS
PP-160-V-CIED Prediction of pacing threshold increase after implantation of leadless pacemaker due to patient age 博士 Sakuramaru Suzuki1 1Eastern Chiba Medical Center, Togane, Japan
Objectives: Elevated thresholds are often a setback in patients with postleadless pacemaker implants. We examined whether predicting an increase in the pacing threshold value was possible.
Materials and Methods: This was a retrospective study. Patients (n = 43) who received implantation of leadless pacemaker Micra™ at Eastern Chiba Medical Center from January 2020 to May 2022 were enrolled. The correlation between the pacing threshold at the time of implantation and 1 month later and the patient's characteristics were analyzed.
Results: Of the 43 patients, seven (16.3%) were excluded because the pacing threshold could not be described 1 month later. Thirty-six patients (83.7%) were included. We categorized them into two groups depending on whether they were younger than 84 (younger group) or not (older group). Seventeen patients were male, and the median age was 84 ± 6.4. Twenty patients (55.6%) were 84 or older. The pacing threshold at the time of implantation was higher in the younger group than the older group: 0.91 ± 0.31 V and 0.52 ± 0.28 V, p < 0.01, respectively. The difference between the pacing threshold at the time of implantation and 1 month after implantation significantly decreased in the younger group: −0.35 ± 0.38 V and 0.03 ± 0.43 V, p = 0.01, respectively.
Conclusion: The pacing threshold in younger patients was high at the time of implantation but then it reduced afterward.
PP-161-V-CIED 3830 Lead deployment use conditions and simulated fracture rate in left bundle branch area pacing Dr Jiangang Zou1, Dr Keping Chen2, Dr Xingbin Liu3, Dr Yuanning Xu3, Dr Lingyun Jiang3, Dr Yan Dai2, Dr Jinxuan Lin2, Dr Xiaofeng Hou1, Dr Yuanhao Qiu1, Mr Adam Himes4, Mr Ryan Lucas4, Mr Wade Demmer4, Ms Nicki Mara4, Dr Xiaohong Zhou4, Dr Hongyang Lu5 1Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 2Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, 3Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China, 4Cardiac Rhythm Management, Medtronic plc., Mounds View, USA, 5Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, ChinaBackground and Objective: Left bundle branch area pacing (LBBAP) is achieved by advancing the lead tip deep in the septum. Most LBBAP implants are performed using the Medtronic SelectSecure™ MRI SecureScan™ Model 3830 (the 3830 lead) featuring a unique 4-Fr fixed-helix lumenless design. Details of lead use conditions and the long-term reliability have not been reported. The objective was to quantify the mechanical use conditions for the 3830 lead during and after implant in the LBBAP position and to evaluate the reliability using bench testing and simulation.
Materials and Methods: Fifty bradycardia patients with the 3830 lead implanted for LBBAP were enrolled. Use conditions of lead deployment at implantation were collected and CT scans were performed at 3-month follow-up. The curvature amplitude along the pacing lead was determined with CT images. Fatigue bending was performed using accelerated life testing in a more severe environment than the routine clinical use conditions of the lead deployment. Conductor fracture rate in a simulated patient population was estimated based on clinical use conditions and fatigue test results.
Results: The number of attempts to place the 3830 lead for LBBAP was 2.1 ± 1.3 (range 1–7) with 13 ± 6 lead rotations at the final attempt. Extreme implant conditions were simulated in bench testing with five applications of 20 turns followed by 400 million fatigue bending cycles. Reliability modeling predicted a fracture rate of 0.02% at 10 years.
Conclusion: LBBAP implant requires more lead rotations. The result in freedom from conductor fracture is similar to traditional RV lead placement.
PP-162-V-CIED Performance of ventricular capture Management in Pacemaker Patients with left bundle branch area pacing Dr Xingbin Liu1, Dr Jiangang Zou2, Dr Keping Chen3, Dr Yuanning Xu1, Dr Lingyun Jiang1, Dr Xiaofeng Hou2, Dr Yuanhao Qiu2, Dr Yan Dai3, Dr Jinxuan Lin3, Dr Jian Cao4, Mr Wade Demmer4, Dr Hongyang Lu5, Dr Xiaohong Zhou4 1Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China, 2Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 3Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 4Cardiac Rhythm Management, Medtronic plc., Mounds View, USA, 5Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, ChinaObjectives: Automated right ventricular capture threshold algorithms have been widely used in pacemaker patients to provide optimal battery use while maintaining a desired safety margin of pacing and enabling remote patient follow-up. We evaluated the accuracy of Medtronic's Ventricular Capture Management (VCM) feature, in pacemaker patients with left bundle branch area pacing (LBBAP).
Materials and Methods: Ventricular pacing capture thresholds were analyzed in 31 bradycardia patients implanted with Medtronic 3830 leads and pacemakers for LBBAP at follow-ups. The VCM threshold measurements from the nightly measurement prior to the follow-up visit were compared with manual measurements. A difference within ± 0.25 Volt (automatic vs. manual) was deemed equivalent.
Results: The automatic vs. manual measurements were equivalent in all 31 patients (17 males; age 68 ± 11 years old; EF = 63 ± 3%; 28 unipolar/3 bipolar; pacing pulse width 0.4–0.5 ms; Figure 1). The average manual pacing capture thresholds (0.73 ± 0.21 V) were not different from automatic measurements (0.76 ± 0.21 V; p = 0.3). At follow-ups (mean duration = 128 ± 60 days), the average manual ventricular pacing thresholds (n = 31) were low in both bipolar (0.83 ± 0.23 V) and unipolar (0.71 ± 0.21 V) settings.
Conclusion: The Ventricular Capture Management algorithm was accurate in bradycardia patients with left bundle branch area pacing therapy. This adaptive algorithm can potentially be used to enable remote follow-up, assure pacing safety and optimize device longevity.
SUPPORTING DOCUMENTS
FIGURE 1 Comparison of pacing capture thresholds at follow-ups (automatic vs. manual).
PP-163-V-CIED Insertable cardiac monitor P-wave visibility in a new clinical report Dr Michael Shehata1, Dr Devi Nair2, Dr Fujian Qu3, Dr Nima Badie3, Praveen Gopalakrishna3, Dr Leyla Sabet3, Dr Kyungmoo Ryu3, Dr Harish Manyam4 1Cedars Sinai Medical Center, Los Angeles, USA, 2St. Bernards Medical Center, Jonesboro, USA, 3Abbott Cardiac Rhythm Management Division, Sylmar, USA, 4Erlanger Health System, Chattanooga, USAObjectives: Adequate P-wave visibility in electrograms (EGMs) recorded by insertable cardiac monitors (ICMs) is important for rhythm interpretation. The visibility of P-waves in Abbott ICMs using a new PDF report with improved display resolution was evaluated.
Methods: A data query conducted on the Merlin.net™ patient care network in December 2021 identified 101 sequential patients with remote transmissions at 30, 60, and 90 days after ICM implant. The presenting rhythm EGMs from these transmissions were displayed in vector-graphic PDF reports and reviewed by two independent reviewers to count the beats with P-waves visible in each EGM. Premature ventricular complexes were excluded.
Results: Of 303 EGMs, 17 were excluded from adjudication due to atrial fibrillation or noise interruption. In the remaining EGMs, P-waves were visible in 89.8% of analyzed beats. P-wave visibility was consistent across days (day-30: 89.1%; day-60: 90.8%; day-90: 89.4%). In addition, 90.9% of EGMs reviewed had P-waves visible in >50% of heart beats. At a patient level, 86.3% had P-waves visible in >50% of heart beats on all 3 days. No patient had zero P-wave visibility in all 3 days.
Conclusion: EGM signals recorded by Abbott ICMs and displayed in vector-graphic clinical reports showed consistent P-wave visibility across all patients. Adequate P-wave visibility may facilitate rhythm interpretation and increase confidence in rhythm diagnosis. The new clinical report will be available in the next generation Abbott ICM system.
SUPPORTING DOCUMENTS
PP-164-V-CIED Evaluating the impact of new arrhythmia detection algorithms in an insertable cardiac monitor Dr Michael Shehata1, Dr Harish Manyam2, Dr Rakesh Gopinathannair3, Dr Fujian Qu4, Dr Nima Badie4, Dr Fady Dawoud4, Dr Leyla Sabet4, Dr Kyungmoo Ryu4, Dr Dhanunjaya Lakkireddy3, Dr Roy Gardner5 1Cedars Sinai Medical Center, Los Angeles, USA, 2Erlanger Health System, Chattanooga, USA, 3Kansas City Heart Rhythm Institute, Overland Park, USA, 4Abbott Cardiac Rhythm Management Division, Sylmar, USA, 5Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, UK
Objectives: Insertable cardiac monitors (ICMs) are commonly used to diagnose cardiac arrhythmias. Due to increased use of these devices and prolonged monitoring duration, minimizing data burden and false detection has become more critical. A set of new discrimination algorithms has been developed to improve the specificity of atrial fibrillation (AF), pause, and tachycardia detection by better identifying sensed events and patterns in ICM electrogram (EGM). The impact of these algorithms on episode review burden and time-to-diagnosis was evaluated using data from existing ICMs.
Methods: Retrospective analyses of randomly selected Abbott ICM devices with >90 days of remote transmission history were performed, with each EGM episode adjudicated as true or false. The reduction in EGM review burden and potential diagnosis delay introduced by the new algorithms were compared to the results in existing ICMs, with the Key Episodes feature on or off (existing cloud-based feature to reduce EGM burden without delaying diagnosis).
Results: In 821 ICMs over a total of 469 patient-year remote follow-up duration, a total of 60,156 EGMs (35,723 AF, 12,194 pause, and 12,239 tachycardia) was transmitted by 644 ICMs. The new algorithms reduced total EGMs by 35.6%. False positives were specifically reduced by 36.0%, 77.2%, and 72.1% for AF, pause, and tachycardia, respectively. As shown in the figure, the new algorithms achieved nearly identical time-to-diagnosis as the existing ICMs.
Conclusion: The newly developed algorithms substantially reduced false AF, pause, and tachycardia episodes while maintaining the time-to-diagnosis by the existing Abbott ICMs.
SUPPORTING DOCUMENTS
PP-165-V-CIED Comparison of delivery catheter- and stylet-based right ventricular Lead placement at the right ventricular septum Dr Yoshihisa Naruse1, Dr. Nobutake Kurebayashi2, Dr. Naoki Tsurumi2, Dr. Tomoyuki Shiozawa3, Dr. Shintaro Takano3, Dr. Michio Ogano4, Dr. Kei Kimura4, Dr. Keisuke Miyajima5, Dr. Ryo Sugiura6, Dr. Ryuta Henmi6, Dr. Masahiro Muto7, Dr. Natsuko Hosoya7, Dr. Hideyuki Hasebe8, Dr. Akira Mizukami9, Dr. Makoto Sano1, Dr. Keiichi Odagiri1, Prof. Yuichiro Maekawa1 1Hamamatsu University School Of Medicine, Hamamatsu, Japan, 2Chutoen General Medical Center, Kakegawa, Japan, 3Juntendo University Shizuoka Hospital, Izunokuni, Japan, 4Shizuoka Medical Center, Sunto-gun, Japan, 5Seirei Mikatahara General Hospital, Hamamatsu, Japan, 6Seirei Hamamatsu General Hospital, Hamamatasu, Japan, 7Hamamatsu Medical Center, Hamamatsu, Japan, 8Shizuoka Saiseikai General Hospital, Shizuoka, Japan, 9Kameda Medical Center, Kamogawa, Japan
Background: Although the delivery catheter system is a new alternative to the stylet system, no randomized controlled trial has addressed right ventricular (RV) lead placement accuracy on the RV septum using a stylet or delivery catheter system. This multicenter prospective randomized controlled trial aimed to prove the efficacy of the delivery catheter system for accurate RV lead anchoring on the RV septum.
Methods: In this trial, 70 patients (mean age 78 ± 11 years; 30 men) with atrioventricular block were randomized to either the delivery catheter or stylet group before the pacemaker implantation procedure. The RV lead tip position was assessed using electrocardiogram-gated cardiac computed tomography in all patients after pacemaker implantation. Lead tip positions were classified into RV septum, anterior/posterior edge of the RV septal wall, and RV free wall. The primary endpoint was the success rate of the RV lead tip placement on the RV septum.
Results: RV lead implantation was performed as per allocation in all patients. The delivery catheter group had a higher RV lead deployment success rate on the RV septum (78% vs. 50%; p = 0.024) and narrower paced QRS width (129 ± 20 vs. 142 ± 15 ms; p = 0.003) than those in the stylet group. However, there was no significant difference in procedure time (91 [IQR 68–119] vs. 85 [59–118] min; p = 0.488) or the incidence of RV lead dislodgment (0% vs. 3%; p = 0.486).
Conclusions: The delivery catheter system can achieve a higher success rate of RV lead placement on the RV septum and narrower-paced QRS width than the stylet system.
PP-166-V-CIED His bundle pacing as alternative strategy to cardiac resynchronization therapy in chronic heart failure Ms Christina Ayu Ariani Rosmaningtyas1, Mr Benny Mulyanto Setiadi1, Mr Janry Antonius Pangemanan1, Mrs Agnes Lucia Panda1, Mr Giky Karwiky2 1Faculty of Medicine, Universitas Sam Ratulangi, Manado, Indonesia, 2Faculty of Medicine, Universitas Padjajaran, Bandung, IndonesiaObjectives: To report safety, feasibility and acute hemodynamic effects of His Bundle Pacing (HBP) as alternative strategy for cardiac resynchronization therapy (CRT) in heart failure reduced ejection fraction (HRrEF) patient.
Material and Methods: A 73-year-old man with chronic HFrEF, hypertension, and type 2 diabetes mellitus came with New York Heart Association (NYHA) class III despite optimal medical therapy. ECG showed 1st degree AV block with complete LBBB. Left ventricular ejection fraction (LVEF) was 26% with basal to apical anterior and septal akinesia. HBP was attempted as a primary strategy. Using right femoral approach, temporary pacing wire was placed at the right ventricular apex. Bipolar lead was inserted into His bundle via left axillary vein and pacing was done after His signal was obtained on electrogram.
Results: QRS complex duration decreased significantly from 162 ms at baseline to 128 ms with pseudo delta wave (non-selective). His bundle capture threshold was 2.5 V at 1 ms at implant and increased slightly to 3.5 V at 1 ms at 6 months follow-up. There was improvement in NYHA functional class by one class and no heart failure hospitalization 6 months after implantation. LVEF improved significantly from 26% to 40% 6 months after HBP implantation. There was absolute reduction in LV end-systolic volume index from 62.275 to 49.76 ml/m2.
Conclusion: HBP was safe, feasible and reasonable primary alternative to biventricular pacing for CRT in patients with cardiomyopathy, AV block and LBBB. HBP could lead to significant improvement in QRS duration, clinical and echocardiographic response.
SUPPORTING DOCUMENTS
FIGURE 1 ECG Pre HBP Implantation.
FIGURE 2 ECG Post-HBP Implantation. PP-167-1-GE Wire mapping for LV summit PVC Dr Muhammad Yamin1, Dr Simon Salim1, Dr Angga Pramudita1, Dr Rubiana Sukardi2, Dr Friska Anggraini Helena Silitonga1, Mrs Catur Wulanningsari2, Mr Rohmad Widiyanto2 1Division Of Cardiology, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Indonesia, 2Integrated Cardiac Centre—Cipto Mangunkusumo Hospital, Indonesia
Objectives: We present a case of LV summit PVC mapping using a single coronary wire.
Results: A 32-year-old female came to our center due to symptomatic PVC. The 12-lead ECG showed RBBB morphology with inferior axis and aVL/aVR ratio of 1.5 which suggests LV summit origin. A 3D electroanatomical mapping was done using EnSite Precision and live wire duodeca catheter. The earliest activation timing in RVOT was −17 ms, while the earliest activation in LVOT was −38 ms. We decide to map LV summit area via GCV/AIV approach by using a single BMW coronary wire through a JR 3,5/6Fr. The distal outerpart of the wire was clipped using modified alligator (Figure A2–A5). BMW wire was then positioned in the S1 branch (Figure A6–8) (1) and showed earlier activation of −53 ms. The complete 3D geometry was shown in Figure A9.
Conclusion: PVC mapping is feasible to be done only using single coronary BMW wire without any help of microcatheter or balloon. SUPPORTING DOCUMENTS
FIGURE A (1) PVC morphology on ECG (2) Black alligator clip (3) Red alligator clip (4) Proximal end of wire (5) Complete wire with alligator clip (6) Left anterior oblique (LAO) caudal view of S1 branch (7) Right Anterior Oblique (RAO) view of S1 branch (8) LAO caudal view with wire on S1 branch (9) Complete 3D geometry.
REFERENCE
- Tavares L, Lador A, Fuentes S, Da-wariboko A, Blaszyk K, Malaczynska-Rajpold K, et al. Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias: Outcomes of a Multicenter Experience. JACC Clin Electrophysiol. 2020;6(11):1420–31.
Objectives: Syncope in young individual is more often due to vasovagal syncope. However dangerous arrhythmia should be excluded as a possible etiology. We report a case of intermittent high degree AV block in a patient with recurrent syncope.
Results: A 34-year-old male with history of polycythemia vera was referred to our cardiology division due to recurrent syncope. Surface ECG showed sinus tachycardia with right bundle branch block and left anterior fascicular block (bifascicular block). Further evaluation using Holter ECG revealed episodes of high-grade AV block induced by ventricular premature beats. One could argue that ablating PVC would help in preventing the phase 4 block. However, the mechanism phase 4 block is usually associated with a diseased His-Purkinje. The diseased His-Purkinje tissue spontaneously depolarize at the start of phase 4 (diastolic phase), property normally reserved only for pacemaker cells. If impulse arrive late (e.g., SA node reset by retrograde atrial conduction of a PVC) during late spontaneous diastolic depolarization, action potential cannot be stimulated to reach depolarization threshold due to sodium channel inactivity. (1) Only after an early escape beat of a timely manner can the phase 4 be reset to its maximum resting value and normal conduction can resume as seen in the Holter. (1,2) This patient was best to have PPM implanted rather than PVC ablation.
Conclusion: Cardiac syncope should be highly suspected in patients found to have bifascicular block on surface ECG. Premature beat can act as a trigger for initiating high grade AV due to phase 4 block. Permanent pacemaker is warranted in this condition.
SUPPORTING DOCUMENTS
FIGURE 1 (a) 1st PVC did not reset SA node. (b) 2nd PVC resets SA node and induces phase 4 block. (c) Escape beat improves conduction. (d) Late PVC no resetting.
REFERENCES
- Shenasa, M, Josephson, ME, Wit, AL. Paroxysmal atrioventricular block: Electrophysiological mechanism of phase 4 conduction block in the His-Purkinje system: A comparison with phase 3 block. Pacing Clin Electrophysiol. 2017; 40: 1234–1241.
- Divakara Menon SM, Ribas CS, Ribas Meneclier CA, Morillo CA. Intermittent atrioventricular block: what is the mechanism? Heart Rhythm. 2012 Jan;9(1):154–5.
Objectives: We report a case of septal Wolff-Parkinson-White (WPW) syndrome which showed lateral breakthrough using automated annotation.
Results: A 36 years old male with WPW type B history came to our center due to chest discomfort for 20–60 s, accompanied with nausea and perspiration. The pain was alleviated by resting and ISDN consumption. A 12 lead ECG showed a positive delta wave in V1 and negative in AVF which favors the right posteroseptal accessories pathway (1). A 3D electroanatomical mapping was done using EnSite Precision and live wire duodeca catheter. We performed automap with absolute dv/dt setting in the right atrium and ventricle using the Open Window Mapping (OWM) concept (2). We found a breakthrough in the lateral wall, however, the local signal showed late activation in this area. At the septal side, we also found a breakthrough ventricular activation with earlier Local Activation Timing (LAT) compared to the lateral side. Ablation performed on this septal area for 10 s diminished the delta waves. No recurrence was observed after 30 min of observation.
Conclusion: OWM simplifies the work of Electrophysiologists by demonstrating automated signal annotation using a certain algorithm to help elucidate the location of antegrade accessory pathway conduction. However, our case highlighted the need for basic EP understanding in interpreting the map provided by automatic annotation.
SUPPORTING DOCUMENTSREFERENCES
- Arruda M, Wang X, McClennand J. (1993). ECG algorithm for predicting sites of successful radiofrequency ablation of accessory pathways. Pacing Clin Electrophysiol, 16(2):865–873.
- Schricker, A. A., Winkle, R., Moskovitz, R., Suchomel, L., Fowler, S., Engel, G., Cho, S., Salcedo, J., & Woods, C. E. (2021). Open-window mapping of accessory pathways utilizing high-density mapping. Journal of Interventional Cardiac Electrophysiology, 61(3), 525–533.
FIGURE 1 ECG Before and After Ablation and Complete 3D Geometry.
PP-170-1-GE Alternating Wenckebach periodicity in a patient implanted with dual chamber pacemaker for sick sinus syndrome Dr Angga Pramudita1, Dr Simon Salim1, Dr Muhammad Yamin1, Dr Rubiana Sukardi2, Dr Friska Anggraini Helena Silitonga1, Mrs Catur Wulanningsari2, Mr Rohmad Widiyanto2 1Division Of Cardiology, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Indonesia, 2Integrated Cardiac Centre—Cipto Mangunkusumo Hospital, IndonesiaObjectives: We present a case of an incidental Alternating Wenckebach Periodicity (AWP) during pacemaker follow-up of a patient with Sinus Node Dysfunction (SND).
Results: A 68-year-old male with a history of SND and implanted dual chamber permanent pacemaker complained of palpitation. During routine PPM evaluation, pacing mode was changed to VVI (40 BPM) and surface ECG was recorded to identify P wave morphology. His 12 lead ECG revealed a complete RBBB with 2:1 atrioventricular (AV) block and progressive prolongation of PR interval in the conducted P waves which ends in 2 blocked P waves (Figure A), known as Alternating Wenckebach Periodicity (AWP) (1). The existence of AWP in this patient could suggests infranodal disease which already mitigated with dual chamber PPM implant. Should the patient had single chamber atrial pacemaker for his SND, the existence of AV node disease would render him still vulnerable and would need upgrading into dual chamber PPM.
Conclusion: We showed an SND patient which later develop AWP pattern that argues for the existence of concomitant AV node disease. Our case highlight that some SND patients will develop AV node disease, therefore, a routine first line therapy of dual chamber pacemaker might be preferred.
SUPPORTING DOCUMENTS
REFERENCE
- Halpern MS, Nau GJ, Levi RJ, Elizari MV, Rosenbaum MB. Wenckebach periods of alternate beats. Clinical and experimental observations. Circulation. 1973 Jul;48(1):41–9.
FIGURE A Alternating Wenckebach Periodicity.
PP-171-1-GE Risk stratification of atrial fibrillation and stroke from blood tests and novel ECG analysis Prof Tetsuo Sasano1 1Tokyo Medical And Dental University, Tokyo, JapanBackground: Atrial fibrillation (AF) is the most common arrhythmia in Japan, and it causes a high rate of complications such as cerebral infarction (CI). It is known that AF begins as paroxysmal form and gradually progresses to persistent form, and sometimes it is difficult to identify paroxysmal AF (PAF) before having CI. The aim of this study is to evaluate the risk of PAF and CI from blood tests and ECG during sinus rhythm.
Materials and Methods: A total of 600 adult subjects were enrolled (300 from PAF and control groups). Blood test was performed to identify the genetic variation and novel biomarkers including microRNA and cell-free DNA (cfDNA). ECG was analyzed using fragmentation analysis.
Results: Genotyping identified three single nucleotide polymorphysms (SNPs) were significantly associated with AF (rs6817105, rs10824026, and rs2106261). Circulating miRNAs and cfDNA did not show significant differences between PAF and control groups, but the cfDNA concentration was significantly higher in patients with history of CI. ECG fragmentation analysis revealed that the number of fragmentation was larger in the PAF group. Combining a genetic risk score and an ECG analysis, we could predict PAF with AUC of 0.654.
Conclusion: The risk of AF could be assessed by combining genetic risk score and ECG fragment analysis. Furthermore, the risk of strokes might be evaluated by plasma cfDNA level, in addition to the AF risk score.
PP-172-1-GE Signal quality and R-wave sensing using chest strap and dry electrode system for arrhythmia monitoring Dr Daljeet kaur Saggu1, Dr Nagamalesh Udigala Madappa2, Mr Arunkumar Sathiyamoorthy3, Mr V Mohan Pinjala3, Mr Satyaprakash Dash4, Mr Vinayakrishnan Rajan4, Mr Shantanu Sarkar5 1AIG Hospital, Hyderabad, India, 2M S Ramaiah Medical College and Hospital, Bangalore, India, 3Medtronic Engineering and Innovation Center, Hyderabad, India, 4India Medtronic Pvt. Ltd, Mumbai, India, 5Medtronic Inc, Minnesota, USAObjective: To investigate the signal quality of electrocardiogram (ECG) as measured by the duration of time the ECG signal is of diagnostic quality during a 24-h period in an inpatient setting.
Methods: The prospective observational Cardilinq external cardiac monitor (ECM) feasibility study enrolled patients with history of cardiovascular disease or increased risk of cardiac arrhythmia. Patients were continuously monitored for 24 h in an inpatient setting. Patients wore ECM prototype in parallel with the DR220 Holter monitor to acquire raw ECG signal from the ECM device and surface ECG from adhesive skin electrodes. The ECM prototype was designed using a chest strap with dry electrodes connected to a coin cell battery powered implantable cardiac monitor electronics capable of patient-initiated loop recording and automatic detection of pause, bradycardia, tachycardia, and atrial tachyarrhythmia (AT/AF).
Results: The study enrolled 20 patients for inpatient monitoring (53% females, average age 63.4 years, average BMI 24.8 kg/m2). Reviewable data were successfully collected for 12 patients. The diagnostic quality ECG was recorded on an average 76.5% of the monitoring duration with successful ECG recording uplink to the Holter device (Figure A). Motion artifacts caused loss in ECG signal for 18.7% of the time leading to detection of false pause or tachycardia. The device also automatically detected true AT/AF in 2 patients (Figure B), junctional rhythm in 1 patient.
Conclusion: The ECM recorded diagnostic quality ECG in over three-fourth of time during a 24-h monitoring period. Motion artifacts caused multiple false detections. Cardiac arrhythmia was detected in 25% of patients.
SUPPORTING DOCUMENTS
PP-173-1-GE Cardiac arrhythmia diagnosis using a chest strap and dry electrode system for longer term monitoring Dr Daljeet kaur Saggu1, Dr Udigala Madappa Nagamalesh2, Mr Arunkumar Sathiyamoorthy3, Mr V Mohan Pinjala3, Mr Satyaprakash Dash4, Mr Vinayakrishnan Rajan4, Mr Shantanu Sarkar5 1Asian Institute of Gastroenterology, Hyderabad, India, 2M.S Ramaiah Medical College and Hospital, Bangalore, India, 3Medtronic Engineering and Innovation Center, Hyderabad, India, 4India Medtronic Pvt. Ltd, Mumbai, India, 5Medtronic Inc, Minnesota, USA
Objective: To investigate cardiac arrhythmia diagnostic yield during a short term (Group-A: 24-h) and longer term (Group-B: 12-weeks) monitoring using a single lead longer term cardiac monitor.
Material and Methods: The Cardilinq external cardiac monitor (ECM) feasibility study is a prospective observational study that enrolled patients with history of cardiovascular disease or increased risk of cardiac arrhythmia. The ECM investigational prototype was designed using a chest strap with dry electrodes connected to a coin cell battery powered implantable cardiac monitor electronics capable of loop recording initiated by patient, and automatic detection of pause, bradycardia, tachycardia, and AT/AF.
Results: The study enrolled 34 patients (38% females, average age 57.5 years, average BMI 25.4 kg/m2, 65% had palpitations, 12% had syncope), 31 patients had their device stored episodes available for review. Total episodes and number of patients with observed cardiac arrhythmia are shown in Table. Cardiac arrhythmia was observed in 4 of 17 patients (24%) in Group-A and 9 of 14 patients (64%) in Group-B respectively. Highest diagnostic yield was observed in AT/AF followed by patient activated and bradycardia episodes. All device detected pause and tachycardia were false detections due to motion artifacts and temporary device removal. Simple algorithm modifications can reduce 97% of false detections.
Conclusion: The ECM was able to observe cardiac arrhythmia in 24% and 64% of patients during 24-h inpatient and 12-week ambulatory monitoring. Motion artifacts caused multiple false automatic detections. Algorithm modifications and tighter chest straps can make this device feasible for routine clinical use.
SUPPORTING DOCUMENTS
| Group-A | Group-B | ||
| Patients | 17 | 14 | |
| Monitoring Duration | 24 h | 12 weeks | |
| Device recorded number of episodes with ECG (patients) | AT/AF | 33 (7) | 33 (7) |
| Bradycardia | 7 (3) | 37 (7) | |
| Pause | 198 (16) | 537 (13) | |
| Tachycardia | 24 (9) | 103 (13) | |
| Patient Activated | 0 (0) | 52 (11) | |
| Number of patients with true cardiac arrhythmia | AT/AF | 3 | 2 |
| Bradycardia/pause | 0 | 2 | |
| PVC | 0 | 3 | |
| Sinus arrhythmia | 0 | 1 | |
| Sinus tachycardia (≥110 bpm) | 0 | 4 | |
| Junctional rhythm | 1 | 0 |
Background: PM2.5 air pollutants increased risk of ventricular arrhythmias. The prolonged corrected QT interval (QTc) and QT dispersion (QTd) is common in patients with chronic airway disease and is associated with heightened risk of ventricular tachyarrhythmia. We sought to examine the effect of PM2.5 exposure on QTc and QTd in patients with chronic airway disease.
Methods: We enrolled 73 patients with chronic airway disease into the study. The 12-lead ECGs were recorded during high-exposure and low-exposure periods of PM2.5. QTc and QTd were compared between 2 periods.
Results: Mean age was 70 ± 10 years. Mean FEV1/FVC was 63 ± 14%. There was no difference in QTc between PM2.5 high-exposure and low-exposure periods. However, QTd was significantly increased during PM2.5 high-exposure compared to low-exposure periods in male patients (43.5 ± 15.0 vs. 38.2 ± 12.1 ms, p = 0.044) but no difference was found in females. We found that patients who worked mostly indoor had less QTd than those working outdoor during PM2.5 low-exposure period. In addition, those who wore face mask tended to have less QTd during low-exposure period than those who did not.
Conclusions: High PM2.5 exposure increased QTd in male patients with chronic airway disease. Working indoors and wearing face mask were associated with less QTd.
PP-175-1-GE Asymptomatic complete heart block: How soon should a pacemaker Be implanted? Dr Watchara Lohawijarn1, Dr Nitchanun Jinpisoot1, Asst Prof Polathep Vichitkunakorn2 1Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince Of Sonkla University, Hat Yai, Thailand, 2Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, ThailandObjectives: To determine timing of adverse events happened during waiting for permanent pacemaker (PPM) implantation in patients diagnosed with asymptomatic complete heart block.
Materials and Methods: A retrospective analysis of data from electronic medical record between 2002 and 2020 was conducted at a university hospital in southern Thailand. Complete heart block diagnosed by standard 12-lead ECGs which were confirmed by attending cardiologists. Patients eligible for the study must not have symptoms related to complete heart block at the time of diagnosis. Kaplan–Meier survival analysis of time from diagnosis to any adverse events was used.
Results: Among 95 patients (mean age 70.4 ± 15.0 years old) presented with incidental detection of bradycardia (40.5 ± 7.2 beats per minute; median QRS duration 110.0 ms (IQR 92.0, 145.8 ms)) during hospital visits for annual physical checkup or other non-related illnesses. The median waiting time for PPM implantation was 61 days (IQR 14, 223 days). Thirty-four patients (35.8%) developed adverse events during the waiting period. Major adverse events included congestive heart failure (4.2%), syncope (4.2%), ventricular arrhythmias (1.1%), and survival of cardiac arrest (2.1%). The first major adverse event—syncope, happened 27 days after diagnosis. In addition, the first cardiac arrest event happened 36 days after diagnosis. Survival analysis revealed 30-day and 90-day event-free survivals of 94.2% and 83.7% respectively.
Conclusion: The waiting period for PPM implantation even in patients with asymptomatic complete heart block carries some risks including cardiac arrest. To avoid major adverse events, PPM implantation should be performed sooner than 27 days after diagnosis.
PP-176-1-GE To see it is to believe it… Dr Wei Shen Chee1, Dr Soot Keng Ma2, Dr Gian Singh Sathvinder Singh1, Dr Chin Yung Chea1, Dr Mat Daud Aimaduddin1, Dr Mohd Yusof Hartini1, Dr Habizal Nor Halwani1, Dr Abd Ghani Abd Raqib1, Dr Selvaraj Kamaraj1, Dr Abdullah Ramaiah Asri Ranga1, Dr Abd Ghapar Abd Kahar1 1Department Of Cardiology, Serdang Hospital, Malaysia, 2Loh Guan Lye Specialists Centre, MalaysiaObjective: To demonstrate PR interval can go up to 932 ms in patient referred to us for complete heart block.
Materials and Methods: For young patients presented with syncope, most often they were referred to cardiology department to rule out cardiac syncope. This 15 years old boy with post-dengue myocarditis was referred to our clinic for complete heart block. Workup done such as Echocardiogram showed Ejection Fraction preserved, Structurally normal heart and in Exercise Stress Test he managed to achieve METS 8 and reached HR 166 beats per minute with 1 to 1 conduction.
Result: With split opinion between first degree AV block and Wenkebach versus complete heart block and he got admitted for recurrent syncope, Electrophysiology Study was done showed the similar finding as our ladder diagram done with AH 230 ms and HV 34 ms with ECG PR 332 ms, QRS 102 ms.
Conclusion: PR interval can go as long as 940 ms and for this gentleman with first degree and second degree type 1 (Wenkebach) he does not require Permanent Pacemaker implantation.
SUPPORTING DOCUMENTS
PP-177-1-GE Looks like me, sounds like me but it is not ME! Dr Wei Shen Chee1, Dr Soot Keng Ma2, Dr Kok Wei Koh3, Dr Abd Ghani Abd Raqib1, Dr Mohd Yusof Hartini1, Dr Habizal Nor Halwani1, Dr Selvaraj Kamaraj1, Dr Abdullah Ramaiah Asri Ranga1, Dr Abd Ghapar Abd Kahar1 1Department Of Cardiology, Serdang Hospital, Malaysia, 2Loh Guan Lye Specialists Centre, Malaysia, 3Subang Jaya Medical Centre, Malaysia
Objectives: To illustrate the clinical significance of relative narrowing of QRS complexes during tachycardia in discriminating Ventricular tachycardia (VT) from Supraventricular Tachycardia (SVT) with aberrancy in patients with pre-existing bundle branch block using a case of middle aged gentleman with Ischemic Dilated Cardiomyopathy with Ejection Fraction of 35% who presented to district hospital with palpitation.
Methods: There are various algorithms in place to guide to discriminate SVT from VT and still clinical dilemma exists for those patients presenting with wide complex tachycardia with pre-existing Bundle Branch Block. Besides this, clinicians tend to see the changes in axis after reversion to sinus rhythm to conclude whether it is SVT with aberrancy versus VT.
Results: With the relative narrowing of QRS duration in tachycardia and for this case from QRS duration in Sinus Rhythm of 240 ms to QRS duration of 160 ms in tachycardia clinched the diagnosis of VT in pre-existing RBBB as the sequential activation of Left ventricle followed by Right Ventricle in RBBB during sinus rhythm became simultaneous activation with the VT origin close to septum during tachycardia. Thus, Implantable Cardioverter Defibrillator was implanted for secondary prevention on top of goal directed medical therapy for heart failure.
Conclusion: Relative narrowing of QRS complexes during Tachycardia suggests VT.
SUPPORTING DOCUMENTS
PP-178-1-GE Association of preterm birth with maternal arrhythmia: Machine learning analysis using National Health Insurance Data Dr Jue Seong Lee1, Dr Eun Saem Choi1, Miss Yujin Hwang1, PhD Kwang-Sig Lee1, Professor Ki Hoon Ahn1 1Korea University Anam Hospital, South Korea
Objectives: The purpose of this study is to build the prediction model of preterm birth (PTB) using machine learning analysis and nation-wide population data and to investigate the association between arrhythmia and PTB.
Materials and Methods: Population-based retrospective cohort data came from Korea National Health Insurance claims for 174,926 primiparous women who aged 25–40 and delivered in 2017. The 36 independent variables were included (demographic/socioeconomic determinants, disease information, medication history, obstetric information). Machine learning analysis was used to establish the prediction model of PTB. Random forest variable importance was used for identifying major determinants of PTB. Furthermore, we calculated the SHAP (Shapley additive explanations) values to identify the direction of association between maternal arrhythmia and PTB in prediction model.
Results: Among the study population, 12,701 women had PTB and 7312 women had arrhythmia. The areas under the operating-characteristic-curve of prediction model with oversampling data were within the range of 88.53–95.31. The prediction model registered the accuracy of 89.59%–95.22%, the sensitivity of 85.34%–95.58% and the specificity of 91.71%–95.04% as well. Based on the variable importance of prediction model, arrhythmia was the most significant determinants of PTB among maternal heart diseases (ranked 15th). Within the arrhythmia group, atrial fibrillation/flutter was the most significant risk factor of PTB in terms of the SHAP value.
Conclusions: Maternal arrhythmia has significant associations with PTB. Careful evaluation and management of maternal arrhythmia during pregnancy may help reduce PTB and improve neonatal outcome.
PP-179-1-GE Efficiency assessment of continuous ambulatory ECG monitoring using patient and workflow analysis Dr Marie Kirk Patrich Maramara1, Dr. Jerome Reymatias1, Dr. Aiza Meriam Tahil1, Dr Michael Joseph Agbayani1 1Philippine General Hospital, Metro Manila, PhilippinesObjective: This is an observational time and motion cross-sectional study with a primary aim of analyzing the Operational delivery of continuous ambulatory ECG monitoring (holter) service in a tertiary hospital.
Method: The data included holter studies of adult patients (19 years old) who were requested for holter monitoring from private or charity services. The observation began with the request for holter study and ended with the official release of the holter result.
Results: A total of 99 Holter studies were included and analyzed. The median total wait time for the clinical service delivery took 5 days. The median total elapsed period for operational service delivery were 28.5 days. The study observed that the process of fellow interpretation to electrophysiology consultant overreading took the most time in the procedure, which they said procedure has an IQR = 4–32 days, wherein its median = 7 days, followed by the duration of Holter which has an IQR = 6–24 days, with a median of 14.5 days.
Conclusion: The median clinical and operational delivery times of the holter service were significantly delayed. The major administrative conveyance delay was in the term from the point of Fellow translation or interpretation to Electrophysiology consultant overreading. The following are important factors to focus on for improvement of timely service of holter monitoring: Simplification of the multi-step process, Digitalization, Strict adherence to protocol, Dedication of machines, Personnel and training.
PP-180-1-GE Delayed effect of catheter ablation for intramural outflow tract ventricular arrhythmias Dr Guan-Yi Li1, Dr Fa-Po Chung1,2, Professor Li-Wei Lo1,2, Professor Yenn-Jiang Lin1,2, Professor Shih-Lin Chang1,2, Dr Yu-Feng Hu1,2, Dr Tze-Fan Chao1,2, Dr Jo-Nan Liao1,2, Dr Ta-Chuan Tuan1,2, Dr Ting-Yung Chang1,2, Professor Shih-Ann Chen1,2,3 1Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan, 2Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, 3Cardiovascular Center, Taichung Veterans General Hospital, Taichung, TaiwanObjectives: Intramural outflow tract ventricular arrhythmia (OT-VA) can be clinically challenging. We aimed to investigate the outcome of intramural OT-VA without complete elimination after sequentially bilateral catheter ablation (CA).
Materials and Methods: During 2008 to 2020, patients with intramural OT-VA undergoing sequentially bilateral CA were recruited. ECG and electrophysiological parameters were analyzed. The intramural OT-VA was defined by one of the following: (1) Difference of activation time between RVOT and LVOT <20 ms; (2) Pacemapping at the earliest activation site could not yield 12/12 matched morphology; (3) CA at the earliest activation site could not completely eliminate the VA. Partial success was defined by a >80% reduction in VA burden immediately after CA. Delayed resolution was defined by a VA burden persistently <2% of total daily beats during follow-up.
Results: One hundred and twenty-four patients (76 men, age: 53.5 ± 14) were studied. Acute success, partial success, and failure were found in 85(68.5%), 26 (21.0%), and 13(10.5%) patients respectively. For those with partial success, delayed resolution were observed in 5 (19.2%) patients, within 3.0 (IQR: 1.9–10.6) months after CA (Figure). The VAs of these five patients were characterized by LBBB morphology and dominantly precordial R/S transition at V3, and the activation time at RVOT was earlier than LVOT.
Conclusion: Despite partial success could be achieved immediately after bilateral CA of intramural OT-VA, the recurrence rate was high. Delayed resolution of intramural OT-VA could only be observed in 19.2% of patients and the majority was observed within 3 months after CA.
SUPPORTING DOCUMENTS
PP-181-2-GE Physical activity on mortality and MACCE in patients with concomitant AF and coronary artery disease Asst Prof Moo-Nyun Jin1, Dr Hye Young Lee2, Dr Jong Kwon Seo2, Dr Byung Gyu Kim2, Dr Gwang Sil Kim2, Dr Young Sup Byun2, Dr Byung Ok Kim2 1Ewha Womans University College Of Medicine, Seoul, South Korea, 2Inje University College of Medicine, Seoul, South Korea
Objectives: Although physical activity benefits cardiovascular health, there is concern that intense exercise is linked promoting atrial fibrillation (AF) and coronary plaque rupture. However, impact of physical activity on outcomes in patients with concomitant AF and coronary artery disease (CAD) is unclear. This study aimed to evaluate the impact of physical activity on outcomes in patients with AF and CAD.
Materials and Methods: We assessed 551 patients with AF and CAD (age, 67.1 ± 9.8 years) who completed self-reported questionnaire for physical activity in single tertiary-care hospital. We examined the associations of physical activity with all-cause mortality and major adverse cardiac and cerebrovascular event (MACCE).
Results: The risk of all-cause mortality (p for linear trend = 0.017) and MACCE (p for linear trend = 0.05) were inversely linear associated with greater level of physical activity. Meeting and exceeding guidelines recommended physical activity were associated with reduced risk of all-cause mortality in unadjusted model, however, this association was not remained significance after adjusting model. There was no evidence of increased risk of mortality and MACCE at levels of physical activity above guidelines recommended key target range, even with vigorous intensity physical activity exceeding the key target range.
Conclusion: Physical activity is inversely associated with all-cause mortality and MACCE in patients with concomitant existing AF and CAD. No excess risk of mortality and MACCE was present at levels of exercise above guidelines recommended key target range. Our findings motivate inactive patients with to begin participation in exercise and refrain from discouraging patients with AF and CAD who exceed guidelines recommended physical activity.
SUPPORTING DOCUMENTS
PP-182-2-GE Prevalence of left ventricular dysfunction after acute myocardial infarction in the primary PCI era Asst Prof Jongmin Hwang1, Associate Professor Hyoung-Seob Park1, Professor Seongwook Han1 1Keimyung University Dongsan Hospital, Daegu, South Korea
Background: Several randomized controlled trials had proven the mortality benefit of implantable cardioverter-defibrillator (ICD) in the primary prevention of sudden cardiac death (SCD) for ischemic cardiomyopathy (ICM). However, it is expected that the prevalence of ICM has changed significantly compared to the thrombolytic era because there is a remarkable progression in the treatment of ischemic heart disease. The ICD utilization for primary prevention in Korea is considered still low. The purpose of this study is to evaluate the real incidence of ICM in Korea.
Methods: We analyzed the data from the Korea Acute Myocardial Infarction Registry enrolled from 2016 to 2019. A total of 3948 patients with acute myocardial infarction (AMI) were received initial (within 3 months) and follow-up (1-year) echocardiography after index event.
Results: The proportion of left ventricular ejection fraction (LV EF) ≤35% at the index event was 7.2% (284/3948). Among these patients, 33.1% (94/284) of patients showed persistent LV EF ≤35% at the follow-up echocardiography. Meanwhile, 3664 patients showed LV EF >35% at the initial echocardiography, and 2.3% of these patients (84/3664) showed deterioration of LV EF ≤35% during the 1-year follow-up period. Overall, 4.5% (178/3948) of (AMI) patients showed decreased LV EF after 1-year, who is the candidate for ICD implantation for the primary prevention of SCD.
Conclusion: In this large AMI registry, the incidence of ICM after 1-year of index event was only 4.5%. This result can explain the low absolute number of ICD implantation for primary prevention of post-AMI ICM patients in Korea.
SUPPORTING DOCUMENTS
PP-183-2-GE Risk of long-term cardiovascular death in patients with mid-range ejection fraction after acute myocardial infarction Dr Soohyun Kim1, Dr Soo-Hyun Kim1, Prof Yong-Seog Oh1, Asst Prof Hwajung Kim1, Asso Prof Sung-Hwan Kim1, Prof Jang Sung-Won2, Prof Jihoon Kim3, Asst Prof Yumi Hwang3 1Seoul St. Mary's Hospital, Seoul, South Korea, 2Eunpyeong St. Mary's Hospital, Seoul, South Korea, 3St. Vincent's Hospital, Suwon, South Korea
Objectives: Prognostic significance of mid-range ejection fraction (mrEF) in acute myocardial infarction (AMI) has not been well demonstrated. We investigated the risk of cardiovascular death in patients with mrEF following AMI.
Materials and Methods: Subjects were enrolled from two multicenter, prospective AMI registries. A total of 19,100 patients with documented left ventricular ejection fraction (EF) at admission were included. Risk of long-term cardiovascular death was evaluated according to EF strata.
Results: There were 2457 patients with reduced EF (EF < 40%), 5276 patients with mrEF (40% ≤ EF < 50%), and 11,367 patients with preserved EF (EF≥50%). Rate of cardiovascular death during a mean 48 (±31) months was 26.3% in the reduced EF group, 11.5% in the mrEF group, and 7.7% in the preserved EF group (p < 0.001). Among patients with mrEF, age > 65 years, hypertension, chronic kidney disease, Killip class ≥3, and cardiac arrest during index hospitalization were independent predictors for cardiovascular death. A presence of ≥2 predictor best discriminated the patients at higher risk of cardiovascular death (sensitivity 0.718, specificity 0.666).
Conclusion: Patients with mrEF after AMI had modest risk of cardiovascular death. Intensive treatment to improve long-term survival is warranted in high-risk patients with mrEF.
PP-184-2-GE Heart rate variability could predict obstructive sleep apnea that is risk factor of atrial fibrillation Dr Kwang Jin Chun1, Dr Woo Hyun Lee1 1Kangwon National University Hospital, Chuncheon, South KoreaObjective: Obstructive sleep apnea is a well-known risk factor of atrial fibrillation. It remains unclear which variable of heart rate variability (HRV) is associated with apnea-hypopnea index (AHI).
Materials and Methods: We prospectively enrolled 66 patients who visited our sleep clinic complaining of habitual snoring or sleep apnea. All underwent 24-h Holter monitoring combined with full-night polysomnography. We evaluated the associations between HRV parameters and polysomnography indices.
Results: The night-time very-low-frequency (VLF), low-frequency (LF), and high-frequency (HF) were significantly higher than the day-time values. On correlation analysis, the day/night VLF (r = 0.550, p < 0.001), LF (r = 0.556, p < 0.001), and HF (r = 0.303, p < 0.001) values were significantly associated with the AHI. Of the day/night HRV ratios, the VLF (p for trend = 0.003) and LF (p for trend = 0.013) ratios decreased significantly by obstructive sleep apnea severity. Multivariable analysis showed that the day/night VLF (β = 16.387, p < 0.001) and day/night LF (β = 25.248, p < 0.001) were independently associated with the AHI.
Conclusion: The day/night VLF and day/night LF ratios were associated with the AHI. These parameters tended to decrease by obstructive sleep apnea severity.
PP-185-2-GE Utility of in vivo zebrafish cardiac assay to predict the functional impact of KCNQ1 variants Mr Shihe Cui1, Assoc. Prof. Kenshi Hayashi1, Dr. Keisuke Usuda1, Dr. Takeshi Kato1, Dr. Toyonobu Tsuda1, Dr. Takashi Kusayama1, Dr. Soichiro Usui1, Dr. Kenji Sakata1, Dr. Noboru Fujino1, Dr. Masayuki Takamura1 1Kanazawa University, Kanazawa, 日本Objectives: Genetic testing for inherited arrhythmias and discriminating pathogenic or benign variants from variants of unknown significance (VUS) are essential for the gene based medicine. KCNQ1 is known as a causative gene of type 1 long QT syndrome (LQTS) and familial atrial fibrillation (AF), and about 30% of the variants found in LQTS are classified as VUS. We studied the role of zebrafish cardiac arrhythmia model in determining the clinical significance of KCNQ1 variants.
Materials and Methods: We generated homozygous kcnq1 deletion zebrafish (kcnq1del/del) by CRISPR/Cas9 technique, and expressed human Kv7.1/MinK channels on kcnq1del/del embryo. We dissected the hearts from the thorax at 72 h-post-fertilization and measured transmembrane potential of the ventricle in zebrafish heart. Action potential duration was calculated as the time interval between the peak maximum upstroke velocity and 90% of repolarization (APD90).
Results: The APD90 of kcnq1del/del embryo was 279 ± 48 ms, which was significantly shortened by injecting KCNQ1 WT cRNA and KCNE1 cRNA (159 ± 29 ms, p < 0.05 vs. kcnq1del/del). The study of 2 pathogenic variants (S277L and T587M) and one VUS (R451Q) associated with LQTS showed the APD90 of kcnq1del/del embryos with mutant Kv7.1/MinK channels was significantly longer than that with Kv7.1 WT/MinK channel. Regarding the pathogenic variant (S140G) associated with familial AF, however, the APD90 of kcnq1del/del embryos with mutant Kv7.1/MinK channel was comparable to that with Kv7.1 WT/MinK channel.
Conclusion: In conclusion, functional analysis of in vivo zebrafish cardiac arrhythmia model might be useful for determining the pathogenicity of loss-of-function variants in patients with LQTS.
PP-186-2-GE Overcoming challenging atrial flutter ablation with point density exclusion electroanatomic mapping Dr Suraya Hani Kamsani1, Mr Yogesh Hiware2, Zunida Ali1, Noor Asyikin Sahat1, Amirzua Ahmad Said1, Azlina Daud1, Halmy Aziman1, Gina Dayang Manit1, Dr Rohith Stanislaus1, Dr Surinder Kaur1, Dr Azlan Hussin1 1Electrophysiology Unit, Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia, 2Abbott (Malaysia), Kuala Lumpur, MalaysiaBackground: Typical atrial flutter (AFL) ablation could usually be performed without utilizing 3D mapping system. However, in rare instances, anatomical challenges including prominent Eustachian ridge could hinder effective ablation delivery.
Objectives: The purpose of this study is to evaluate the use of point density exclusion (PDX) electroanatomic mapping in typical AFL ablation.
Materials and Methods: Procedures were performed under sedation. 3D electroanatomical map of the RA with PDX was created with a multipolar mapping catheter. During ablation, areas with absent 3D points but increased contact force were identified as endocavitary structure. CTI line was ablated and bidirectional block determined for all the cases. Comparison was made with cases that did not utilize this technique.
Results: Five patients (all males, mean age 64.4 ± 16.1 years) underwent the procedure with PDX mapping whilst 23 patients (15 males and 8 females, mean age 60.7 ± 10.9 years) underwent typical AFL ablation without PDX mapping. Procedure time was shorter in the PDX group although this was not statistically significant (102.0 ± 45.5 mins vs. 124.8 ± 88.2 min, p = 0.42). Lesion delivery was also lower in the PDX group (16 ± 7.1 vs. 18.7 ± 21.7, p = 0.64) with shorter ablation duration (10.6 ± 2.1 mins vs. 11.7 ± 12.1 mins, p = 0.68). Bidirectional block was demonstrated in all patients in both groups. No procedural complication was observed.
Conclusion: PDX mapping could facilitate the success of otherwise challenging AFL ablation procedures without the need of specific software nor intracardiac imaging.
PP-187-2-GE Prevalence of atrial fibrillation at referral Hospital in Indonesia: A smartphone based diagnosis Dr Alice Supit1, Prof. DR. dr. Yoga Yuniadi1, DR. dr. Dicky Hanafy1, dr. Ph.D Sunu Raharjo1, dr. Dony Hermanto1 1National Cardiovascular Center Harapan Kita, Jakarta Barat, IndonesiaObjective: Atrial fibrillation (AF) is one of the most common arrhythmic disorders worldwide. This study aims to describe the prevalence of AF from various cities in Indonesia using single lead electrocardiography (AliveCor Kardia Mobile system) linked to a smartphone-based application.
Methods: This is a cross-sectional epidemiological study conducted at several referral hospitals in Indonesia between January 2018 and July 2019. This study utilized AliveCor device as a screening tool for AF and confirmed its finding with clinical diagnoses by cardiologists. Variables assessed were gender, age, history of heart failure, hypertension, diabetes, stroke, coronary artery disease, peripheral artery disease and prior history of AF.
Results: A total of 9773 subjects were enrolled in this study. The prevalence of atrial fibrillation reported by AliveCor and cardiologist was 3.3% and 3.5%, respectively. Sensitivity and specificity of AliveCor in our study were 93.3% and 100%, respectively. AF is more common in men than women. Based on risk factors, majority of patients with AF did not report a history of heart failure, stroke, diabetes mellitus, hypertension, peripheral artery disease, coronary artery disease and history of AF.
Conclusion: The prevalence of AF at referral hospital in Indonesia based on smartphone diagnosis in Indonesia was 3.3%. Sensitivity and specificity of AliveCor in our study were 93.3% and 100%, respectively.
PP-188-2-GE A non-invasive method to detect sinoatrial node function in human Dr Kenta Tsutsui1, Ido Weiser-Bitoun2, Dr Taisuke Nabeshima1, Assistant Professor Hitoshi Mori1, Professor Ritsushi Kato1, Shintaro Nakano1, Associate Professor Yael Yaniv2 1Saitama Medical University International Medical Center, Hidaka, 日本, 2Technion, Haifa, IsraelObjective: The sinoatrial node (SAN) is the main pacemaker of the heart, and it governs the heart rate. Two main mechanisms control the SAN function: the autonomic nervous system (ANS) that stimulates receptors on the pacemaker cell membrane, and the intrinsic mechanisms of the SAN cells. Because the systems work in synergy, it is challenging to separate their individual contribution and identify SAN dysfunction in early state. We hypothesized that a signal processing algorithm could be developed to identify the unique SAN signature on the Heart Rate Variability (HRV) by exploring short-term and long-term HRV indices.
Materials and Methods: As a part of electrophysiological evaluation, 39 patients having paroxysmal supraventricular tachycardia underwent autonomic blockade with intravenous propranolol and atropine. The patients were divided into two age groups: minors (bellow 21) and elderly, and their ECG recordings were analyzed.
Result: Reducing the ANS activity by autonomic blockade reduced HRV parameters in time domain (e.g. mean RR Interval duration and standard deviation), frequency domain (e.g. normalized low frequency content), and non-linear domain (e.g. multiscale entropy of mid and high scales).
For both age groups, we designed an algorithm containing low-pass filter acting on RR interval time series that allows us to evaluate SAN signature. Our method includes filtration targeting low and high frequency bands of RR interval spectrum.
Conclusion: Our novel method can serve as a unique non-invasive diagnostic tool for cardiac conditions in health and disease, affecting the SAN and heart.
PP-189-2-GE Heart rate variability according to ambulatory glucose profile in patients with diabetes mellitus Dr Sung Il Im1, Dr Sung Pil Cho, Dr Jung Hwan Park, Dr Chul ho Oak 1Kosin Univ Gospel hospital, Busan, South KoreaObjectives: Autonomic neuropathy commonly arises as a long-term complication in diabetes mellitus (DM) and can be diagnosed from heart rate variability (HRV), calculated from electrocardiogram (ECG) recordings. There are limited data about HRV using real-time ECG and ambulatory glucose monitor in patients with diabetes mellitus.
Materials and Methods: Total of 43 patients (66.3 ± 7.5 years) with DM underwent continuous real-time ECG monitor (225.7 ± 107.3 h) for HRV and ambulatory glucose monitor using remote monitoring system. And we compared HRV according to ambulatory glucose profile.
Results: During the monitor, we checked total 15,090 times of ECG and ambulatory glucose level simultaneously of all patients. Both time and frequency domain HRV were lower when the patients had poor controlled glucose level (>200 mg/dl) as compared with normally controlled glucose levels (<200 mg/dl) in Table. In addition, Heart rate and respiration rate increased according to real-time glucose level (p < 0.001).
Conclusions: Poor controlled glucose level was independently associated with lower HRV in patients with DM. This is further substantiated by independent continuous associations between real-time measures of hyperglycemia and lower HRV. These data strongly suggest that cardiac autonomic dysfunction can be caused by elevated blood sugar alone.
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PP-190-2-GE Contemporary review of temporary transvenous pacing: Indications, complications, and prognosis Dr Hooi Khee Teo1, Dr Ignasius Jappar1, Prof Chi Keong Ching1 1National Heart Centre Singapore
Objectives: This study aims to review TTP procedural indications, rates, types of complications, and patient prognosis in a tertiary teaching hospital's cardiac intensive care unit.
Material and Methods: A retrospective analysis was performed on the medical records of consecutive patients who required TTP insertion between August 2014 to June 2017.
Results: 106 patients underwent TTP insertion. Symptomatic bradyarrhythmia was the most common indication (101 patients [95%]), ventricular overdrive pacing for tachyarrhythmias (3 [3%]), and perioperative prophylactic insertion (2 [2%]). Ultrasound guidance for central venous access and fluoroscopy for positioning of the pacing wire in the right ventricle were used routinely. A total of 135 TTP procedures performed. The femoral vein was the most common access site (65%); followed by right internal jugular vein (IJV) (30%) and least frequently left IJV (4%). Mean duration of temporary pacing was 5 days (range 1–19 days).
There were no significant vascular complications. Revision was needed in 21 cases due to pacing wire dislodgement or loss-of-capture. Two right ventricle (RV) perforations required emergency pericardiocentesis. Permanent pacemaker or defibrillator were implanted in 61 patients (58%). Twenty patients (19%) recovered and did not require permanent implantable system, while others declined further therapy or died prior to definitive therapy. Twenty-one patients (20%) died within the same hospital admission, with 2 deaths related to TTP complications (RV perforation).
Conclusion: TTP remains an important urgent cardiac procedure. Serious complications like RV perforation may occur and should be considered in patients who become haemodynamically unstable post-insertion.
PP-193-2-GE WPW and PVC ablation: Kill two birds with one stone Dr Norhaida Ibrahim1, Dr Mohd Khairi Othman1, Dr Ahmad Zakirin Zakaria1, Dr Saravanan Krishinan2, Prof. Dr Zurkurnai Yusof1, Dr W Yus Haniff W Isa1 1Universiti Sains Malaysia, Kubang Kerian/Kota Bharu, Malaysia, 2Hospital Sultanah Bahiyah, Alor Setar, MalaysiaIntroduction: Wolff Parkinson White (WPW) and premature ventricular complex (PVC) are a common cardiac arrhythmia. However, the occurrence same arrhythmia in one patient is rare. We are reporting a case of successful ablation of left sided WPW and outflow tract PVC in same procedure.
Case Report: A 19-year-old girl previously well presented with sudden onset palpitation associated with giddiness. On examination, her blood pressure was normal with a heart rate of 170 bpm. Initial ECG showed broad complex atrial tachycardia and terminated with Valsalva maneuver. ECG post-Valsalva showed sinus rhythm, presence of delta wave, and unifocal posteroseptal RVOT PVC. She underwent an electrophysiology study with single catheter 3D mapping. The procedure was done by via right femoral vein and transeptal puncture using the HeartSpan transeptal needle. The accessory pathway was identified at the left posterior atrioventricular groove and ablated with 35 W. Subsequently, proceed with mapping at RVOT and earliest prepotential signal 28 ms found at posteroseptal subpulmonic. The lesion was ablated with 35 W and further consolidated. Patient was observed and no inducible tachycardia after 30 min. Two weeks post-procedure, she was asymptomatic.
Discussion: WPW with tachycardia manifestation is an indication of catheter ablation as this condition potentially leads to sudden cardiac death, especially in the presence of PVC. This case illustrate the successful ablation of two cardiac arrhythmia at same procedure.
Conclusion: WPW and PVC in the same patient is a rare condition. Catheter ablation is useful to treat this condition in the same setting with minimal cardiac risk.
PP-194-2-GE A successful PVC ablation with ‘zero fluoroscopy’ in pregnancy: A case report Dr Ahmad Zakirin Zakaria1, Dr Mohd Khairi Othman1, Dr Saravanan Krishinan2, Prof. Dr Zurkurnai Yusof1, Dr W Yus Haniff W Isa1 1Universiti Sains Malaysia, Kubang Kerian, Malaysia, 2Hospital Sultanah Bahiyah, Alor Setar, MalaysiaIntroduction: Premature ventricular complex (PVC) known to be a benign condition and in pregnancy it may cause unwanted consequences to both mother and fetus. Here we are reporting a successful abolishment of PVC of outflow tract origin using 3D electroanatomical mapping system and zero radiation.
Case Report: A 30-year-old primigravida lady at her 31 weeks period of gestation complained of gradual worsening shortness of breath and lethargy for since early pregnancy. On admission, incidental finding of ventricular bigeminy. Clinical examination was unremarkable. Holter revealed PVC burden of 25.6% with structurally normal heart. She subsequently underwent for PVC ablation with a single catheter 3D mapping system with abdominal shield due to unable to tolerate beta blocker. During mapping the right ventricular outflow tract (RVOT), we found the earliest activation on the posteroseptal aspect of RVOT with sharp presystolic potential and match with baseline clinical PVC. PVC signal was terminated with single attempt ablation. The patient was observed for 30 min post-ablation with no recurrence of PVC. After 2 weeks post-procedure, she was asymptomatic, and ECG showed normal sinus rhythm.
Discussion: In pregnancy, the PVC frequency can increase due to structural and hormonal changes. Our patient unable to tolerate beta blocker hence 3D electrophysiology mapping was done. In the advancement of 3D mapping, PVC ablation can successfully be done in pregnancy without radiation.
Conclusion: This case highlights the successful ablation of high burden PVC in a pregnant mother without radiation to prevent adverse event in both mother and fetus.
PP-195-2-GE Utilization of artificial intelligence for detection of critical arrhythmias in portable ECG monitoring device Asst Prof Chih-Min Liu1, Professor Shih-Lin Chang1, Master Chih-Wei Yu2, Master Yi-An Chen2, Master Po-Hung Lin2, Master Wei-En Hsu2, Master Shih-Hung Pai2, Professor Yenn-Jiang Lin1, Professor Li-Wei Lo1, Professor Yu-Feng Hu1, Associate Professor Fa-Po Chung1, Associate Professor Tze-Fan Chao1, Assistant Professor Ta-Chuan Tuan1, Assistant Professor Jo-Nan Liao1, Assistant Professor Chin-Yu Lin1, Assistant Professor Ting-Yung Chang1, Dr. Ling Kuo1, Dr. Cheng-I Wu1, Dr. Shin-Huei Liu1, B.S.Eng. Yang-Che Shiu1, Professor Shih-Ann Chen1 1Taipei Veterans General Hospital, Taipei, Taiwan, 2Cloud Solution Division, Quanta Computer Inc., Taoyuan, TaiwanObjectives: We aim to create a new artificial intelligence (AI) algorithm to detect critical cardiac arrhythmias in patients with continuous single-lead ECG monitoring.
Materials and Methods: This prospective clinical study enrolled patients suspected of arrhythmias from Taipei Veterans General Hospital, a single tertiary center. Each patient underwent a continuously portable ECG monitoring device (Figure 1A) for minutes to several days in the outpatient or inpatient departments. Three types of critical arrhythmias were classified: pause ≥3 s, atrial fibrillation (AF)/atrial flutter (AFL) (irregular R-R interval without P wave ≥30 s), and ventricular tachycardia (VT)/ventricular fibrillation (VF). A total of 188 patients were recruited (12 [6.4%] with pauses, 63 [33.5%] with AF/AFL, and 8 [4.3%] with VT/VF). One hundred seven patients and open resources were utilized for AI training, and 81 patients were divided into the test set. The proposed AI algorithm is illustrated in Figure 1B.
Results: In the test set, the pause achieved a sensitivity of 100%, specificity of 99.8%, and accuracy of 99.8%. The AF/AFL and VT/VF could achieve a sensitivity of 84.8%, specificity of 99.6%, accuracy of 98.8%, and a sensitivity of 94.7%, specificity of 99.8%, accuracy of 99.8%, respectively (Figure 1C). The portable ECG device detected critical arrhythmias (pauses, AF/AFL, or VT/VF) in 44.1% of patients suspected of arrhythmias. No serious adverse events in patients wearing the portable ECG device were reported.
Conclusions: The incorporated AI algorithms in portable ECG devices are capable of real-time identifying individuals with hidden critical arrhythmias in the outpatient or inpatient settings.
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FIGURE 1 The portable ECG monitoring device for detection of critical arrhythmias. (A) The portable ECG monitoring device. (B) The AI algorithm for critical arrhythmias. (C) The confusion matrix of test results of AI module.
PP-196-2-GE Impact of Holter monitoring on cardiac resynchronization therapy in heart failure patients with atrial fibrillation Dr Natchayathipk Kittichamroen1, Dr. Thoranis Chantrarat2, Dr. Preecha Uerojanaungkul2 1Charoenkrungpracharak Hospital, Bang Kho Laem, Thailand, 2Phramongkutklao hospital, Ratchathewi, Thailand
Objectives: Cardiac resynchronization therapy (CRT) in heart failure (HF) patients with atrial fibrillation (AF) have poor outcome due to AF can lead to ineffective biventricular pacing (BiVP) and cause fusion, pseudo-fusion beats and even loss of capture.
Material and Methods: This prospective cohort study evaluated the impact of 24-h Holter monitoring on CRT treatment in HF patients with AF on the incidence of effective and ineffective pacing. AF patients who had CRT, LVEF ≤ 35%, NYHA FC II-IV, BiVP ≥ 93% were enrolled. The results from 24 h-Holter monitoring were used to evaluate the percentage of truly effective BiVP and identify fusion and pseudo-fusion beats and loss of capture.
Results: Twenty-five HF patients with AF were analyzed (14 and 11 patients in PAF and non-PAF groups, respectively) with 6 months follow-up period. The overall incidence of ineffective BiVP was 28%. A total of seven patients had inadequate BiVP, six patients in non-PAF group. PAF patients were less likely to have subsequent adjusted treatment (p-value 0.032). CRT interrogation was likely to overestimate the degree of effective BiVP in non-PAF group more than PAF group significantly (p-value 0.009). In PAF group, there was higher average of percentage of true BiVP (p-value 0.046) and a significantly lower incidence of pseudo-fusion beats (p-value 0.044). A higher percentage of adequate BiVP was achieved in six patients after subsequent adjusted treatment.
Conclusion: Current CRT interrogation alone in HF patients with AF could overestimate the effective BiVP. The 24-h Holter monitoring is a useful and convenient tool to uncover the incidence of truly effective and ineffective BiVP.
SUPPORTING DOCUMENTS
TABLE 1 Comparison of an adequate and inadequate biventricular pacing between PAF and non-PAF group
FIGURE 1 Each bar represents an individual subject in the study who had percentage of true biventricular pacing < 93. Colors represent the timing that patient had 24 h-Holter monitoring, the first time (blue), the second time (orange). *NPAF3 patient died before second follow-up.
TABLE 2 The change in percentage of biventricular pacing after treatment in subjects with first 24 h-Holter monitoring demonstrated <93% true biventricular pacing
Note: A = Amiodarone, B = Beta Blocker. BiVP = Biventricular Pacing. Π = was done.
Abbreviation: AVJ, atrioventricular junctional ablation.
PP-197-V-GE The relationship of conduction disorder and prognosis in patients with acute coronary syndrome Dr Wei-chieh Lee1 1Chi Mei Medical Center, Tainan, TaiwanObjective: Conduction disorders with a widened QRS are associated with poor prognosis in patients with acute coronary syndrome (ACS). Previous studies did not have conflicting results regarding the type of bundle branch block (BBB) with the worst prognosis, and few studies have focused on the prognosis of patients with NICD.
Methods: Patients with ACS were enrolled between January 2005 and December 2019. Following clinical outcomes were compared between patients with and without conduction disorders.
Results: This study enrolled a total of 33,970 participants and involved 3392 and 30,578 patients with and without conduction disorders, respectively. Lower mean LVEF was exhibited in patients with conduction disorders (with vs. without; 44.64 ± 20.73% vs. 49.85 ± 20.63%; p < 0.001). Higher incidences of HF hospitalization (21.55% vs. 17.51%; p < 0.001), CV mortality (17.98% vs. 12.14%; p < 0.001), and all-cause mortality (38.86% vs. 31.15%; p < 0.001) were noted in patients with conduction disorder. The lowest mean of LVEF was presented in the patients with RBBB (LBBB vs. RBBB vs. NICD; 41.00 ± 19.47% vs. 47.73 ± 20.82% vs. 34.57 ± 20.02%; p < 0.001). The highest incidence of HF hospitalization was noted in patients with LBBB and the lowest incidence of CV and all-cause mortality was observed in patients with RBBB.
Conclusions: In ACS population, patients with conduction delay had a poor prognosis due to higher prevalence of comorbidities and lower mean LVEF. Those with LBBB and NICD had a higher incidence of clinical outcomes. Patients with NICD had the lowest mean LVEF compared to those with LBBB and RBBB.
PP-198-V-GE Impaired regional strain by CMR-FT predicts low sensing value after ICD implantation in ACM patients Dr Zhongli Chen1, Dr Yanyan Song2, Dr Liang Chen3, Dr Xuan Ma2, Prof Shihua Zhao2, Prof Keping Chen1 1State Key Laboratory Of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, Beijing, China, 2Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China, 3Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, ChinaObjectives: Inadequate ventricular sensing at implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) is troubling and might cause inappropriate ICD interventions and complications. We aimed to evaluate the value of ventricular mechanics features in predicting low sensing value by emerging cardiovascular magnetic resonance-feature tracking (CMR-FT) in ACM patients.
Hypothesis: CMR-FT characteristics prior to ICD implantation might assist in predicting low R wave amplitude.
Materials and Methods: We retrospectively enrolled ACM patients undergoing CMR examinations prior to ICD implantation at our center from January 2011 to July 2021. The strain parameters of LV and RV were analyzed by CMR-FT. The R wave amplitude (RWA) was obtained within 24 h of completion of the ICD implantation and its association with CMR strain parameters was analyzed.
Results: We enrolled 83 ACM patients with a median RWA of 8.0 mV (Interquartile range: 5.4–12.1 mV) and impedance within the normal range. 18 (21.7%) patients were found with low RWA (<5 mV) despite attempts in over five positions. RV strain parameters including RV global longitudinal, circumferential and radial strain rather than LV strain parameters correlated significantly with RWA (Spearman's correlation coefficients: GLS: −0.35, GCS: −0.58, GRS: 0.59, all p < 0.01). RVGRS and RVGCS were found independently associated with RWA, and valuable in predicting low RWA (areas under the curve: 0.76 and 0.73 respectively; sensitivity: both 0.72, specificity: both 0.71).
Conclusion: Low sensing of ICD lead in ACM patients was associated with impaired RV mechanics. RVGCS and RVGRS by CMR-FT were valuable parameters for predicting low RWA.
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PP-199-V-GE Single Centre experience of radiofrequency catheter ablation at a tertiary Care Centre in Northern India Dr Archit Dahiya1, Dr Rajeev Sharma1, Dr Harsh Wardhan1, Dr Piyush Joshi1 1Mahatma Gandhi Medical College And Hospital, Jaipur, India
Objectives: The purpose of this study was to analyse the epidemiological characteristics, findings, acute success and complications of radiofrequency catheter ablation for cardiac tachyarrhythmias at a tertiary care centre in Northern India.
Materials and Methods: This retrospective observational study was conducted at the Department of Cardiology, Mahatma Gandhi Medical College & Hospital, Jaipur. Prior approval was taken from the institutional ethics committee. All patients who underwent RF catheter ablation for cardiac tachyarrhythmias from October 2018 to August 2021 were included in this study. Data recorded for this study included age, gender, indication for RF ablation, type of arrhythmia, location of accessory pathway(s), concomitant structural heart disease, fluoroscopy time, ablation results and complications.
Results: The study analysed 273 patients of which AVNRT was the commonest (52.0%), followed by AVRT at 33.3% and focal atrial tachycardia at 3.6%. The initial success rate was significantly higher in the patients with atrioventricular nodal reentry tachycardia 99.29% and lower in those with VPC/NSVT/VT 88.2%. The mean fluoroscopy time was 12.9 ± 7.9 min and was more prolonged in atrial flutter at 20.2 ± 8.9 min.
Conclusion: RF catheter ablation proved to be a safe and effective method for treating arrhythmias in our study. It can act as a more economical treatment modality for a select group of patients. Our results support the use of RF catheter ablation therapy in the management of cardiac tachyarrhythmias with a high rate of success and low complication rates.
PP-200-V-GE VT or SVT: A common intrigue dilemma Dr Doreen Sumpat1, Dr Simon Salim2, Dr Ong Yu Ying3, Dr Azrina Abdul Kadir3, Dr Mexmollen Marcus1, Dr Chua Shee Wen1, Dr Chang Chee Keong1, Dr Abdul Jabbar bin Ismail1, Dr Constance Liew Sat Lin1 1Universiti Malaysia Sabah, Kota Kinabalu, Malaysia, 2Division of Cardiology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Salemba Raya, Indonesia, 3Hospital Sultanah Aminah, Johor Bharu, MalaysiaObjectives: We present a case of palpitation with wide complex tachycardia and extreme axis deviation.
Materials and Methods: A 40-years-old gentleman come to our center with palpitation, dyspnea and chest tightness. He was an active smoker with history of diabetes and hypertension. His ECG showed an RBBB with LPFB pattern and extreme axis deviation (EAD) and no apparent V-A dissociation (Figure A). The emergency team used Amiodarone 150 mg iv drip first but failed to terminate the tachycardia, and subsequent verapamil bolus of 5 mg over 1 min succeed in terminating the tachycardia. His ECG during sinus rhythm show similar morphology (Figure B).
The golden rule is to treat any wide complex tachycardia as VT until proven otherwise. Amiodarone had a delayed onset of action hence need a higher loading dose whereas verapamil had rapid onset. Faced with RBBB + LPFB and EAD morphology, a differential of fascicular VT surfaced and verapamil was given, as this kind of VT reportedly to respond well with verapamil (verapamil sensitive). However, the similar axis and morphology during sinus rhythm favor SVT as the underlying mechanism. Should the patient did not respond with medication or deteriorating even further an electrical cardioversion might be mandated.
Results: There are several differential diagnoses in regards to wide complex tachycardia with right bundle branch block (RBBB). It could be supraventricular tachycardia (SVT) with underlying aberrancy or ventricular tachycardia (VT) mainly idiopathic fascicular left ventricular tachycardia (ILVT). VT from intramyocardial reentry or from mitral annulus which is close to the conduction system has narrow QRS due to an early invasion of the His-Purkinje system. Both can present morphology of RBBB, right axis and a relatively narrow QRS. VT from interfascicles has QRS morphology that is similar in sinus rhythm and tachycardia and anterior or posterior hemiblock as the tachycardia circuit is established between the two fascicles. Upper septal fascicular VT will present as RBBB, narrow QRS and normal frontal axis. In this case, RBBB, QRS morphology and cardiac axis which is left axis deviation remain similar during tachycardia and sinus rhythm. No ventriculoatrial dissociation in the ECG It responded very well to verapamil. Based on clinical presentation and ECG, the most probable diagnosis is SVT with aberrancy or posterior fascicular VT. Established criteria that are traditionally used for VT versus SVT discrimination do not apply to posterior fascicular VT and SVT with RBBB and LAHB. Criteria that support the diagnosis of VT may not be relevant to posterior fascicular VT. These criteria include atypical RBBB pattern in V1, QRS duration >140 ms, RS time >100 ms, initial R wave in aVr or Q >40 ms, and initial-to-terminal ventricular activation ratio (Vi/Vt) >1. Criteria that exclude SVT, such as QRS duration >140 ms, R/S ratio <1 in V6, and positive QRS in aVr have bigger overlap in cases of RBBB and LAHB compared with RBBB alone. In the absence of ventriculoatrial dissociation or fusion/capture beats, it is difficult to achieve correct diagnosis. Furthermore, it is also difficult to differentiate posterior fascicular VT with posterior papillary muscle VT just based on ECG alone.
Conclusion: Our case highlight that not all wide complex tachycardia (WCT) were caused by VT. The algorithms we had differentiating SVT with VT were never had 100% accuracy. Even in this case, EP study is warranted to elucidate the real cause of WCT.
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FIGURE A
FIGURE B PP-201-V-GE Arrhythmic storm with acquired LQTS after esophagectomy: Is sepsis or ICIs responsible for these? Dr Weizhuo Liu1, Dr Saiqi Li1, Dr Yi Shen1, Dr Qianyun Zhang1, Pro. Bin He1 1Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
Objectives: Sepsis-induced cardiomyopathy (SIC) is one major cause of death for sepsis which is a known risk factor for arrhythmias. Immune checkpoint inhibitors (ICIs) also have potential cardiotoxicity manifesting as ECG abnormalities. However, data on repolarization changes and ventricular arrhythmias in these situations are limited. Here we report a case of arrhythmic storm with acquired LQTS with history therapy of ICIs after esophagectomy.
Methods: An 67-year-old male patient underwent esophagectomy who had received three cycles of immunity therapy before. Basic vital signs were monitored and recorded. Blood tests including BR, CRP, PCT, blood culture etc. were performed if needed. ECG, echocardiography and X-ray were closely followed up.
Results: ECG displayed sinus rhythm with normal QT interval at baseline and the operation went well. However, he got high fever 6 days after the surgery. Leukocytosis and elevated CRP, PCT and pro-BNP were observed while echocardiography showed no valve vegetation, after which esophagobronchial fistula was proven by bronchoscopy and Escherichia coli was recognized by blood cultures. Soon he suffered from arrhythmic storm caused by prolonged QT-Interval, including monomorphic VT and TdP, which could not be terminated by antiarrhythmic agents till his death. After tracing medical history, we found the patient had had once QT prolongation after the use of ICIs.
Conclusion: We assumed it could be a rare case of SIC associated acquired LQTS, causing severe cardiac function decline and lethal ventricular arrhythmia. ICIs may have occult cardiotoxicity manifesting ECG abnormalities which should be monitored carefully. However, the mechanism needs further discussion.
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Graphical Abstract:
PP-202-1-HF Different Β-blocker effects according to heart rate in Hfpef and atrial fibrillation Prof Minsoo Ahn1, Assist Prof Young Jun Park1 1Wonju College Of Medicine Yonsei University, Wonju, South Korea
Objectives: Beta-blockers (BBs) improve the prognosis of patients with heart failure (HF) by lowering the heart rate (HR). However, HR has no prognostic implication in cases of atrial fibrillation (AF). Furthermore, BBs do not improve the prognosis in cases of heart failure with preserved ejection fraction (HFpEF) and AF. Thus, the prognostic implications of BBs in patients with HFpEF and AF based on HR at discharge were assessed.
Material and Methods: A total of 5625 patients hospitalized for acute HF were enrolled from the Korean Acute Heart Failure Registry, of whom 687 with HFpEF and AF were selected. The participants were divided into high HR (355) and low HR (332) groups.
Results: BBs were used to treat 128 (36.1%) and 121 (36.4%) patients in the low and high HR groups. In the low HR group, BBs did not improve 60-day rehospitalization or mortality rates. In the high HR group, BBs were associated with 82% reduced 60-day rehospitalization due to HF but not with mortality.
Conclusions: When the high HR at discharge was maintained using a BB, there was a reduction in the 60-day rehospitalization rate than when a BB was not administered.
PP-203-1-HF Patient centric outcomes of cardiac resynchronization therapy with SyncAV dynamic optimization Mr Bharat Phani Vaikuntam1, Mr Arif Fahim2, Mr John Gillespie1, Ms Claire Cottrell1 1Abbott Medical Australia Pty Ltd, Sydney, Australia, 2Abbott Medical SingaporeObjectives: Cardiac resynchronization therapy (CRT) is a well-established treatment for patients with heart failure, LV dysfunction, a low ejection fraction, and prolonged QRS duration. However, one-third of patients do not benefit from CRT, owing to anatomical and procedural issues in achieving efficient LV-pacing or changes in LV threshold over time, which may result in sub-threshold stimulation or inadequate CRT delivery due to suboptimal AV and VV delays.
SyncAV CRT technology, which uses a unique device-based algorithm to dynamically adjust AV delay timing based on the intrinsic AV interval, may benefit patients with heart failure both clinically and economically.
Materials and Methods: This review summarizes the latest evidence for SyncAV CRT use in patients with Heart Failure (HF) with LV-systolic dysfunction and prolonged QRS interval.
Results: Clinical benefits: SyncAV™ CRT adjusts the timing of AV delays based on intrinsic AV interval to create a triple fusion between LV and right-ventricular pacing with patient-tailored intrinsic conduction and delivers improved electrical-synchrony and narrower QRS-duration (1, 2).
Patient outcomes: Improved quality of life and significant reduction in all-cause readmissions (34%), cumulative HF hospitalizations (HFH) (30%), and HF-readmissions (41%) (3). Decreased mortality rates with 82% survival in super-responders and 70% survival in responders at 5-years (4).
Conclusion: Improving patient response to CRT is associated with decreased mortality rates, reduced HF-events and is expected to decrease healthcare expenditures due to reductions in rehospitalizations. Furthermore, first and second HF events have been linked to 7 and almost 19-fold increased mortality risk, hence, SyncAV CRT reduction of HF-events is important for improving patient survival (5).
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REFERENCES
- Wisnoskey BJ, Cranke G, Cantillon DJ, and Varma N. “Feasibility of Device-Based Electrical Optimization via Application of the Negative AV Hysteresis Algorithm during Cardiac Resynchronization Therapy (CRT).” Heart Rhythm. 2016; 13 (5 S): S443.
- Varma N, O'Donnell D, Bassiouny M, et al. Programming cardiac resynchronization therapy for electrical synchrony: reaching beyond left bundle branch block and left ventricular activation delay. J Am Heart Assoc. 2018;7:e007489.
http://jaha.ahajournals .org/content/7/3/e007489. - Varma, N., Hu, Y., Connolly, A. T., Thibault, B., Singh, B., Mont, L., … Zareba, W. (2021). Gain in real-world cardiac resynchronization therapy efficacy with SyncAV dynamic optimization: Heart failure hospitalizations and costs. Heart Rhythm.
- Rickard J, Cheng A, Spragg D, et al. Durability of the survival effect of cardiac resynchronization therapy by level of left ventricular functional improvement: fate of “nonresponders.” Heart Rhythm. 2014;11(3):412–416.
https://doi.org/10.1016/j.hrthm.2013.11.027 - Varma, N., Hu, Y., Connolly, A. T., Thibault, B., Singh, B., Mont, L., … Zareba, W. (2021). Gain in real-world cardiac resynchronization therapy efficacy with SyncAV dynamic optimization: heart failure hospitalizations and costs. Heart Rhythm, 18(9), 1577–1585.
Objective: To initiate an audit of heart failure patients in our locality receiving Entresto, taking into account rate of re-hospitalization, NYHA class improvement and safety outcomes.
Materials and Methods: Retrospective cohort study of heart failure patients, assigned to receive Entresto twice a day as recommended by guidelines, within 6 months period. Patients with cardiac device and those who underwent electrophysiological study were excluded from this audit.
Results: Patients were of mean age of 56 years. Majority were NYHA class II and III (81.4%) with 35.6% of them having history of heart failure admission. NYHA class improved during the 1st and 6th months follow-up (62.7% and 74.1% respectively). Large improvement were also seen in rate of readmission (8.5% and 18.6%). Diuretics usage were reduced considerably for 30.5% of patients at 1 month follow-up while 52.4% did not require escalation of diuretics. At 6 months, similar improvements were seen at 40.7% and 47.5% respectively. Entresto, was well tolerated with only six cases of adverse drug reactions. Two hypotensive cases noted after 1 month follow-up and one at 6 months. Two renal impairment and one hyperkalemia at 6 months follow-up.
Conclusion: Entresto was effective and safe in heart failure patients of Asian origin within our locality. For a more significant outcome, study with larger sample size and longer follow-up is required.
PP-205-2-HF Relationship between heart sounds detected with 3D-Accelerometer and heart failure status in acute decompensated patients Dr.Med Olena Nemchyna2, Dr John Gill1, Dr Luke McSpadden1, Mr Nikolaos Politis1, Dr.Med Nikolaos Cholevas2, Dr.Med Isabell A. Just2,3, Prof. Evgenij Potapov2,3, Prof. Christoph Starck2,3, Prof. Volkmar Falk2,3,4, Prof. Felix Schoenrath2,3 1Abbott, Sylmar, USA, 2Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany, 3DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany, 4Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, GermanyObjective: The S1 Heart sound (HS) is a surrogate for the beginning of systole. When combined with electrocardiogram, it can be used to measure electromechanical activation time (EMAT). In this clinical investigation, EMAT obtained from HS using a 3D accelerometer was compared against NT-proBNP on patients hospitalized due to acute heart failure (HF) decompensation (ADHF).
Methods: Data were collected using a custom wearable data collection unit (DCU) which included a 3D accelerometer capable of x/y/z axis recording of HS and electrodes for simultaneous electrocardiogram collection. The DCU was placed on the chest of pts hospitalized for ADHF. EMAT measurement, defined as the interval between QRS peak and S1, was compared against NT-proBNP measured at baseline and again 48 h later.
Results: Seven HF pts in NYHA class III-IV (7 male, median age 52 years) were included in the analysis. During the first 48 h of hospitalization, average NT-proBNP decreased by −369.4 pg/ml (9.6% reduction from an average of 3843 pg/ml baseline) while the average EMAT decreased by −10.1 ms (12.5% reduction from an average of 81 ms baseline). EMAT and NT-proBNP changed in the same direction for 5 out of 6 pts who had significant changes in NT-proBNP. In one pt with low NT-proBNP at baseline (134 pg/ml), EMAT decreased by 22% while the NT-proBNP increased slightly to 138 pg/ml.
Conclusions: EMAT changes directionally correlated with NT-proBNP changes in five of six patients. Change in electromechanical interval did not correlate well in one pt whose NT-proBNP was very relatively normal.
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PP-206-2-HF Conduction system pacing in heart failure with reduced ejection fraction: A systematic review and meta-analysis Dr Julian Gin1, Dr Geoff Wong1 1Austin Health, Heidelberg, Australia
Objectives:
Conduction system pacing (CSP)—including His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP)—are emerging alternatives to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) in heart failure. However, evidence is limited to small and observational studies. This meta-analysis aims to assess CSP pacing and clinical outcomes compared to BVP.
Materials and Methods: We conducted a literature search of PUBMED, MEDLINE and EMBASE of randomized control trials (RCTs) and non-RCTs which compare CSP (HBP & LBBAP) with BVP in patients with CRT indications. Out of 12 studies with 2138 patients, we assessed the mean difference in QRS duration (QRSd), pacing threshold, left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) class score.
Results: With CSP, the pooled mean QRSd improved by 21.8 ms (95% CI −27.96 to −15.63, p < 0.05, I2 = 86.77%) versus BVP. For LVEF, a weighted mean increase of 6.46% (95% CI 4.58–8.35, p < 0.05, I2 = 44.74%) was seen following CSP versus BVP. The mean NYHA score was lowered by 0.43 (95% CI −0.62 to −0.24, p < 0.05, I2 = 60.03%) post-CSP compared to BVP. These QRSd, LVEF and NYHA benefits were uniformly seen across HBP and LBBAP groups. When compared with BVP, the mean pacing threshold significantly improved by 0.52 V (95% CI −0.65 to −0.4, p < 0.05, I2 = 82.27%) for LBBAP, while this was non-significantly reduced (−0.46 V, 95% CI −0.34 to −1.27, p = 0.26, I2 = 95.59%) for HBP.
Conclusion: Overall, both CSP techniques are feasible and effective CRT alternatives for heart failure. Further RCTs are needed to establish long term efficacy and safety.
PP-207-2-HF Bradycardiomyopathy post-atrial septal defect (ASD) closure—Late complication: A case report Dr Azizi Ab Rahman1, Dr Mohd Khairi Othman1, Prof. Dr Zurkurnai Yusof1, Dr Ahmad Aizuddin Mohamad Jamali1, Dr Zul Khairul Azwadi Ismail1, Dr Mohd Rizal Mohd Zain1, Dr Khairil Amir Sayuti1, Dr W Yus Haniff W Isa1 1Universiti Sains Malaysia, Kota Bharu, MalaysiaIntroduction: Conduction disorder complication post-atrial septal defect (ASD) closure with heart failure is rare. We are reporting a case of delayed complication of percutaneous ASD closure leading to sinus node dysfunction with heart failure.
Case presentation: A 19-year-old girl with a history of percutaneous closure of patent ductus arteriosus (PDA) and ASD in 2005 and 2014, respectively. She had complained of reduced effort tolerance for 3 months. It was associated with orthopnea and paroxysmal nocturnal dyspnea with NYHA II-III. On examination, her vital sign was stable. Presence of elevated jugular venous pressure, pedal edema and fine crepitation both lower zone. Her ECG showed intermittent accelerated junctional rhythm with a QRS duration of 136 ms. Her echocardiogram showed a dilated left ventricle chamber, and LV function was 43%. Cardiac MRI showed fibrous tissue below ASD occlude with the pattern of non-ischemic cardiomyopathy. She was started with heart failure therapy and underwent a dual chamber permanent pacemaker with left bundle branch pacing and symptom was improved.
Discussion: Sick sinus dysfunction is common in surgical ASD closure up to 10%–15% and rare in percutaneous ASD closure. In our patient, she was asymptomatic initially then progressed to heart failure as result from chronic sick sinus node. Hence, the left bundle branch pacing strategy was chosen to improve the LV synchronization and function.
Conclusion: This is an interesting case report of delayed complication of percutaneous ASD closure leading to non-ischemic heart failure and treated with left bundle branch pacing.
PP-210-1-PEDS Refractory ventricular arrhythmias in a neonate with CPT II deficiency Dr Charmaine Chan1, A/Prof Suresh Chandran1, Dr Yee Yin Tan1, Dr Nikki Fong1 1Singhealth/KKH, SingaporeObjectives: A term infant female born to first-degree consanguineous couple developed recurrent apneas, generalized seizures, complicated by severe hyperkalaemia (potassium 8.1 mmol/L) with ventricular tachycardia (VT) and circulatory collapse at 55 h of life. She required cardiopulmonary resuscitation, defibrillation, and her hyperkalaemia was corrected. She converted to sinus rhythm. Echocardiography showed normal heart function, biventricular hypertrophy.
On day 5 of life, she was hypotensive again. ECG showed ischaemic changes, with elevated troponin I. She developed runs of VT requiring synchronized cardioversion. However, she developed refractory VT/VF. She was placed on ECMO and amiodarone infusion.
Tandem mass spectrometry (TMS) screen results on day 7 was suggestive of carnitine palmitoyltransferase II (CPT II) deficiency, confirmed by genetic test. She was started on intravenous carnitine and medium chain triglyceride formula milk. She remained in refractory VF. This was complicated by intracranial bleed. ECMO support was withdrawn and she passed away shortly after.
Results: Cardiac arrest from ventricular arrhythmias is rare in neonates with structurally normal heart. Underlying metabolic disorder or primary electrical disease should be considered. CPT II deficiency is a rare autosomal recessive mitochondrial fatty acid oxidation disorder. The enzymatic defect prevents long-chain fatty acids from being transported to the mitochondria for utilization. It is frequently lethal in neonates. Intermediate fatty acid metabolites accumulate e.g. long-chain acylcarnitine, and have proarrhythmic effects. Treatment is to avoid prolonged fasting, and high-carbohydrate low-fat diet.
Conclusion: CPT II deficiency is a rare cause of refractory ventricular arrhythmias in newborns. Despite medical therapy, this condition is usually lethal.
PP-211-1-PEDS Adenosine-sensitive bypass tract-mediated tachycardia in repaired TOF with post-operative heart block—PJRT Variant? Dr Jason Tan1, Miss Chatyapa Sriprom1, Dr Supaluck Kanjanauthai1 1Mahidol University, Siriraj Hospital, Bangkok, ThailandObjectives: 6 years old boy underwent TOF repair at the age of 1 year old. He had post-operative heart block requiring insertion of dual chamber epicardial pacemaker. During early post-op follow-up, pacemaker interrogation revealed frequent runs of SVT, consistent with symptom of palpitation. Intrinsic rhythm was in first degree alternates with Mobitz I. SVT occurred following intrinsic rhythm with prolonged AV interval (255 ms). He was started on atenolol and digoxin to suppress these episodes at the expense of increasing pacing requirements. He was thus scheduled for EP study. Antiarrhythmic drugs were discontinued. He had baseline prolonged PR (285 ms), AH (234), HV (44). Baseline ECG showed RBBB with superior axis suggesting bifascicular block. Atrial extrastimulus induced SVT with eccentric atrial activation in CS poles. Ventricular entrainment findings favoured ORT as mechanism (PPI—TCL 89 ms; SA—VA 63 ms). Adenosine administration during SVT with background ventricular pacing showed VA block. The bypass tract was mapped to the lateral mitral annulus and ablation there was successful.
Conclusion: This case illustrates a concealed retrograde-conducting left lateral bypass tract that only manifests following prolonged AV delay. Being adenosine sensitive, we postulate that this could be a rare site of decremental by-pass tract but with short RP interval seen during SVT due to significant intraventricular conduction delay.
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FIGURE 1 SVT during intrinsic rhythm.
FIGURE 2 Pathway block during adenosine. FIGURE 3 Ablation at left lateral mitral annulus. PP-212-1-ST Young boy with recurrent wide QRS tachycardia-narrowing down to the diagnosis Dr Suchit Majumdar1 1Apollo Multispeciality Hospital, kolkata, India
Material and Methods: A young boy of 16 years presented with recurrent palpitations with a structurally normal heart by echo. Episode ECG showed regular wide QRS tachycardia, was taken up for Electrophysiology study. Baseline HV was normal. VA conduction was central and decremental. Wide QRS Tachy induced after VA jump, which showed VA dissociation sometimes. Morphology of tachy was LBBB with late transition and leftward axis. Tachy was also induced by ventricular and atrial pacing, where it was sustained with 1:1 VA conduction and fixed VA. The ventricular beats during tachycardia had RV egm significantly early than His V. Atrial pacing also reproduced the tachy morphology with negative HV, suggestive of a preexcitation. During the wide QRS tachycardia, septal synchronous atrial extra beats did not pull the next V.
Results: The analysis of all these maneuvers pointed towards possibility of a nodofascicular or nodoventricular pathway which was causing antidromic AVRT. VT was unlikely as the CS pacing resulted in gradual change from sinus morphology to full preexcited morphology. As these pathways are commonly related to slow pathway area, ablation was given during atrial pacing to that area which resulted in disappearance of preexcitation and further noninducibility of the tachycardia.
Conclusion: When dealing with wide QRS negative HV tachycardia with VA dissociation, NF/NV pathway should always come into mind as atrium is not a part of the circuit. Here VT was ruled out by atrial pacing.
PP-213-1-ST Electrogram changes as predictor of fast pathway heating during AVNRT ablation Dr Suchit Majumdar1 1Apollo Multispeciality Hospital, Kolkata, IndiaMaterial and Methods: It is known that cause of complete heart block during slow pathway radiofrequency ablation in AVNRT is the collateral heating of the fast pathway and injury to it. It is manifested by fast junctional rhythm, VA prolongation (in slow fast AVNRT), AH prolongation (if atrial paced during ablation) or VA block. Our patient is a 47 years lady with recurrent palpitations, EP study showed induced AVNRT. While ablating the slow pathway area, we noticed there was shortening of the interval between the local v at RV apex and local V at his distal significantly with the junction speeding up to around 350 ms from 430 to 500 ms (Figure 1).
Conclusions: The finding of the shortening of the interval between the local v at RV distal and His distal during radiofrequency ablation of slow pathway in AVNRT can predict fast pathway heating and increased chance of complete heart block. This and presence of frequent his ectopics can be a warning sign.
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FIGURE 1 Also there was ectopics from near the his associated with this acceleration (arrow). This was reproducibly noticed and the radiofrequency delivery was discontinued whenever the junctional sped to less than 350 ms cycle length. Hence this shortening of the interval or his ectopics can serve as warning sign for fast pathway heating and can indicate us to stop the RF, to reduce the chance of complete heart block.
PP-214-1-ST The first case series on Fluoroless ganglionated plexus ablation for symptomatic bradycardia Dr Sri Sundaram1, Benjamin Jones2, Thomas Rogers2, Tolga Aksu3, William Choe, Daniel Alyesh1 1South Denver Cardiology, Littleton, USA, 2Abbott, Chicago, USA, 3Yeditepe University, Istanbul, TurkeyObjective and Background: Ganglionated plexus ablation (GP) and Fluoroless ablation (FA) are two emerging trends that have gained prominence in EP. GP has been proposed as a treatment for symptomatic bradyarrhythmias. With the young age of most of these patients, avoidance of ionizing radiation is important to limit potential long term deleterious effects. We report a case series of nine subjects who presented for GP ablation without fluoroscopy. Our objective is to describe a case series of GP ablation performed without the use of fluoroscopy.
Methods: A retrospective analysis was performed of nine subjects that had GP ablation performed.
Results: Nine subjects (4F) were evaluated in a retrospective analysis. The mean age was 45 ± 15 years. Using a 3D impedance based system and intracardiac echo (ICE) catheters, mapping of the right and left atrium (RA, LA) was performed without fluoroscopy. Both the RA, SVC and LA were mapped for High Amplitude Fractionated Electrograms (HAFE), Low Amplitude Fractionated Electrograms (LAFE) and parasympathetic response evoked during high-frequency stimulation (HFS). With ablation in these GP locations, HAFE was eliminated and there was no increase in HR with atropine post. After a follow-up of 6 ± 3.2 months, all nine subjects had no further symptoms. There were no complications noted.
Conclusion: GP and FA ablation has emerged as new treatment modalities. As most patients that need GP ablation are young, the need to avoid ionizing radiation is important. This case series illustrates that GP ablation can be performed safely and effectively without the use of radiation.
PP-215-1-ST Successful ablation of an epicardial left anterior-lateral accessory pathway inside the distal coronary sinus Dr Chi-Jen Weng1, MD, PHD, Cheng-Hung Li1,2, MD, Shang-Ju Wu1, MD, PHD, Yu-Cheng Hsieh1,2, MD, PHD, Shih-Ann Cheng1,2 1Taichung Veterans General Hospital, Taichung, Taiwan, 2Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, TaiwanObjectives: Catheter ablation of accessory pathway (AP) is the standard treatment for AVRT. The presence of epicardial AP is challenging for AP ablation. We presented a case with concealed left anterolateral AP, which was successfully ablated at the distal coronary sinus (CS) area.
Materials and Methods: A 45-year-old woman received electrophysiology study due to palpitation, and the event ECG showed a short RP supraventricular tachycardia. The induced supraventricular tachycardia (SVT) demonstrated retrograde eccentric atrial activation, and the SVT terminated with AV block, supporting the diagnosis of AVRT. With trans-aortic approach, we found a VA fusion signal over the left atrial appendage region (Figure IA). However, ablation at this site failed to eliminate the AP. Considering an epicardial AP, we mapped inside the CS and found a good VA fusion signal at the distal CS area (Figure IB). Radiofrequency energy (slowly titrated from 20 to 30 W) was applied at this point, and successfully eliminated the AP in 2 s. An occlusive CS venogram disclosed the successful site was at the junction of great cardiac and anterior interventricular veins (Figure II). The patient was uneventful at 6-month follow-up.
Conclusion: Although most left-sided APs cross the AV groove between the CS and the annulus fibrosus, epicardial APs might be located over the left anterolateral region. These APs could be treated from the LA appendage, left sinus of Valsalva, CS, or surgical approach. This case indicated that ablation inside the CS also provided good catheter stability for a successful epicardial AP ablation.
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FIGURE I
FIGURE IA VA fusion signal at LAA region, mapped by trans-aortic approach and during PSVT.
FIGURE IB VA fusion signal at distal CS, mapped inside the CS and during RV pacing.
FIGURE I I
FIGURE I I Occlusive CS venogram and right atrial angiography to delineate the structure in the vicinity of the successful ablation site.
PP-216-1-ST The fat and thin complexes: COUMEL'S law Dr Mohanaraj Jayakumar1, Dr Kantha Rao Narasamuloo1, Dr Saravanan Krishinan1 1Ministry of health Malaysia, Cheras, MalaysiaWe present to you a case of a 17 years old teenager whom presented with recurrent palpitations and unable to play sports due to feels palpitations upon strenuous exertion.
ECG noted narrow complex regular tachycardia, with suspicious of long RP tachycardia together with QRS alternans.
Differential of orthodromic AVRT, AT and atypical AVNRT was made. Echocardiography showed structurally normal heart.
EP study performed, AH and HV were within normal ranges. Noted similar morphology tachycardia was induced with earliest fused signal was at C5,6, eccentric activation. RVOP was not able to perform as it terminates the tachycardia. AH jump was noted during single extrastimulus.
Antegrade pacing re-induced the tachycardia and subsequently noted the change of QRS from narrow to broad to narrow. Patient claims this tachycardia is similar to his complains of palpitations.
Here, we measured the AH during the broad complex tachycardia and narrow complex tachycardia. During broad, it was 105 ms and during narrow it was 72 ms. We measured the tachycardia cycle length (TCL) during broad complex tachycardia to be longer compared to narrow complex tachycardia.
The LA was mapped at the CS 5.6 area. Earliest and fused signals seen with Kent potentials. The area was ablated. Tachycardia still persisted, and seemed like a slanting pathway. Ablated throughout the area up till CS 7,8.
After few consolidations, the tachycardia were not inducible anymore. No more eccentric activation seen either. AH Jump still present.
Post-ablation, patient is well now and able to play sports like before and asymptomatic.
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ECG on presentation
Baseline ECG during EP study AH Jump Broad and narrow complexes VA during broad complex VA during narrow complex Different TCL during broad and narrow complexes
Coumel's Law
Ablated lesions over LA PP-217-2-ST A case of atypical atrioventricular nodal reentrant tachycardia with alternating retrograde slow pathway conduction Mr Arsha Pramudya1,2, Shim Jaemin1, Chu Amy MW1,3, Anand Gankhuyag1,4, Lee Hyoung Seok1, Jeong Joo Hee1, Min Kyongjin1, Choi Yun Young1, Kim Yun Gi1, Choi Jong-Il1, Kim Young-Hoon1 1Korea University College Medicine and Korea University Medical Center, Seoul, South Korea, 2Hasna Medika Cirebon Heart Hospital, Cirebon, Indonesia, 3United Christian Hospital, Hong Kong, 4The First Central Hospital of Mongolia, Mongolia
Background: We report a case of atypical fast-slow AVNRT with alternating retrograde slow pathway conduction that successfully ablated at a typical slow pathway location.
Case Illustration: A 49-year-old male was referred to our clinic for recurrent palpitation for 7 years. The ECG during tachycardia showed regular narrow QRS tachycardia with short RP intervals with RP more than 90 ms. The patient underwent an electrophysiology study and ablation. We could induce tachycardia during RVP 600 ms. It had a narrow QRS duration, AH < HA, and AH interval of 80 ms, with the earliest A at CS ostium. The tachycardia cycle length was alternating due to alternating HA intervals (320 and 290 ms). His refractory PVC could not reset the subsequent A. V entrainment showed VAV response with cPPI-TCL 180 ms. No AH jump was observed. Our conclusion was atypical fast-slow AVNRT with alternating HA intervals. We ablated the slow pathway at typical RIE with induction of junctional rhythm during ablation. Tachycardia could not be induced despite isoproterenol. VA jump with the change of earliest A activation to proximal CS was observed after ablation.
Conclusion: The precise mechanism of atypical AVNRT remains elusive. It has been reported that atypical AVNRT uses a different fast pathway from typical AVNRT. Its reentry circuit involves both right inferior extension (RIE) and left inferior extension. In our case, we speculated that the tachycardia utilized two retrograde slow pathways alternatively due to concealed conduction. A conventional ablation at RIE was safe and effective because part of the critical tachycardia circuit.
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FIGURE 1 ECG tracing during tachycardia.
FIGURE 2 Electrogram tracing during tachycardia.
PP-218-2-ST Forbidden touch Dr Ahmad Faiz Mohd Ezanee1, Dr Leong Chew Wei1, Dr Mohanraj Jayakumar1, Dr Phang Yuen Hoong1, Dr Vijayendran Rajalingam1, Dr Kantha Rao Narasamuloo1, Dr Saravanan Krishinan1 1Hospital Sultanah Bahiyah, Alor Setar, MalaysiaObjective: This study explores the feasibility and safety of radio frequency ablation of AT under EnSite NavX mapping guidance.
Materials and Methods: Electrophysiology study and radio frequency ablation done using Ensite NavX 3D system from St Jude Medical (Abbott).
Baseline AH 60 ms (54–130 ms), HV 40 ms (31–55 ms) were normal.
PR 140 ms.
RR 600 ms.
QRS 68 ms.
QT 330 ms.
Noted narrow complex tachycardia. Long VA >50% of R-R interval.
p wave morphology during tachycardia and sinus beats was similar with paroxysmal & runs of tachycardia. Thus, suspicious focal origin from RA.
RA was mapped using 3D EnSite NavX.
During tachycardia, noted early burst atrial electropotential waves (EPW) arranged to p wave during tachycardia.
Earliest breakthrough site was identified in the Superior Vena Cava (SVC)—anteroseptal site ablation with 8 French non-irrigated catheter at 65oC, 30 watts abolished the AT promptly at 17 s. Several lesions were applied to consolidate the earliest burst signal.
Result: Post-ablation no AT observed. No inducible SVT out of programmed electrical stimulation (PES)/burst pacing from coronary sinus (CS) catheter.
Impression: Focal AT of SVC done. Successful radiofrequency ablation (RFA).
Conclusions: In conclusion, 3D system helps to protect patient and the health provider from radiation. Radio frequency ablation of AT under the guidance of EnSite NavX and conventional X-ray fluoroscopy are equally effective and safe.
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PP-219-2-ST Outcome of supraventricular tachycardia ablation in a single Centre northern Malaysia from 2016 to 2022 Dr Chew Wei Leong1 1Hospital Sultanah Bahiyah, Alor Setar, Malaysia
Objectives: To compare patient demographic, safety and clinical outcome of catheter ablation of supraventricular tachycardia (SVT) in a single centre experience in Northern Region of Malaysia.
Materials and Methods: A retrospectively collected data on cardiac ablation procedures performed from 2016 to 2022. A total of 225 patients who underwent catheter ablation for AtrioVentricular Nodal Re-entrant Tachycardia (AVNRT, 167), focal Atrial Tachycardia (AT, 35) and AtrioVentricular Re-entrant Tachycardia (AVRT, 23), were retroprospectively collected.
The aim was to compare patient baseline characteristics, demographic, safety, outcome and efficacy of conventional catheter ablation of supraventricular tachycardia (SVT).
Results: From these data, the most common gender is female. Ethnicity Malay with 150 out of total Malaysia population 32.7 million. Most common age group 20–60 years old. Overall, procedural success rate was high in the three groups. The periprocedural success rate was 99.10%, ranging from 99.39% (AVNRT) to 100% (AT). A total of 221 out of 223 patients (99.10%) had successful SVT ablation. Recurrence rate with repeat ablation was performed in 2 (0.90%). of patients.
Conclusions: Patients undergoing SVT ablation exhibit high overall success rates and low major complication rates, despite higher age, disadvantageous baseline characteristics. These data highlight the safety and efficacy of SVT ablation in patients regardless age, gender and ethnic. Although periprocedural success rate has approached 99.10%, late arrhythmia recurrence requiring repeat ablation in 0.90% of patients.
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PP-220-2-ST Left atrial flutter ablation in a patient of DVR with CS OS AT Dr Ramdeo Yadave1 1Batra Hospital, Faridabad, India
Clinical Presentation: Fifty-eight-year-old male with RHD having severe MR and AR underwent DVR. Fifteen days after DVR he developed Regular Wide QRS Tachycardia with RBBB and RAD. Baseline ECG showed Atrial flutter with positive P wave in V1 and leads II, III, and aVF suggestive of LA flutter after they treated with Diltiazem injection. LVEF was 40% with global hypokinesia may be due to tachycardiomyopathy. Taken up for 3D mapping of LA flutter.
Summary and Conclusion: LA flutter is relatively rare arrhythmia after vale surgery. But this flutter was roof dependent and having slow conducting channel from roof to anterior wall of LA.
As the channel was narrow so with single RF at 45° ad 30 W cool tip ablation lead to termination of LA Flutter but we connected and made roof line.
This patient also had AT from CS OS which was easily induced in lab which was ablated in the posterior part of CS OS with termination of AT.
Over 6 months of follow-up there was no recurrence of tachy cardia. LVEF become 50%.
PP-222-V-ST “Wolf in Sheep's clothing or sheep in Wolf's clothing”—An unusual form of preexcitation Dr Vrandha Garikapati1, Dr Krishna Kumar Mohanan Nair, Dr Narayanan Namboodiri KK, Dr Ajitkumar Valaparambil. 1Sree Chitra Tirunal Institute Of Medical Sciences And Technology, Thiruvananthapuram, IndiaPP-223-1-SCD Temporary cardiac pacing in electrical storm due to long QT syndrome—A case report Dr Huy Nguyen The Nam1, Dr, PhD Hung Pham Nhu1, Dr Tuan Nguyen Xuan1, Dr Dan Nguyen Van1 1Hanoi Heart Hospital, Ha Noi, Viet Nam
Objectives: Management of the electrical storm caused by long QT syndrome remains challenging. Current recommendations for the management of arrhythmias in the acute phase still focus primarily on cardioversion and drug administration. Temporary cardiac pacing can be a safe and effective method to terminate electrical storm.
Materials and Methods: We report a clinical case of a patient with onset of episodes of ventricular tachycardia due to the use of an anxiolytic drug (sulpiride). After 1 week of taking sulpiride, the patient developed multiple episodes of ventricular tachycardia within 24 h and required electric shocks. We decided to insert a temporary pacemaker for the purpose of pacing faster than the baseline to shorten the QT interval, in combination with beta-blockers.
Results: In the following 48 h, the patient did not have any episodes of ventricular tachycardia, we stopped the pacemaker to re-evaluate the QT interval, excluding the possibility of long QT secondary to drugs. The patient was followed up for the next 5 days and was implanted an ICD to prevent cardiac sudden death.
Conclusion: Temporary pacemaker placement may be useful to control the electrical storm caused by long QT syndrome.
PP-224-1-SCD Predicting arrhythmic event score in Brugada syndrome: Worldwide pooled analysis with internal and external validation Dr Pattara Rattanawong1, Dr Natthinee Mattanapojanat2, Dr Kumpol Chintanavilas3, Dr Dujdao Sahasthas2, Dr Tachapong Ngarmukos3, Charles Van Der Walt4, Carolyn Mead-Harvey4, Associate Professor Dan Sorajja4, Associate Professor Pattarapong Makarawate2, Professor Win-Kuang Shen4 1Massachusetts General Hospital Harvard Medical School, Boston, USA, 2Faculty of Medicine, Khon Kaen University, Thailand, Khon Kaen, Thailand, 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 4Mayo Clinic, Phoenix, USAObjectives: Brugada syndrome (BrS) is an inherited arrhythmic disease associated with major arrhythmic events (MAE). Risk predictive scores were previously developed with various performances. We develop a novel score, Predict Arrhythmic evenTs (PAT), with internal and external validation.
Materials and Methods: A systematic review was performed to identify risk factors for MAE. The odds ratios (OR) of each factor were pooled across studies. The PAT scoring scheme was developed based on pooled ORs of only significant risk factors. The cut-off point was identified as the point that maximized the Youden index. The PAT score was internally validated with 105 published Asian BrS patients (mean age:52.2 ± 12.0 years, follow-up 8.0 ± 4.1 years) and externally validated with 164 unpublished multiracial (82.2% White, 14.6% Asian, 3.0% Black, mean age 46.5 ± 14.3 years, follow-up 8.0 ± 6.9 years) BrS patients. Performances were assessed and compared with previous scores using receiver operating characteristic curve (ROC) analysis.
Results: Sixty-one studies published between 2002 and 2020 from 23 countries (n = 5134 patients) were included. Pooled ORs were estimated, indicating that 15 of 18 risk factors were significant. The PAT score was then developed accordingly. In the external validation BrS cohort, a score ≥10 predicted MAE with a sensitivity of 100.0% and specificity of 82.6% and had significantly better discrimination (ROC: 0.9611) compared to BRUGADA-RISK (ROC: 0.7427; p = 0.02), Shanghai (ROC:0.7204; p = 0.007), and Sieira et al. (ROC: 0.8213; p = 0.02) scores. The PAT predicted MAE well in both primary prevention (ROC: 0.9737) and recurrent shocks (ROC: 0.8750).
SUPPORTING DOCUMENTS
TABLE 1 Basic characteristics of included Brugada syndrome patients for internal and external validation from Thailand and the United States
Abbreviations: IQR, inter quartile range; SCA, sudden cardiac arrest; SCD, sudden cardiac death; SD, standard deviation; USA, United States of America.
ANOVA F-test p-value.
Fisher Exact p-value.
TABLE 2 Pooled odds ratio and 95% confidence interval of 15 significant predicting factors, their natural-log scale, and a linear combination of PAT scores
| Predicting factors | Studies (N) | Total population (n) | Pooled OR | 95% CI | p-value | Ln(OR) | PAT score |
| Major arrhythmic events | |||||||
| History of SCD/SCA/VT/VF | 18 | 2947 | 14.67 | 8.97–24.01 | <0.001 | 2.69 | 8 |
| VT/VF during drug challenge testing | 3 | 776 | 3.73 | 1.77–7.86 | 0.001 | 1.32 | 4 |
| Baseline ECG | |||||||
| Type-1 in peripheral leads | 2 | 438 | 8.29 | 1.69–40.63 | 0.009 | 2.12 | 6 |
| T-peak T-end 100 ms | 5 | 1045 | 4.99 | 1.99–12.54 | 0.001 | 1.61 | 5 |
| aVR sign | 4 | 323 | 4.72 | 2.19–10.21 | 0.001 | 1.55 | 5 |
| Prolong PR 200 ms | 3 | 692 | 3.40 | 1.82–6.35 | <0.001 | 1.22 | 4 |
| Fragmented QRS | 13 | 2965 | 3.08 | 1.90–4.97 | <0.001 | 1.12 | 3 |
| Early repolarization in inferolateral leads | 9 | 1524 | 2.66 | 1.65–4.28 | <0.001 | 0.98 | 3 |
| Spontaneous Type-1 | 15 | 2831 | 1.47 | 1.04–2.07 | 0.027 | 0.39 | 1a |
| History | |||||||
| Arrhythmic syncope | 7 | 2465 | 4.48 | 2.87–7.01 | <0.001 | 1.50 | 5 |
| Unclear syncope | 5 | 455 | 4.71 | 1.34–16.57 | 0.016 | 1.55 | 5 |
| Family history of SCD at <40 years | 3 | 807 | 2.03 | 1.11–3.73 | 0.022 | 0.71 | 2a |
| Atrial fibrillation | 5 | 1678 | 1.60 | 1.01–2.55 | 0.045 | 0.47 | 1a |
| Laboratory | |||||||
| Positive electrophysiology study | 13 | 1844 | 1.71 | 1.10–2.73 | 0.017 | 0.55 | 2a |
| Positive SCN5A | 11 | 1827 | 1.52 | 1.10–2.09 | 0.010 | 0.42 | 1a |
Abbreviations: CI, confidence interval; OR, odds ratio; PAT, predicting arrhythmic event for ICD therapy; SCA, sudden cardiac death; SCD, sudden cardiac death; VF, ventricular fibrillation; VT, ventricular tachycardia.
Low-impact significant predictor: SCD in the family at an age younger than 40 years old = 2, positive electrophysiology study = 2, spontaneous Type-1 ECG = 1, atrial fibrillation = 1, positive SCN5A mutation = 1.
TABLE 3 The sensitivity and specificity of Predicting Arrhythmic evenT (PAT) score ≥ 10 in predicting the overall major arrhythmic events in external validation Brugada syndrome patients (primary prevention and recurrent shocks)
| Statistic | Estimate | 95% confidence limits | |
| Sensitivity | 1.0000 | 0.7820 | 1.0000 |
| Specificity | 0.8255 | 0.7549 | 0.8827 |
| Positive Predictive Value | 0.3659 | 0.2212 | 0.5306 |
| Negative Predictive Value | 1.0000 | 0.9705 | 1.0000 |
TABLE 4 Performance comparison between Predicting Arrhythmic evenT (PAT) score and previously published scores by the receiver operating characteristic (ROC) curve analysis for the overall major arrhythmic events in external validation Brugada syndrome patients (primary prevention and recurrent shock)
| ROC statistics | ROC contrast estimation and testing | ||
| ROC model | Area (95% CI) | Estimate (95% CI) | Chi-square p-value |
| PAT | 0.9611 (0.9315, 0.9906) | Reference | — |
| Shanghai | 0.7204 (0.5556, 0.8852) | −0.2407 (−0.4142, −0.0672) | 0.007 |
| Sieira | 0.8213 (0.6998, 0.9427) | −0.1398 (−0.2603, −0.0193) | 0.02 |
| Brugada-Risk | 0.7427 (0.5742, 0.9112) | −0.2183 (−0.3974, −0.0393) | 0.02 |
TABLE 5 Performance comparison between Predicting Arrhythmic evenT (PAT) score and previously published scores by the receiver operating characteristic (ROC) curve analysis for the first major arrhythmic events in external validation Brugada syndrome patients (only primary prevention)
| ROC model | ROC statistics | ROC contrast estimation and testing | |
| Area (95% CI) | Estimate (95% CI) | Chi-square p-value | |
| PAT | 0.9737 (0.9491, 0.9983) | Reference | — |
| Shanghai | 0.8070 (0.6430, 0.9711) | −0.1667 (−0.3377, −0.0044) | 0.06 |
| Sieira | 0.8289 (0.6801, 0.9777) | −0.1448 (−0.2965, −0.0069) | 0.06 |
| Brugada-Risk | 0.8124 (0.6416, 0.9831) | −0.0912 (−0.3401, −0.0174) | 0.08 |
TABLE 6 Sensitivity and specificity for all risk scores using overall patients (combined internal and external validation), stratified by patients with primary and secondary prevention. Using the following cutoffs for risk scores: BRUGADA-RISK ≥21, Shanghai ≥7, and Sieira et al. ≥5, and PAT ≥10
| Scores | Overall | Primary prevention | Secondary prevention | |||
| Sensitivity (95% CI) | Specificity (95% CI) | Sensitivity (95% CI) | Specificity (95% CI) | Sensitivity (95% CI) | Specificity (95% CI) | |
| PAT | 0.9467 (0.8958, 0.9975) | 0.7784 (0.7199, 0.8368) | 0.9333 (0.6805, 0.9983)a | 0.8364 (0.7120, 0.9223)a | 0.9455 (0.8488, 0.9886)a | 0.2903 (0.1422, 0.4804)a |
| Shanghai | 0.0667 (0.0220, 0.1488)a | 0.9691 (0.9339, 0.9886)a | 0.0667 (0.0017, 0.3195)a | 1.0000 (0.935, 1.000)a | 0.0727 (0.0202, 0.1759)a | 0.8065 (0.6253, 0.9255)a |
| Sieira et al. | 0.6267 (0.5172, 0.7361) | 0.8711 (0.8240, 0.9183) | 0.1333 (0.0166, 0.4046)a | 0.9818 (0.9028, 0.9995)a | 0.8182 (0.7162, 0.9201) | 0.2581 (0.1040, 0.4121) |
| BRUGADA-RISK | 0.3067 (0.2023, 0.4110) | 0.7474 (0.6863, 0.8086) | 0.9333 (0.6805, 0.9983)a | 0.4727 (0.3365, 0.6120)a | 0.1273 (0.0527, 0.2448)a | 0.8387 (0.6627, 0.9455)a |
Abbreviations: CI, confidence interval; ROC, receiver operating characteristic curve.
Clopper-Pearson exact CI.
TABLE 7 Summary characteristics of individual included studies for world-wide pooled analysis of patients with Brugada syndrome
| Study/year | Study design | N | Country | Men (%) | Age (years) | Brugada ECG type | Symptomatic BrS (%) | Follow-up (months) | Risk factors used in analyses | Outcomes |
| Benito et al. (2008) | Prospective cohort | 384 | Canada | 70.8 | 45.9 ± 15.3 | I, II, III | 78.4 | 58.0 ± 48.0 | Male gender, AF, Spontaneous type 1 ECG, Hx of SCA | VF or SCD |
| Bigi et al. (2007) | Case–control study | 24 | Iran | 100.0 | 32.1 ± 13.6 | I | 54.2 | 50 | aVR signs, Hx of SCA | Clinical (syncope, aborted sudden death) and/or documented VT/VF |
| Calò et al. (2016) | Prospective cohort | 347 | Italy | 78.4 | 45 ± 13.1 | I | 20.5 | 48.0 ± 38.6 | Male gender, Hx of SCD, QRS interval ≥ 120 ms, fQRS | VF or SCD |
| Castro et al. (2006) | Case–control study | 29 | USA | 86.2 | 42.3 ± 12.2 | I | 41.4 | 42.7 ± 24.4 | TpTe | Clinical (syncope, aborted sudden death) and/or documented VT/VF |
| Chinushi et al. (2007) | Prospective cohort | 28 | Japan | 92.9 | 54 ± 14 | I, II | 46.4 | 45.0 ± 37.0 | MAE | VT/VF |
| Conte et al. (2013) | Prospective cohort | 503 | Belgium | 58.1 | 26 ± 18 | I, II | 29.4 | 29.0 ± 8.0 | MAE | Ajmaline-induced sVAs |
| De Asmundis et al. (2017) | Retrospective cohort | 289 | Belgium | 70.2 | 45 ± 16 | I | 41.5 | 120.6 ± 55.7 | SCN5A, QRS interval ≥ 120 ms, fQRS. ERP | VF or SCD |
| Deliniere et al. (2019) | Retrospective cohort | 115 | France, Romania, Switzerland | 91.3 | 45.1 ± 12.8 | I | 39.1 | N/A | positive EPS, ERP, TpTe, QRS interval ≥ 120 ms, SCN5A | VF or SCD |
| Delise et al. (2011) | Prospective cohort | 320 | Italy | 80.6 | 48 ± 6.1 | I, II, III | 67.2 | 41.8 ± 13.6 | Male gender, positive EPS, Spontaneous Type 1 ECG | VT/VF or SCD |
| Eckardt et al. (2002) | Case–control study | 23 | Germany | 61 | 46 ± 13.8 | I | 69.6 | 34.0 ± 26.0 | Hx of SCD | VT/VF or SCD or an appropriate ICD shock |
| Eckardt et al. (2005) | Prospective cohort | 212 | the Netherlands, Germany, and France | 71.7 | 45 ± 6 | I | 32.1 | 40.0 ± 50.0 | Positive EPS | VF or SCD |
| Furushima et al. (2005) | Case–control study | 24 | Japan | 95.9 | 61 ± 16 | I, II | 62.5 | 33.0 ± 16.0 | Positive EPS, Hx of SCD | VT/VF |
| Garcia-lglesias et al. (2019) | Prospective cohort | 337 | Spain | 70.33 | 41 ± 14.4 | I, II, III | 32.6 | 55.8 ± 39.35 | Positive EPS, male gender, Syncope Hx, Spontaneous Type 1 ECG, SCN5A | VT/VF or SCD or an appropriate ICD shock |
| Gasparini et al. (2002) | Case–control study | 21 | Italy | 85.7 | 34 ± 15 | I, II | 42.9 | 20.0 ± 12.0 | Hx of SCD | VT/VF |
| Giustetto et al. (2009) | Prospective cohort | 166 | Italy | 83.0 | 45 ± 14 | I, II, III | 38.0 | 30.0 ± 21.0 | Hx of SCD | VT/VF or SCD or an appropriate ICD shock |
| Giustetto et al. (2014) | Prospective cohort | 560 | Italy | 75.7 | 44.8 ± 14.2 | I | 23.6 | 62.5 ± 29.5 | AF | VT/VF or SCD or an appropriate ICD shock |
| Gonzalez Corcia et al. (2017) | Prospective cohort | 95 | Belgium | 55.8 | 12.9 ± 8.3 | I | 28.4 | 43.6 ± 25.6 | PR | VT/VF or SCD |
| Gray et al. (2017) | Prospective cohort | 54 | Australia | 81.4 | 44 ± 13 | I | 33.3 | 27.6 ± 30 | Male gender, Hx of SCD, SCN5A, Spontaneous type 1 ECG, fQRS, Syncope Hx | Clinical (syncope, aborted sudden death) and/or sustained VT/VF |
| Juang et al. (2003) | Case–control study | 10 | Taiwan | 100.0 | 46 ± 7 | I | 100.0 | 29.0 ± 17.0 | Hx of SCD, SCN5A | Appropriate ICD discharges |
| Juang et al. (2013) | Retrospective cohort | 47 | Taiwan | 93.6 | 45.3 ± 14.2 | I | 100.0 | N/A | AF | VT/VF |
| Kamakura et al. (2009) | Prospective cohort | 330 | Japan | 95.5 | 51.4 ± 14.8 | I, II | 37.3 | 48.7 ± 15.0 | Spontaneous Type 1 ECG | VF or SCD |
| Kawazoe et al. (2016) | Case–control study | 143 | Japan | 97.9 | 46 ± 12 | I, II, III | N/A | 82.8 ± 49.0 | fQRS | VF |
| Kharazi et al. (2006) | Case–control study | 12 | India | 91.7 | 46.5 ± 11.8 | I | 83.3 | 27.8 ± 11.3 | Male gender, Syncope Hx, FHx of SCD, Spontaneous type 1 ECG | VF or SCD |
| Kyun Son et al. (2014) | Retrospective cohort | 69 | South Korea | 98.6 | 46.2 ± 13.5 | I, II, III | 79.7 | 59.0 ± 46.0 | Male gender, Syncope Hx, Hx of SCD, Spontaneous Type 1 ECG | Appropriate ICD shock for VT or VF |
| Leong et al. (2018) | Retrospective cohort | 133 | United Kingdom | 68.4 | 44.5 ± 14.8 | I | 53 | 42.0 ± 26.0 | Male gender, Positive EPS, Spontaneous Type 1 ECG, ERP, fQRS | VT/VF or SCD or an appropriate ICD shock |
| Letsas et al. (2008) | Prospective cohort | 290 | Germany, France | 76.9 | 48.3 ± 14.2 | I | 30.3 | 44.9 ± 27.5 | ERP | VT/VF or SCD or an appropriate ICD shock |
| Letsas et al. (2019) | Prospective cohort | 111 | Greece | 77.5 | 45.3 ± 13.3 | I, II, III | 33.3 | 55.2 ± 42.0 | fQRS, Syncope Hx, Spontaneous Type 1 ECG | VT/VF or SCD or an appropriate ICD shock |
| Makarawate et al. (2014) | Prospective cohort | 90 | Thailand | 97.8 | 46 ± 5.6 | I | 87.8 | N/A | Male gender, Hx of SCD, Spontaneous Type 1 ECG | Appropriate ICD Shock |
| Makarawate et al. (2017) | Retrospective cohort | 40 | Thailand | 97.5 | 43.5 ± 12.7 | I | 100.0 | 28.3 ± 11.3 | SCN5A | Appropriate ICD Shock |
| Masaki et al. (2002) | Case–control study | 13 | Japan | 92.3 | 52.4 ± 11 | I, II | 23.1 | 34.0 ± 32.0 | Male gender | VT/VF or SCD |
| Maury et al. (2013) | Retrospective cohort | 325 | France | 79.4 | 47 ± 13 | I | 30.5 | 48.0 ± 34.0 | fQRS, Spontaneous type 1 ECG, PR, SCN5A | VT/VF or SCD or an appropriate ICD shock |
| Maury et al. (2015) | Retrospective cohort | 325 | France | 79.7 | 47 ± 13 | I | 27.7 | 48.0 ± 34.0 | TpTe | VT/VF or SCD or an appropriate ICD shock |
| Migliore et al. (2019) | Prospective cohort | 272 | Italy | 82 | 43 ± 12 | I | 30 | 85.0 ± 55.0 | Syncope Hx, ERP, AF, fQRS, Hx of SCD, PR | VT/VF or SCD or an appropriate ICD shock |
| Mok et al. (2004) | Prospective cohort | 50 | China | 94.0 | 53 ± 14.6 | I, II | 40.0 | 25.0 ± 11.0 | Male Gender, Hx of SCD, Positive EPS | VT/VF or SCD |
| Morita et al. (2018) | Retrospective cohort | 471 | Japan | 94.9 | 46.8 ± 13.8 | I | 30.8 | 91.0 ± 64.0 | ERP, fQRS, aVR sign, TpTe | VT/VF or SCD or an appropriate ICD shock |
| Nagase et al. (2018) | Retrospective cohort | 209 | Japan | 96 | 45 ± 14 | I | 38.3 | 56.0 ± 48.0 | ERP, fQRS | VF or an appropriate ICD shock |
| Nakano et al. (2010) | Prospective Cohort | 52 | Japan | 94.2 | 42 ± 3 | I, II, III | 53.8 | 39.0 ± 4.0 | Spontaneous Type 1 | VF |
| Ouali et al. (2011) | Retrospective cohort | 24 | Tunisia | 91.7 | 40.8 ± 13.7 | I, II | 79.1 | 26.0 ± 21.0 | Male Gender, Hx of SCD, Spontaneous type I ECG | VT/VF or SCD or an appropriate ICD shock |
| Ohkubo et al. (2007) | Prospective cohort | 34 | Japan | 97.1 | 52 ± 13 | I, II, III | 33.4 | 47.1 ± 33.7 | Positive EPS, | VT/VF or SCD or an appropriate ICD shock |
| Okamura et al. (2015) | Retrospective cohort | 218 | Japan | 96.8 | 46 ± 13 | I | 39.9 | 78.0 ± 49.0 | Positive EPS | Appropriate ICD shock, SCD |
| Olde Nordkamp et al. (2014) | Retrospective cohort | 342 | Netherlands | 59.9 | 44 ± 14 | I, II, III | 41.2 | 57.5 ± 17.3 | Syncope Hx, Hx of SCD | Aborted cardiac arrest |
| Pappone et al. (2018) | Prospective cohort | 191 | Italy | 78.5 | 39.9 ± 11.6 | I | 46.1 | N/A | Male gender | |
| Park et al. (2003) | Retrospective cohort | 15 | South Korea | 86.7 | 44 ± 10 | I, III | 86.7 | 19.0 ± 14.0 | Positive EPS | Appropriate ICD shock, syncopal VT/VF |
| Priori et al. (2002) | Prospective cohort | 200 | Italy | 76.0 | 41 ± 18 | I, II | N/A | 34.0 ± 44.0 | Positive EPS, SCN5A | SCD |
| Priori et al. (2012) | Prospective cohort | 308 | Italy | 80.2 | 47 ± 12 | I | N/A | 36.0 ± 8.0 | Male gender, fQRS, Syncope Hx | Appropriate ICD shock, SCD, VF |
| Probst et al. (2010) | Prospective cohort | 1029 | France, Germany, Italy, Netherlands | 72.4 | 45 ± 5.8 | I, II, III | 36.4 | 33.1 ± 11.7 | Male gender, Syncope Hx, Hx of SCA, Positive EPS, Spontaneous type I ECG | VT/VF or SCD or an appropriate ICD shock |
| Ragab et al. (2017) | Retrospective cohort | 132 | Netherlands | 65.1 | 47 ± 15 | I, II | 15.2 | 44.0 ± 33.0 | Male gender, SCN5A, aVR signs | VT/VF |
| Rivard et al. (2016) | Retrospective cohort | 105 | Canada | 79.0 | 46.2 ± 13.3 | I | 44.8 | 59.6 ± 16.4 | Male gender, Syncope Hx, fQRS, TpTe, ERP | Appropriate ICD shock, SCD |
| Rosso et al. (2008) | Retrospective cohort | 59 | Israel | 89.8 | 44.1 ± 14 | I, II, III | 71.2 | 45.0 ± 35.0 | Hx of SCD | Appropriate ICD shock |
| Sacher et al. (2008) | Prospective cohort | 58 | France, Germany, Netherlands | 86.2 | 47 ± 11 | I | 100.0 | 48.0 ± 36.0 | Male gender, Syncope Hx | Appropriate ICD shock, SCD, VT/VF |
| Sakamoto et al. (2016) | Case–control study | 129 | Japan | 94.6 | 52 ± 12 | I | 20.2 | 68.0 ± 37.0 | Spontaneous Type 1 | VF |
| Sakamoto et al. (2017) | Prospective cohort | 81 | Japan | 96.3 | 51 ± 12 | I | 24.7 | 69.6 ± 33.6 | Positive EPS | Appropriate ICD shock, VT/VF |
| Schukro et al. (2010) | Prospective cohort | 26 | Austria | 76.9 | 43.2 ± 11.6 | I, II, III | 42.3 | 60.7 ± 44.2 | Male gender, Spontaneous Type 1 ECG | Appropriate ICD shock |
| Sieira et al. (2015) | Prospective cohort | 363 | Belgium | 55.1 | 40.9 ± 17.2 | I, II | 0 | 73.2 ± 58.9 | Male gender, Positive EPS, Spontaneous Type 1 ECG | Appropriate ICD shock, SCD, VT/VF |
| Sieira et al. (2017) | Prospective cohort | 400 | Belgium | 58.3 | 41.1 ± 17.8 | I, II | 32.8 | 80.7 ± 57.2 | Syncope Hx, Hx of SCD | Appropriate ICD shock, SCD |
| Subramanian et al. (2019) | Retrospective cohort | 103 | India | 86.4 | 44.5 ± 12.7 | I | 11.7 | 72.1 ± 29.2 | positive EPS, ERP, fQRS, Male gender, Syncope Hx | VT/VF or SCD or an appropriate ICD shock |
| Takagi et al. (2007) | Prospective cohort | 188 | Japan | 94.7 | 53 ± 14 | I | 47.9 | 37.0 ± 16.0 | Syncope Hx | SCD, VF |
| Tse et al. (2018) | Retrospective cohort | 51 | China | 90.2 | 56 ± 2 | I, II, III | N/A | N/A | Spontaneous Type 1 ECG | Appropriate ICD shock, VT |
| Uchimura-Makita et al. (2014) | Prospective cohort | 45 | Japan | 97.8 | 45.1 ± 15.3 | I | 40.0 | 45.2 ± 37.9 | Hx of SCD | Appropriate ICD shock, SCD, VT/VF |
| Ueoka et al. (2018) | Prospective cohort | 245 | Japan | 98.0 | 46.2 ± 13 | I, II, III | 37.1 | 113.0 ± 57.0 | MAE | Appropriate ICD shock, SCD, VT/VF |
| Yamagata et al. (2017) | Prospective cohort | 415 | Japan | 97.1 | 46 ± 14 | I | 45.1 | 98.5 ± 71.6 | Male gender, Syncope Hx, Hx of SCD, AF, SCN5A, QRS interval ≥ 120 ms | Appropriate ICD shock, ACA, SCD |
Abbreviations: AF, atrial fibrillation; CI, confidence interval; ECG, electrocardiogram; EPS, electrophysiology study; ERP, early repolarization; FHx, family history; Hx, history; ICD, implantable cardioverter-defibrillator; MAE, major arrhythmic events; OR, odds ratio; N/A, not applicable; PAT, predicting arrhythmic event for ICD therapy; SCA, sudden cardiac death; SCD, sudden cardiac death; TpTe, T-peak to T-end; VF, ventricular fibrillation; VT, ventricular tachycardia.
PP-225-1-SCD A case of recurrent syncopal attack due to sinus node dysfunction with concomitant Brugada syndrome Dr Aimaduddin Mat Daud1, Dr Nor Halwani Habizal1, Dr Abdul Raqib Abd Ghani1, Dr Hartini Mohd Yusof1, Dr Yoon Kee Siow1, Dr Emma Yaakop1, Dr Sathvinder Singh Gian Singh1, Dr Chin Yung Chea1, Dr Wei Shen Chee1, Dr Kamaraj Selvaraj1, Dr Asri Ranga Abdullah Ramaiah1, Dr Abd Kahar Abd Ghapar1 1Hospital Serdang Malaysia, Kajang, Malaysia
Objectives: To report a commonly unrecognized case of Sinus Node Dysfunction with concomitant Brugada Syndrome.
Results: We present a case of a young patient who had recurrent syncopal attack with Brugada syndrome and ventricular arrhythmias. During further investigation he was also found to have sinus node dysfunction.
A 36-year-old man was referred for recurrent syncopal attack for the past 4 years. It was associated with chest discomfort, dizziness and ‘black-out’ sensation that caused him to fall and sustained injury. There were no seizure symptoms. He had no past medical illness and was not taking any medications. There was no family history of sudden cardiac death. His physical examination and blood investigation were unremarkable. His baseline ECG showed coved ST segment elevation and T inversion on leads V1, V2 consistent with Type 1 Brugada pattern. Echocardiogram findings were unremarkable. During coronary study his ECG showed persistent bradycardia of heart rate <40 beats per minute with recurrent long pause of >4 s. This was associated with dizziness similar to what he had been feeling before. The coronary arteries were normal. The diagnosis of Brugada syndrome with Sinus Node Dysfunction was made. He was put on dual chamber Implantable Cardioverter Defibrillator (DC ICD) and was discharged well a few days later.
Conclusion: Sinus node dysfunction is not a rare concomitant disorder in Brugada Syndrome; although it is still under-diagnosed. Understanding the common genetic mutations and recognizing the broad clinical manifestations of the condition will help physician in choosing an appropriate device therapy to the patient; as well as being vigilant of possible lethal cardiac arrhythmias that may arise.
SUPPORTING DOCUMENTS
PP-226-1-SCD The amalgamation of diagnostic algorithm and HCM sudden cardiac death risk score for ICD implantation Ms Andini Wardhani1,2, Mrs Rarsari Soerarso Pratikto1,2, Dr Sunu Budhi Raharjo1,2, Mr Ario Soeryo Kuncoro1,2 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, West Jakarta, Indonesia, 2National Cardiovascular Centre Harapan Kita, West Jakarta, IndonesiaObjective: To present the clinical background and steps of ICD implantation as considered management of HCM.
Case Illustration: A 22-years-old man experienced two syncopal episodes. For the past 3 years, he had made several visits with complaints of palpitation, and he was diagnosed with HOCM and treated with beta-blockers. In his recent visit, he underwent a re-assessment of ECG, TTE and stress echocardiography which revealed no LVOT obstruction with a provoked peak at mid and LVOT gradient less than 50 mmHg and was diagnosed with HCM (hypertrophic cardiomyopathy). According to the patient's history of syncope with HCM-SCD risk variables and having relatives with similar cardiac medical problems (younger brother with palpitation and diagnosed with cardiomyopathy; mother was a DCM patient with a history of CRTD implantation), the patient was referred to the arrhythmia division to undergo an EP study and considered to implant an ICD as patient's primary prevention.
Conclusion: HCM is defined as a genetic disorder of cardiac myocytes characterized by cardiac hypertrophy with the greatest involvement of the basal interventricular septum subjacent to the aortic valve. Thorough diagnostic approaches of HCM are needed to differentiate the diagnosis between HCM and HOCM. In addition to exercise restriction and appropriate drug therapy in HCM, ICD implantation was considered to prevent future syncopal episodes and sudden cardiac death in patients with HCM to improve patient quality of life.
SUPPORTING DOCUMENTS
PP-227-2-SCD Extensive clinical investigation for patient with recurrent syncope to establish diagnosis of ARVC Dr Tranggana Nugrahaputra1, Dr Giky Karwiky1, Dr Mohammad Iqbal1, Dr Chaerul Achmad1 1Department Of Cardiology And Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
Case presentation: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an uncommon and underdiagnosed cardiomyopathy characterized by the replacement of right ventricular myocardium with fibrofatty tissue. It may be asymptomatic or symptomatic and may cause abrupt cardiac death, particularly during physical activity. ARVC must be diagnosed and treated promptly in order to prevent adverse consequences such as sudden cardiac death. Here we presented 60 year old man with recurrent syncope and aborted sudden cardiac death.
A 60-year-old man was referred for recurrent five episode of syncope during activity without a firm etiological diagnosis. An electrocardiogram obtained at admission indicated sinus bradycardia with incomplete right bundle branch block, epsilon wave and frequent extra systole. During hospitalization patient experienced cardiac arrest due to polymorphic ventricular tachycardia (VT) and ventricular fibrillation (VF). Patient was admitted to secondary hospital given high dose beta-blocker and temporary pacemaker to override the extra systole.
Thus patient was referred into our cardiac center for further examination. Echocardiography, cardiac magnetic resonance and endomyocardial biopsy findings fulfilled with ARVC. The patient was diagnosed with ARVC and treated with high dose beta blocker and ICD. Follow-up for in 1 week for ICD interrogation showed good result with sensing 3.8–6.8 mV, impedance 53 Ω and threshold 1.25 V with no event of ventricular arrhythmia.
Conclusion: Patients with recurrent syncope need to get vigorous examination immediately to find the etiology and determine the appropriate management. A diagnosis of ARVC entails management of life-threatening arrhythmias with ICD implantation for the associated increased risk of sudden death.
SUPPORTING DOCUMENTS
FIGURE 1 During hospitalization patient experienced cardiac arrest due to polymorphic ventricular tachycardia (VT) and ventricular fibrillation (VF).
FIGURE 2 Myocyte degeneration and fibrofatty replacement in right ventricular mid-septal region biopsy samples.
PP-228-2-SCD Sensorineural deafness and refractory seizures: A missed connection Dr Jaskaran Singh Gujral1, Dr Dinkar Bhasin2, Dr Anunay Gupta3 1Government Medical College and Hospital Sector 32, Chandigarh, India, Chandigarh, India, 2Postgraduate Institute of Medical Education and Research, Chandigarh, India, 3Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IndiaBackground: Cardiac channelopathies, most commonly Long QT syndrome may be misdiagnosed as refractory epilepsy when in reality, these events represent convulsive syncope.
Clinical Case: A 6-year-old girl was referred to us in view of multiple episodes of loss of consciousness while running. The episodes were diagnosed as generalized tonic–clonic seizures and persisted on anti-epileptic medications. The patient also had bilateral sensorineural deafness. Her cardiovascular examination and routine blood investigations including serum electrolyte levels and transthoracic echocardiogram were normal. The initial ECG at presentation showed deep inverted T waves in the precordial leads V1–V4 with prolonged QTc of 576 ms. Beat-to-beat variability was noted in the T wave amplitude, consistent with macroscopic T wave alternans. Whole exome sequencing revealed a pathogenic homozygous splicing variation in the KCNQ1 gene. Hence the diagnosis of Jervell and Lange Nielsen syndrome was confirmed in the patient. The patient was initiated on oral propranolol. Repeat ECG showed a decrease in QTc with the resolution of T wave inversions. The patient did not have any episodes of seizures and syncope after the initiation of propranolol.
Conclusion: An ECG should be considered as a part of the evaluation of children with seizures especially if poorly responding to therapy.
SUPPORTING DOCUMENTS
FIGURE 1A 12-lead ECG at presentation. Deep inverted T waves are present in the precordial leads V1-V4(Vertical arrows) with prolonged QT interval The corrected QT interval is 576 ms. Macroscopic T wave alternans is best seen in leads V3, V4 (angled arrows). FIGURE 1B 12-lead ECG on beta-blocker therapy. There is resolution of the inverted T waves. The corrected QT interval is 438 ms.
FIGURE 2 Sanger Sequence Electropherogram of Proband and Parents showing Homozygous and heterozygous variants respectively.
PP-229-2-SCD Second degree atrioventricular block in an accessory pathway related to (WPW) syndrome and AVN dysfunction DR Ronaldi Rizkiawan1, DR Rerdin Julario1, DR Budi Baktijasa Dharmadjati1, DR Rafdi Muhammad Rafdi1, DR Ivana Purnama Dewi1 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, Surabaya, IndonesiaSyncope related to an accessory pathway and atrioventricular (AV) dysfunction is a rare condition. This condition is usually related to conduction capacity along the pathway, which sometimes necessitates immediate ablation. Proper electrophysiology study (EPS) may contribute to the best patient management. A 64-year-old female with a preexcited QRS consistent with WPW syndrome was hospitalized for syncope. ECG monitoring indicated advanced AV block events. An EPS indicated a total block was found in the AV Node, with the conduction system being completely taken over by the accessory pathway. A DDD pacemaker was implanted without accessory pathway ablation.
PP-230-2-SCD Refractory vasovagal syncope treatment with Cardioneural ablation: An early experience Dr Suraya Hani Kamsani1, Dr Rohith Stanislaus1, Dr Muhammad Izzad Johari1, Zunida Ali1, Noor Asyikin Sahat1, Amirzua Ahmad Said1, Azlina Daud1, Halmy Aziman1, Gina Dayang Manit1, Dr Surinder Kaur1, Dr Azlan Hussin1 1Electrophysiology Unit, Department of Cardiology, National Heart Institute, Kuala Lumpur, MalaysiaBackground: Vasovagal syncope (VVS) is the commonest cause of syncope, mediated by the autonomic nervous system. A promising catheter-based approach for cardioneural modulation has emerged recently.
Objectives: We examined a series of eight patients with refractory VVS who underwent cardioneural ablation (CNA) from July 2021 to July 2022.
Methods: Three-dimensional mapping system was used to create an electroanatomic map of both atria. The main ganglionated plexi were identified using anatomical assumptions and electrocardiogram analysis. These areas were then ablated. Twenty-four-hour Holter, tilt table test (TTT) and atropine challenge were performed at baseline and post-procedure to determine the outcome.
Results: Eight patients were analysed in this series (seven males, one female, mean age = 36.5 ± 14.8 years). Procedures were completed within 143.1 ± 56.9 min. The response to TTT at baseline was type 1 (mixed) in four patients, type 3 (vasodepressor) in one patient and negative in one patient. Baseline Holter showed minimum heart rate (HR) of 38.0 ± 8.1 bpm with average HR of 65.7 ± 15.8 bpm, which increased to 58.3 ± 12.8 bpm and 78.0 ± 8.4 bpm post-procedure, respectively. Pre-procedure atropine response showed an average increase in HR of 12.8 ± 24.8% from baseline, which was less dramatic post-procedure with a change of 3.6 ± 5.9%. No acute procedural complication was observed in all patients. Resolution of symptoms was seen in 7 out of eight patients. One patient was started on midodrine post-procedure with improvement in his vasodepressor syncope.
Conclusion: CNA is safe and effective in treating patients with refractory VVS. Patient selection is important to determine the outcome.
PP-231-2-SCD Diagnostic yield of an ambulatory photoplethysmography (PPG) monitor in patients with unexplained syncope Dr So Young Yang1, Dr Myung-Jin Cha1, Cha Min Soo Ch1, Dr Jun Kim1, Dr Gi-Byoung Nam1, Dr KEE-Joon Choi1 1Asan Medical Center, Seoul, South KoreaObjectives: Diagnosis of underlying arrhythmia in patients with recurrent syncope remains a problem. We investigate the impact of photoplethysmography (PPG) monitors on diagnostic yield, event prevalence, and compliance in patients with unexplained syncope.
Materials and Methods: Prospective cohort study was conducted in a single tertiary hospital. Fifty-one consecutive patients with unexplained syncope were followed with a ring-type smart wearable heart rhythm monitoring medical device which provides PPG signals to measure heart rate (HR) and spot atrial fibrillation or its burden. The data collected compared patients with newly diagnosed arrhythmias with undiagnosed patients.
Results: During the follow-up period for 1 month, arrhythmias were first diagnosed in 27 patients, and identified as the cause of syncope in nine patients. The patients wore the device for average of 386.4 h, and the average time available for signal analysis was 283.5 h.
Patients with arrhythmia had higher rate (%) of irregular pulse (11.43 ± 16.31 vs. 0.44 ± 1.33, p = 0.0137) than those without arrhythmias, and there was no significant difference in mean HR (bpm) between patients with and without arrhythmia (62.89 ± 9.31 vs. 66.09 ± 9.02, p = 0.2343). Patients with arrhythmias as the cause of syncope had a lower minimum HR (bpm) (40.17 ± 0.37 vs. 41.84 ± 2.24, p = 0.0154), and had higher rate (%) of irregular pulse (14.80 ± 24.25 vs. 3.72 ± 10.56, p = 0.0343) than those without arrhythmias as the cause of syncope.
Conclusion: In patients with unexplained recurrent syncope, continuous PPG and ECG monitoring using medical device can be a useful monitoring tool for cardiac arrhythmia detection.
PP-232-2-SCD Apical hypertrophic cardiomyopathy and sudden cardiac death: BENIGN INDEED? Assoc Prof Yae Min Park1, Dr Jeongduk Seo1, Ms Mi Suk Cha1, Prof Jaemin Shim2, Prof Jong-Il Choi2, Dr Sang Weon Park3, Prof Young-Hoon Kim2, Prof In Suck Choi1 1Gachon University Gil Medical Center, Incheon, South Korea, 2Korea University Anam Hospital, Seoul, South Korea, 3Sejong General Hospital, Bucheon, South KoreaBackground: Apical hypertrophic cardiomyopathy (HCM) is considered to have a benign prognosis in terms of cardiovascular mortality. Sudden cardiac arrest and ventricular fibrillation (VF) in patients with apical HCM is rarely reported.
Methods: Between July 2001 and May 2021, 96 HCM patients who had undergone ICD implantation from three tertiary hospitals were reviewed. We evaluated the prevalence of aborted sudden cardiac death and/or documented VF in apical HCM and known risk markers for sudden cardiac death in those populations.
Result: Fifteen patients (15.6%) were apical HCM in total population. Among apical HCM, seven patients (40.0%) presented with aborted sudden cardiac death or documented VF, therefore received ICD implantation for the secondary prevention. All seven patients had at least one risk marker suggested either 2020 ACC/AHA guideline or 2014 ESC guideline. One patient had three risk factors and two patients had two risk factors and four patients had one risk factor. Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR), personal history of unexplained syncope and non-sustained ventricular tachycardia (VT) were the common risk factors.
Conclusions: Clinical outcomes in patients with apical HCM are not always as benign as previously thought. ICD implantation should be considered in high-risk patients with apical HCM as the same manner with the septal type of HCM according to the current guideline recommendations.
PP-233-2-SCD Gastrointestinal dysfunction in postural orthostatic tachycardia syndrome and its association with health-related quality of life Ms Amy Langdon1, Ms Marie-Claire Seeley1, Ms Celine Gallagher1, Mr Eric Ong1, Associate Professor Dennia Lau1 1Centre for Heart Rhythm Disorders, Adelaide University, Adelaide, AustraliaObjectives: Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogeneous disorder with frequently occurring symptoms beyond orthostatic intolerance, palpitations, and syncope. Here we aim to characterize the prevalence and severity of gastrointestinal symptoms and their impact on overall health-related quality of life.
Materials and Methods: Consecutive patients enrolled in a POTS patient registry (OzPOTS) were included in the study. A diagnosis of POTS was confirmed via internationally recognized criteria. The Gastroparesis Cardinal Symptom Index (GCSI) was utilized to assess the prevalence and severity of gastroparesis symptoms (GCSI score >2 indicates significant gastroparesis symptoms). Health-related quality of life was assessed by the EuroQol 5 dimensions (EQ-5D-5L) questionnaire. All data were analysed in R, version 4.1.2.
Results: A total of 149 consecutive individuals (mean age 30.7 ± 11.9 years old and 95.8% female) were enrolled into the study. There was a high prevalence of gastroparesis symptoms with 133 individuals (89.3%) scoring >2 on the GCSI questionnaire whilst 16 individuals (10.7%) scored ≤2, reflecting an absence of significant gastroparesis symptoms. Overall health-related quality of life was significantly poorer in the group with GCSI score of >2 (43.6 ± 21.0) compared to those scoring ≤2 (58.3 ± 20.6; p = 0.02).
Conclusion: Gastrointestinal symptoms are highly prevalent in POTS and significantly impact quality of life. Our data call for multidisciplinary care of patients with POTS, beyond management of rate-control, volume expansion, lifestyle and exercise interventions.
PP-234-V-SCD Treatment of Exercise-Induced neurocardiogenic syncope In a young adult Dr Rui Yi Pang1, Dr Shonda Ng1, Dr Violet Hoon1 1Tan Tock Seng Hospital, SingaporeObjectives: Exercise-related neurocardiogenic syncope can be debilitating in young active patients as it may prevent them from engaging in sports. Available literature are mostly case reports on young Caucasian athletes. We present a local case of exercise-induced neurocardiogenic syncope in a young non-athlete adult.
Materials and Methods: An 18-year-old Chinese male with no medical history presented with recurrent near-syncope post-exercise since he was 14 years old. He had a syncope after resistance training with squats.
Physical examination, baseline electrocardiogram, echocardiogram and computed tomography coronary angiogram were normal. In view of his family history of sudden death, he underwent an exercise treadmill test. He completed the test with good cardiac workload, without electrocardiogram changes and arrhythmias. However, he developed near-syncope during recovery, without bradycardia or hypotension, and instead had tachycardia and hypertension during that period. He recovered spontaneously after 3 min with complaints of lethargy.
Results: The patient was diagnosed with exercise-induced neurocardiogenic syncope which was thought to be due to poor cardiovascular fitness and lower limb muscle strength. We devised a targeted progressive exercise prescription, including a graduated cool-down exercise regime. With this, we were able to minimize his post-exercise dizziness and prevent his exercise-induced syncope.
Conclusion: In the absence of structural heart disease, exercise-induced neurocardiogenic syncope should be considered. It is important to identify the exact pathophysiology and triggers to provide targeted management. We hope to share our experience in devising a patient-centered exercise prescription and hopefully conduct further studies to evaluate its effectiveness in treating exercise-induced syncope.
PP-235-1-VT Characterization of arrhythmogenic substrates for ventricular tachycardia needing surgical approach in patients with Non-Ischemic cardiomyopathy Dr Hiroshige Murata1, Dr Yu-ki Iwasaki1, Dr Takashi Nitta1, Dr Yosuke Ishii1, Dr Yuhi Fujimoto1, Dr Hiroshi Hayashi1, Dr Teppei Yamamoto1, Dr Kenji Yodogawa1, Dr Mitsuki Maruyama1, Dr Yasushi Miyauchi1, Dr Wataru Shimizu1 1Nippon Medical School, Tokyo, JapanObjective: Despite recent advances of medication and catheter ablation for ventricular tachycardia (VT), surgical approach is still necessary. The purpose of this study was to characterize arrhythmogenic substrates of VT refractory to non-surgical treatments.
Methods: We analyzed the etiology and perioperative features in 27 patients (50 ± 21 years, six females) with non-ischemic cardiomyopathy and refractory VT undergone VT surgery at our institute between 1990 and 2020.
Results: The major etiology indicated for VT surgery was hypertrophic cardiomyopathy (HCM) in 17 (63%) patients, followed by cardiac tumor in six, arrhythmogenic cardiomyopathy in three, and sarcoidosis in one patient. Their substrates were classified into three groups. First, the existence of large substrates including six aneurysms and six tumors was a reason why catheter ablations were failed. Removal of substrates and surgical cryoablation along the resection line were effective in suppressing VTs. Second, epicardial/intramural foci within left ventricular (LV) hypertrophy were observed as deep substrates of refractory VT originating from lateral/septal LV in six HCM patients. Finally, LV summit VTs in eight HCM patients had a complex substrate. Their epicardial/intramural foci were located close to anatomical obstacles. The coronary artery and rich fat-pad disturbed epicardial ablations; hence, transmural lesion should be achieved by surgical cryothermia after removal of epicardial fat. During the follow-up period after surgery (10 ± 5 years), four patients developed documented/non-documented VT, which could be treated by additional catheter ablations and/or medications.
Conclusion: Large and deep arrhythmogenic substrates with anatomical obstacles were reasons for VT surgery.
PP-236-1-VT Radiofrequency catheter ablation of idiopathic premature ventricular contractions from the mitral annulus Dr Yoshibumi Antoku1, Dr Masao Takemoto1 1Steel Memorial Yawata Hopital, Kitakyushu, JapanObjectives: We previously reported the clinical benefits of radiofrequency catheter ablation (RFCA) of premature ventricular contractions (PVCs) from the right ventricular outflow tract. PVCs from the mitral valve (MA-PVCs) also often deteriorate the patients' clinical status. This study aimed to evaluate the effect of ablating MA-PVCs with RFCA from a trans-interatrial septal approach on the clinical status in symptomatic patients with frequent MA-PVCs without structural heart disease.
Methods: The frequency of PVCs per the total heart beats by 24-h Holter monitoring and New York Heart Association (NYHA) functional class in 22 patients with MA-PVCs were evaluated before and 6 months after RFCA.
Results: Procedural success was achieved in 20 (91%) of 22 patients. Of the 22 patients, in 15 (68%) and 1 (5%) patient, a successful RFCA on the left ventricular side of the MA using the trans-interatrial septal approach and trans-coronary sinus approach was achieved. Interestingly, in four (18%) patients, a successful RFCA on the left atrial (LA) side of the MA using a trans-interatrial septal approach was achieved. Ablating MA-PVCs readily improved the NYHA functional class compared to that before. A ≥0.62 peak deflection index and ≤30 years old may be one of the important predictors of successfully ablated MA-PVCs from the LA side of the MA.
Conclusions: RFCA produces clinical benefits in patients with MA-PVCs. Further, it may be necessary to initially consider a trans-interatrial septal approach to ablate these PVCs.
PP-237-1-VT Early experience with epicardial access facilitated by carbon dioxide insufflation for ablation of ventricular arrhythmias Dr Fang Shawn Foo1, Associate Professor Raymond W Sy1,2, Dr Paolo D'Ambrosio1, Dr Luis Quininir1, Dr Joanne Irons3, Dr John Silberbauer4, Dr Kim H Chan1,2 1Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia, 2Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 3Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia, 4Royal Sussex County Hospital, Brighton, UKObjective: Epicardial access may be required in catheter ablation of ventricular tachycardias (VT). Recently, a novel method of intentional coronary vein (CV) exit with pericardial carbon dioxide (CO2) insufflation to facilitate epicardial access was described. This study describes our initial experience with this technique.
Methods: Patients undergoing epicardial VT ablation between 1 February 2021 to 31 May 2022 at the Royal Prince Alfred Hospital were included. Via femoral venous access, a branch of the coronary sinus was sub-selected and intentional CV exit was performed with a high tip load coronary angioplasty wire. A microcatheter was advanced over the wire into the pericardial space, followed by pericardial CO2 insufflation, facilitating subxiphoid pericardial puncture.
Results: Five patients underwent epicardial access for VT mapping and ablation. All patients had successful intentional CV exit and CO2 facilitated epicardial access. The mean time to successful epicardial access was 37.2 ± 17.5 min. With increasing operator experience, the fifth case required only 13 min to achieve epicardial access. There was one case of inadvertent right ventricular puncture (without haemodynamic or ventilatory compromise) due to inappropriate CO2 insufflation into the right ventricle. Epicardial access was successful on the second attempt.
Conclusion: This is the first case series of epicardial access facilitated by CO2 insufflation in Australia. This technique enabled successful epicardial access in all patients in our early experience, with no adverse outcomes from epicardial access. With increasing operator experience, this technique may allow for more widespread adoption of up-front epicardial access for the treatment of VT.
PP-238-1-VT Impact of de novo tachyarrhythmias in patients with prior acute coronary syndrome Asst Prof Youmi Hwang1, R.T Jae Hoon Kim1 1St.Vincent's Hospital, Catholic University Of Korea, Suwon, South KoreaBackground: Although the incidence of acute coronary syndrome (ACS) has increased over the decades, the overall prognosis has improved with newer stents, tailored medication, and better intervention techniques. Atrial fibrillation (AF) and ventricular arrhythmia at the time of ACS diagnosis are known indicators of a poor acute prognosis. However, there is a lack of data regarding the long-term arrhythmic impact on mortality in ACS patients. This study sought to elucidate the impact of tachyarrhythmia in patients with a history of ACS.
Methods: This study was conducted in a university hospital, and it evaluated the clinical outcomes, especially regarding cardiovascular mortality and readmission. The enrolled patients underwent percutaneous coronary intervention (PCI) for ACS between February 2004 and March 2018. Clinical information was attained by a thorough chart review.
Results: We retrospectively analyzed 560 ACS patients. We reviewed all electrocardiograms (ECGs) before and immediately after PCI, during hospitalization, and within 3 months of the index PCI. Three months after the index PCI procedure, any Holter monitoring/ECG was also reviewed for arrhythmia diagnosis. During follow-up, 91 patients were diagnosed with AF and 36 patients were diagnosed with VA. Overall mortality was related to the presence of anemia, low body mass index, low left ventricular ejection fraction after PCI, late diagnosed AF, and any VA during follow-up. Readmission was higher in patients with chronic kidney disease and newly diagnosed AF during the follow-up.
Conclusions: Diagnosis of late tachyarrhythmia during follow-up was associated with increased mortality in post-ACS patients.
SUPPORTING DOCUMENTS
PP-239-1-VT Catheter ablation of ventricular arrhythmia originating from the papillary muscle by semi-circumferential isolation Dr Tomomichi Suzuki1, Dr Keiji Nomoto1, Dr Daizo Ishihara1 1Department of Cardiology, Inazawa Municipal Hospital, Inazawa, Japan
Objective: The purpose of this study was to investigate the semi-circumferential ablation at the base of the ventricular papillary muscles (PMs) using an automated template matching.
Methods: A consecutive five patients with premature ventricular contractions (PVCs) originating from PMs enrolled in this study. Activation mapping for ventricle was performed during ventricular arrhythmias (VAs) using an electro-anatomical mapping system. Subsequently, pace mapping based on automated template matching algorithm using correlation coefficient was performed circumferentially at the base of the targeted PM to identify the potential pathway of PM VA. Radiofrequency was delivered at the best correlation site of the pacemapping. Moreover, continuous semi-circumferential catheter ablation were performed at the excellent correlation sites (correlation index ≥90%).
Results: The earliest ventricular activation sites during PVCs were detected at the left ventricular posterior papillary muscle in 3 patients, the left ventricular anterior papillary muscle in 1, and right ventricular anterior papillary muscle in 1. Perfect pacemaps were identified at the base of the targeted PMs in all patients. The maximal correlation index in each patient varied from 96.7 to 99.0% (mean 98.1 ± 0.8). The Purkinje potentials were always recorded at the perfect pacemap sites in all patients. During radiofrequency catheter ablation, a mean number of 9 ± 3.8 application were delivered. Radiofrequency catheter ablation was successful in all patients, and VA recurred in no patients during mean follow-up period of 15 ± 8 months.
Conclusion: This novel catheter ablation strategy could effectively eliminate PM VAs.
PP-240-1-VT MRI characteristics and long-term outcomes of patients with Left-Ventricular papillary muscle arrhythmias undergoing catheter ablation Ms Lukah Q. Tuan1, Ms Adriana Tokich1,2, Ms Sienna Wu1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev K. Pathak1,2,3,4 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, Australia, 4The University of Canberra, Bruce, AustraliaObjectives: Ventricular arrhythmias (VAs) originating from the left ventricular (LV) papillary muscles (PMs) can be targeted by catheter ablation (CA). However, the cardiac imaging characteristics and their relevance to the outcome of catheter ablation are not well defined.
Methods: Of the 89 patients with had PVCs activation and pace mapped to the LV PMs, 35 patients had cardiac magnetic resonance (CMR). The clinical characteristics, CMR imaging characteristics and outcomes of patients were investigated.
Results: Of the 35 patients, 21 pts (60%) had idiopathic VAs and in 14 pts (40%) the site of origin of VA was confined to endocardial scar tissue. Acute success was achieved in 85% of patients. During the 20 ± 3 months of follow-up, VA free survival was 70% after a single procedure and 78% after repeat procedure. The volume of the arrhythmogenic PAP was significantly larger in the patients with failed versus as successful ablations (5.1 ± 2.1 g vs. 3.1 ± 0.8 cm3; p < 0.001). No significant difference was observed in the shape of arrhythmogenic PAPs in the patients with failed ablations (Conical 63% and 41% Broad apex) as compared to those with effective ablations (Conical 54% and 51% Broad apex) (p = 0.89). DEA were seen in 8 pts (22%) and were not different between those with successful versus failed ablation (3 vs.5 pts).
Conclusion: Pre-procedural CMR imaging can help to assess the volume of the arrhythmogenic PM. A larger PM volume may be a predictor of more challenging ablation procedure.
PP-241-1-VT Ventricular tachycardia originating near the His-Bundle: Electrocardiographic and catheter ablation characteristics Ms Sienna Wu1,2, Ms Lukah Q. Tuan1, Ms Adriana Tokich1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev K. Pathak1,2,3,4 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, Australia, 4The University of Canberra, Bruce, AustraliaIntroduction: Premature ventricular contractions (PVCs) not uncommonly originate from the Para Hisian (PH) region. The clinical and electrophysiological (EP) characteristics of these PVCs are important to recognize given risk of injury to the conduction system.
Methods: 41 patients had PVCs activation and pace mapped to the PH region. The electrocardiographic and EP characteristics of these PH PVCs were compared in 50 patients with PVCs originating from right ventricular outflow tract (RVOT).
Results: Mean QRS width was narrower in PH PVCs (p = 0.01) and the R wave amplitude was lower in the inferior leads (p = 0.02) as compared to RVOT PVCs. PH PVCs had an R wave amplitude greater in lead I (p = 0.003) and lead aVL (p = 0.005) than RVOT PVCs. For PH PVCs earliest in RV, the R wave amplitude ratio in leads II/III was greater than those in LV (p = 0.02). All left sided PH PVCs had early transition (≤ Lead V2) while 18/26 Right sided PVCs had later transition (≥ Lead V3). Radiofrequency ablation (RFA) was used upfront in 37 pts. Cryo-ablation used upfront in 3 pts and after RFA in 1 pts. In 29 pts (71%) PVCs were eliminated; 8 (19%) had significant suppression (≤5% total residual burden) and 4 (10%) had acute recurrence (<48 h). During follow-up of 328 ± 9 months, EF normalized in 38/41(92%).
Conclusions: PVCs originating near the His-bundle have distinctive ECG characteristics which aid in recognition and mapping. Catheter ablation can generally be performed safely and effectively.
PP-242-1-VT Right ventricular pacing has short and long-term deleterious effects on ventricular physiology Ms Adriana Tokich1,2, Ms Lukah Q. Tuan1,2, Ms Sienna Wu1,2, Mr Jaganaathan Srinivasan3, Ms Natasha Jones-Lewis1, Ms Taylah Abbott1, Ms Lisa George1, Mr Troy Rimando1, Prof Rajeev K. Pathak1,2,3,4 1Canberra Heart Rhythm Centre, Garran, Australia, 2Australian National University, Canberra, Australia, 3The Canberra Hospital, Garran, Australia, 4The University of Canberra, Bruce, AustraliaObjective: To evaluate short and long term adverse effects of RV pacing (apical and septal) on RV physiology.
Methods: Consecutive pts who underwent device implantation (permanent pacemaker and implantable defibrillator) were screened. Chart review was performed to determine patient demographics, procedural details and outcomes. In patients who underwent transthoracic echocardiography (TTE) before and after (12 months and 5 years) were included in this study. The images were assessed for tricuspid regurgitation (TR), RV size and systolic function, left atrial (LA) volume and left ventricular diastolic function.
Results: Between 2006 and 2016, out of 4108 patients with device implantation, 200 patients (71% male, age 70 ± 14 years) had TTEs at baseline, 12 months and at 5 years. 170 pts. apical pacing and 30 pts had septal pacing. At baseline, 109 (54%) had no TR, 66 (33%) mild TR and 20 (10%) had moderate TR. In 160 (80%) RV size was normal with 40(20%) having mildly dilated RV. At 12 months, Mild TR was seen in 112 (56%), 39 (20%) moderate TR and 39 (9.5%) had severe TR. At 5 years, some worsening of TR in 90% with increase in RVSP and RV size was seen in 37% and 28% respectively (See table 1).
Conclusion: Long-term RV pacing has significant deleterious effects on tricuspid valve function, RV size and RV systolic function. An alternative pacing site such as His pacing can be attempted to avoid long term RV pacing complications.
SUPPORTING DOCUMENTS
PP-243-1-VT Burden of non-cardiac symptoms in postural orthostatic tachycardia syndrome: Focusing on pain and autonomic symptoms Mr Eric Ong1, Professor Dennis Lau1, Mrs Marie-Claire Seeley1, Dr Celine Gallagher1, Ms Amy Langdon1 1Flinders University, South Australia, Australia
Objectives: Autonomic symptoms and pain are highly prevalent in patients with Postural Orthostatic Tachycardia Syndrome (POTS). We aim to delineate the prevalence and severity of these symptoms in a contemporary cohort of individuals with POTS and to identify factors associated with higher pain scores.
Materials/Methods: Individuals with a physician confirmed POTS diagnosis who provided informed consent were included. Data collected included demographics, comorbidities and questionnaires including health-related quality of life (EQ-5D-5L), the Hospital Anxiety/Depression Scale and COMPASS questionnaire to determine autonomic symptom burden. Pain was self-reported on a scale from 1 to 5 within the EQ-5D-5L questionnaire. One representing no pain or discomfort, 5 representing extreme pain or discomfort. A multivariate regression model was undertaken to determine the relationship between demographics, comorbidities, questionnaire data and pain levels. All statistical analysis was undertaken in R version 4.1.2.
Results: A total of 162 individuals (mean 30 ± 11.44 years, 90.8% female) were enrolled. 149 (92%) reported presence of comorbidities, 45.68% reported migraines. Majority reported significant pain, with 67% scoring ≥3, indicating moderate to extreme pain scores. Median reported pain score was 3. Median compass score was 50.92 indicating a moderate level of autonomic dysfunction. Multivariate regression analysis demonstrated that depression, migraine and COMPASS scores were significantly associated with pain, but the model had weak overall discrimination with an adjusted R2 of 0.33.
Conclusions: Moderate to severe pain was highly prevalent in our POTS cohort. Factors contributing to high pain burden were unclear, establishing the need to understand reasons underpinning high pain scores in POTS.
PP-244-2-VT That one spot, and finally! Dr Mohanaraj Jayakumar1, Dr Kantha Rao Narasamuloo1, Dr Saravanan Krishinan1 1Hospital Sultanah Bahiyah, Alor Setar, MalaysiaWe present to you a lady 65 years old, she presented with multiple episodes of palpitations and pre-syncopal attack. She had history of Takotsubo cardiomyopathy in 2019. At the time, noted high burden PVC of 28% and episodes of nonsustained VT from Holter.
During presyncopal attack in 2021, ECG showed trigeminy with PVC morphology arising from outflow tract as inferior leads PVC were upright and earliest transition of R wave was at lead V3, which points towards LV summit or AMC region.
She was admitted and underwent ablation with Ensite 3D mapping system January 2022, her PVC was successfully terminated after mapping and noted earliest signal was at AMC region and thus ablated.
Four months later she represented with another episode of presyncopal attack, 12 lead ECG showed PVC of similar morphology as previous.
She was planned for another ablation procedure under 3D Ensite system. We mapped the RVOT first which showed earliest signal were -31 ms presystolic and late potential signals and we ablated the areas, PVC still persistent. We mapped GCV and noted earliest signal was -41 ms with presystolic and late potential signals and we ablated. The PVCs were still there.
From the maps, we saw both lesions were at opposite side. We then mapped the aortic cusps and this time we were able to connect both previous ablated lesions, we found the earliest signal between the LCC/RCC commissures at −71 ms with late potentials. With one ablation, the PVCs disappeared and she has been keeping well till now.
SUPPORTING DOCUMENTS
PP-245-2-VT Prevalence and circadian variation of prominent J waves In idiopathic VF without structural heart disease Dr Rahul Singhal1 1Fortis Heart Institute Jaipur, Jaipur, India
Background: J point & ST elevation in right precordial leads known risk factors for increased arrhythmias in structurally normal heart like Brugada syndrome (BS). However, same findings in lateral leads now considered significant due to link between early repolarization (ER), J-point elevation and/QRS slurring in inferior, lateral leads and risk of idiopathic VF (IVF).
Objective: To elucidate prevalence, circadian pattern of J wave IVF pts.
Methods: Study enrolled 30 pts.; 21 men; 38.3 years, SCA survivor, none had SHD, divided based on ± of J waves. Risk stratifies: late potentials (LPs)/24 h, TWA and QT dispersion. Results compared to 12 control with VF and no J wave.
Results: J waves were present in 12 with IVF. In 8-inferior leads while both inferior and lateral leads in 4. BS in 6 (41.1) and normal QRS in 6 (42.3). Incidence of LP in IVF with J-wave higher than in non J IVF (p = 0.01). Repolarization abnormality same among two. J-wave +, dynamic changes in LPs, pronounced at night; not found in J-wave −. VF induced by PES from RVA/OT in 7/12 J-wave syndrome pts., 4/6 BS, in all with normal ECG.
Conclusion: Showed increased prevalence of J-wave syndrome with history of IVF, consistent with previous studies. J wave was present in inferior or inferolateral leads compared to that in BS. Also, IVF patients with J waves had high incidence of LP with circadian variation and predominance in night and close association with depolarization than with repolarization abnormality.
PP-246-2-VT Non-Fluoroscopic 3D mapping/navigation using EnsiteTM NavX and RFA idiopathic VT in a pregnant lady: Case report Dr Muhammad Izzad Johari1, Yogesh Hiware2, Dr Rohith Stanislus1, Zunida Ali1, Noor Asyikin Sahat1, Amirzua Ahmad Said1, Azlina Daud1, Gina Dayang Manit1, Mohamad Halmy Aziman1, Dr Low Ming Yong1, Dr Suraya Hani Kamsani1, Dr Surinder Kaur Khelae Atma Singh1, Dr Azlan Hussin1 1National Heart Institute, Jalan Tun Razak, Malaysia, 2Abbott, MalaysiaObjective: To illustrated the feasibility of non- fluoroscopic catheter ablation in incessant ventricular tachycardia during pregnancy, guided by the Ensite NavX system.
Materials and Methods: We report our case of a pregnant lady who presented with incessant outflow tract ventricular tachycardia, which was successfully treated using non fluoroscopic techniques.
Results: A 37 years old woman, in the 26th week of her fourth pregnancy presented with recurrent syncopal episodes. ECG showed multiple runs of right outflow tract VT. Echocardiogram revealed structurally normal heart. She did not respond to treatment with beta blockers/Flecainide. Multidisciplinary consultations came to a mutual understanding that she required to undergo VT ablation. The procedure was performed under local sedation. A multipolar mapping catheter, Advisor™ HD Grid Mapping Catheter, was tracked up the IVC into the RA and up the RV outflow tract using EnsiteTM NavX Cardiac Mapping System. A voltage and Omnipolar activation map was then constructed using the Advisor™ HD Grid Mapping Catheter and the EnsiteTM NavX Cardiac Mapping System. The earliest activation point was subsequently mapped to right anteroseptal outflow tract. A sensor enabled ablation catheter, TactiCath™ Contact Force Ablation Catheter, was tracked upward by the Mapping System and non- fluoroscopically guided to the earliest activation point and the subsequent activation exit shifts was successfully ablated using radiofrequency energy. Post-ablation, she did not have any ventricular ectopics or VT despite augmentation with Isoprenaline.
Conclusion: The procedure has a safe outcome and were able to totally eliminate radiation exposure to fetus.
PP-247-2-VT Carbon dioxide insufflation technique for epicardial ventricular tachycardia ablation after failed subxiphoid surgical approach Dr Ming Yoong Low1, Dr Surinder Khelae1, Dr Khai Chih Teh1, Dr Azlan Hussin1 1National Heart Institute, Kuala Lumpur, MalaysiaObjective: To demonstrate the feasibility of coronary vein exit and CO2 insufflation technique to facilitate sub-xiphoid epicardial access for epicardial VT ablation in a patient with previous failed sub-xiphoid surgical approach.
Material and Methods: A 49-year old gentleman with background non-ischemic dilated cardiomyopathy on a single chamber ICD for resuscitated VT and chronic kidney disease was referred for VT storm. We attempted the first VT ablation via endocardial approach, ablating at the base of antero-lateral papillary muscle. The tachycardia recurred within 24 h and he was planned for re-do radiofrequency ablation (epicardial) 2 days later, via sub-xiphoid surgical approach. This attempt, however, failed as there were pericardial adhesions obstructing catheter placement. Hence, the endocardial approach was re-attempted, and the same area ablated. Patient was initiated on anti-arrhythmic agents and discharged.
He was admitted 4 months later with another VT storm. We attempted the coronary vein exit and CO2 insufflation technique for epicardial access. The distal coronary sinus was punctured with a 0.014″ guidewire and CO2 was delivered via a microcatheter. A sub-xiphoid puncture with CO2 tamponade as a marker successfully passed the ablation catheters into the pericardial space. Radiofrequency ablation was applied to the posterolateral area, with successful termination of VT.
Results: The patient was arrhythmia-free on follow-up and had no therapy delivered.
Conclusion: This case demonstrated that the coronary vein exit and CO2 insufflation technique for access in epicardial VT ablation is a viable option in patients with previous failed sub-xiphoid surgical approach due to pericardial adhesions.
SUPPORTING DOCUMENTS
The guidewire passed after surgical sub-xiphoid approach showed an obstruction at the area annotated. Sub-xiphoid puncture guided by CO2 tamponade from CO2 insufflation. After CO2 insufflation, the guidewire could be passed via a sub-xiphoid puncture to the epicardial space. PP-248-2-VT Current status of stereotactic radiotherapy for ventricular tachycardia in the Czech Republic Dr Jana Haskova1, Dr., PhD Petr Peichl1, Dr., Phd Dan Wichterle1, Dr Radek Neuwirth2, Dr Otakar Jiravsky2, Dr., PhD Jakub Cvek3, Ing Lukas Knybel3, Dr., PhD Marek Sramko1, Dr., PhD Josef Kautzner1 1Ikem, Prague, Czech Republic, 2Podlesí Hospital, Třinec, Czech Repubic, 3University Hospital, Ostrava, Czech Republic
Objectives: To describe experience with stereotactic body radiotherapy (SBRT) for VT in the Czech Republic.
Materials and Methods: Since 2014, a total of 36 patients (3 women, mean age 66 ± 9 years, 63% ischemic cardiomyopathy) underwent SBRT after a median of 2 (range: 1–5) CA (epicardial access 42%). Seventy-seven percent were on amiodarone. A dose of 25 Gy was delivered. Since 2020, 10/292 patients undergoing CA (3.4%) were enrolled in one center in a randomized trial comparing SBRT versus another CA for VT recurrences (NCT04612140).
Results: Twenty (57%) patients died during the mean follow-up of 22.5 ± 42.8 months, mainly due to the progression of heart failure, one death was SBRT-related. A total of 19 patients had a recurrence of VT during the first 3 months, 34/35 had any recurrence of VT. Overall, the number of DC shocks decreased significantly from 0.9 ± 1.9 per month in the period of 6 months before SBRT to 0.1 ± 0.3 per month in the period of 6–12 months after SBRT (p = 0.008). However, 15 patients (42.8%) had to undergo additional CA due to VT recurrences at a mean interval of 11.6 ± 23.6 months after SBRT, and 3 of them also repeated SBRT.
Conclusion: SBRT in pts with structural heart disease and failed CA decreases the number of VT therapies from ICD, although the majority underwent another CA. This may suggest a synergistic effect of both treatment modalities. The need for SBRT in an expert center is low (3.4%).
PP-249-2-VT Periaortic ventricular tachycardia in a patients with aortic valve replacement and biventricular assist device support Dr Chiao-Chin Lee1, Dr Wen Yu Lin1, Dr Yuan Hung1, Dr Wei Shiang Lin1 1Tri-Service General Hospital, Taipei, TaiwanObjectives: We present a case of drug-refractory periaortic ventricular tachycardia in a patient with biventricular assist device (BiVAD) mechanical support after aortic valve replacement.
Materials and Methods: A 65-year-old male received a BiVAD for hemodynamic support due to ventricular tachycardia (VT) storm after coronary artery bypass surgery and aortic valve replacement. Electrophysiologist was consulted for further intervention.
Results: There were no substrate modifications required according to bi-ventricular substrate mapping result. After activation mapping and paced mapping, the earliest lesion located at basal posterior septum of right ventricle (RV) was ablated successfully. The patient underwent implantable cardioverter defibrillator implantation 10 days after. BiVAD was weaned after that. Two months later, recurrent VT having the exact same QRS morphology with the previous clinical VT happened. Second ablation procedure was arranged. A SL1 long sheath was placed at left ventricular (LV) outflow tract below the prosthetic aortic valve. Electrophysiologic ECG system could record couplet premature ventricular complexes (PVCs) with two QRS morphologies (PVC1 and PVC2). The activation map demonstrated PVC1 exit breakout through RV basal septum and PVC2 exit breakout through LV basal septum, para-Hisian area. After the ablation of these sites, no PVCs was noted. Periprocedural intracardiac echocardiography showed no evidence of aortic valve injury.
Conclusion: We presented a case who had BiVAD mechanical support and underwent electrophysiologic study and ablation. Periaortic VT may happen within short period after valve replacement. It is practicable using SL1 long sheath to cross the prosthetic aortic valve without complications.
SUPPORTING DOCUMENTS.
FIGURE 1
FIGURE 2 FIGURE 3 PP-250-2-VT Safety and efficacy of ventricular tachycardia ablation at a nascent unit; a single Centre experience Dr Timothy Ryan1, Dr Sohail Popal1, Dr James Lambert1, Dr Nikola Stoyanov1,2, Dr Tim Gattorna1, Dr Rafeeq Samie1, Dr Anne Powell1,2, Dr Vince Paul1, Dr Ben King1 1Department of Cardiology, Fiona Stanley Hospital, Perth, 2Department of Cardiology, Royal Perth Hospital, Perth
Objectives: We sought to examine the activity of a recently established ventricular tachycardia (VT) service and the safety and efficacy of VT ablation at our unit.
Materials and Methods: A retrospective observational study was performed on all patients referred to the VT service at Fiona Stanley Hospital, Western Australia from 2018 until 2021. Patients undergoing VT ablation were analyzed for cardiovascular-specific adverse events, acute periprocedural hemodynamic decompensation, 6-month rate of hospitalization for heart failure/VT and 6-month rate of shocks from implantable cardioverter-defibrillator (ICD).
Results: 100 patients were referred for management of ventricular tachycardia. Adjustments to antiarrhythmic drugs occurred in 59% and ICD programming changes occurred in 49% of patients with an existing ICD. A new ICD was implanted in 22 patients and cardiac-resynchronization therapy was provided in 16 patients. 55 VT ablation procedures were performed on 47 patients including 8 epicardial, 4 cardiac stereotactic body radiotherapy and 1 alcohol ablation. Of patients undergoing ablation, 64% had ischemic cardiomyopathy and 98% had structural heart disease. The mean PAINESD Risk score was 15.1/35. Acute periprocedural hemodynamic decompensation rate was 7.3% (4 of 55 ablations) and the cardiovascular-specific adverse events rate was 3.6% (2 of 55 ablations) with no deaths. Rates of ICD shocks and hospitalization for heart failure/VT decreased from 71% and 79% in the 6-month pre-ablation to 14.6% and 19% in the 6-month post-ablation respectively.
Conclusion: Ablation for ventricular tachycardia can be performed at a nascent service with safety and efficacy comparable to current published data.
PP-254-V-VT Alcohol septal ablation as bailout in incessant ventricular tachycardia Dr Yoon Kee Siow1, Dr Nor Halwani Habizal1, Dr Hartini Mohd Yusof1, Dr Abdul Raqib Abd Ghani1, Dr Sathvinder Singh Gian Singh1, Dr Chin Yung Chea1, Dr Wei Shen Chee1, Dr Aimaduddin Mat Daud1, Dr Kamaraj Selvaraj1, Dato' Dr Asri Ranga Abdullah Ramaiah1 1Serdang Hospital, Kajang, MalaysiaObjectives: To report a challenging case of incessant ventricular tachycardia (VT).
Results: We reported a case of 32 years old male diagnosed with hypertrophic cardiomyopathy in 2020. In 2021, a single-chamber implantable cardioverter-defibrillator (ICD) was implanted for primary prophylaxis of VT. He experienced multiple ICD shocks in 2021 and early 2022 before referring to our centre. Cardiac MRI showed thickening and late gadolinium enhancement in focal basal to mid anterior and anteroseptal region. The patient was intubated with general anaesthesia. Three distinct morphologies of premature ventricular complexes (PVC) were identified during mapping: the first one was basal in origin with superior axis; the second showed pattern break which the earliest signal located at middle cardiac vein (MCV); the third one was inferior axis with transition at V3. Isochronal late activation mapping (ILAM) with HD-Grid showed deceleration zone at basal and mid-apical septal region. RFA was performed at MCV, anterobasal, mid-septum and apical region with steerable irrigated ablation catheter (TactiCath). However, the second PVC persisted and was easily induced and terminated by ventricular overdrive pacing. The procedure lasted for more than 7 h. He was then brought for alcohol septal ablation the next day. One of the septal branches was identified and total of 3 cc ethanol was introduced. VT was terminated soon after that.
Conclusion: Despite the advancement of three-dimensional mapping systems and ablation, this case is to highlight alcohol septal ablation as a bailout approach in a patient with incessant VT.
SUPPORTING DOCUMENTS
FIGURE 1 (a) ILAM mapping; (b) Targeted septal branch (yellow arrow) for alcohol septal ablation; (c) Post-alcohol septal ablation (white arrow); (d) Device electrogram showed VT and ICD shock (red arrow) delivered.
PP-255-V-VT The correlation between mapping catheters with Wavefront propagation in detecting deceleration zone Dr Yoon Kee Siow1, Dr Abdul Raqib Abd Ghani1, Dr Nor Halwani Habizal1, Dr Hartini Mohd Yusof1, Dr Sathvinder Singh Gian Singh1, Dr Chin Yung Chea1, Dr Wei Shen Chee1, Dr Aimaduddin Mat Daud1, Dr Kamaraj Selvaraj1, Dato' Dr Asri Ranga Abdullah Ramaiah1, Datuk Dr Abd Kahar Abd Ghapar1 1Serdang Hospital, MalaysiaObjectives: This case shows the correlation between different mapping catheters and propagating wavefront to detect deceleration zone of ventricular tachycardia (VT).
Results: 73 years old male, underlying ischemic heart disease and stented left anterior descending artery (LAD) in 2004. In 2020, he developed recurrent VT. Percutaneous coronary intervention (PCI) to stent restenosis of LAD was performed. Two weeks later, he was subjected to radiofrequency ablation (RFA) and subsequently implantable cardioverter-defibrillator (ICD) was implanted. One year later, he experienced multiple ICD shocks. PCI was done to mid-distal severe LAD lesion. During that admission, substrate mapping by Carto® system showed dense scar area over mid-apical anterior and basal inferior, with no area of deceleration zone. Seven months later, he was admitted again for multiple ICD shocks. During substrate mapping, HD-Grid® (HDG) demonstrated deceleration zone (isochronal crowding) (Figure a) and fractionated signals (Figure b) in apical septum. We noticed that there was rotational activation pattern described by Hattori et al. RFA was performed over apical, inferior and lateral region (Figure c). Deceleration zone was eliminated post-ablation (FIGURE d).
Conclusion: Wavefront propagation is detected in parallel manner by conventional and multi-spline mapping catheters (Figures e1 & e2). However, both catheters fail to detect the perpendicular wavefront propagation (Figures e4 & e5). HDG catheter utilizes linear and orthogonal bipoles to detect highest amplitude wavefront for more reliable results (Figures e3 & e6). Therefore, high-density mapping catheters and good tissue contact increase the detection of deceleration zone and successful rate of VT ablation.
SUPPORTING DOCUMENTS
FIGURE 1 Refer texts for details. Red arrow (right lower corner) indicates the direction of wavefront propagation.
PP-256-V-VT Health economics of LV summit versus Non-LV summit VT: A Cost-Based comparison of Non-Ischaemic cardiomyopathies Dr Abdul Rahman Mohammed1, Dr Shah Rukh Farhan1, Dr Miguel Munoz1, Dr Sing Huey Cheng1, Dr Graeme Nusca1, Dr Sachin Nayyar1 1Townsville University Hospital, Douglas, AustraliaObjective: Recurrent presentations with ventricular tachycardia (VT) represent a major cause of healthcare burden in non-ischaemic cardiomyopathy. The location of the VT exit whether at the left ventricular (LV) summit (i.e., the region at the bifurcation of the left main coronary artery) versus those elsewhere may have a different case-proposition. Understanding their cost implications can allow better financial planning for healthcare systems. We aim to characterize the costs of managing LV summit VTs versus VTs arising from other locations.
Methods: Patients with non-ischaemic cardiomyopathy and recurrent VT (11 patients) who underwent endo-epicardial mapping at a single centre from 2019 to 2021 were retrospectively reviewed. Three patients with LV summit VT were analysed against three comparable patients with clinical VTs from other locations. Data were obtained for inpatient stay costs (including bed days, allied-health services, medications, pathology), coronary care unit (CCU) days, emergency room (ER) and outpatient presentations, and cost of multiple ablation procedures (including surgical ablation).
Results: The median total cost for LV summit versus non-LV summit group was $211,328 (range: $143,637–$268,087) versus $78,495 (range: $76,005–$119,920). There was a similar cost pattern for CCU bed usage median $92,929 versus $6664; ER presentations: $10,657 versus $1173; outpatient visits: $14,476 versus $6897. The ablation costs were higher in the LV Summit group: $29,320 (range: $28,729–$58,045) against $15,451 (range: $8797–$22,245).
Conclusion: There is higher healthcare economic burden for LV summit VTs, likely associated with the costs of recurrent presentations and multiple long inpatient procedures. Further large-scale studies are needed to validate these findings.
PP-264A-1-VT Hybrid surgical Cryo-ablation and endocardial radiofrequency ablation in LVAD patients with ventricular tachycardia Dr Wood-Hay Ian Ling1, Dr Katherine Fan1, Dr Cathy Lam1, Dr Marc Cheng1, Dr CY Yung1, Dr KL Wong1, Dr Cally Ho2, Dr Timmy Au2 1Cardiac Medical Unit, Grantham Hospital, Hong Kong, 2Cardiothoracic Surgical Unit, Queen Mary Hospital, Hong KongObjective: Report efficacy and safety of cryo-ablation and endocardial radiofrequency ablation for ventricular tachycardia in patients with left ventricular assist device (LVAD).
Materials and Methods: Eight LVAD patients underwent hybrid ablation for medically refractory VT. Four presented with STEMI with LVAD implanted as INTERMACS I (Urgent group). Four had chronic heart failure and received LVAD implant as INTERMACS II (Chronic group). Mean LVEF was 16%. All patients received amiodarone, lignocaine and mexiletine. One patient received stellate ganglion block, which failed to resolve the arrhythmia. Intraoperative surgical epicardial and endocardial cryoablation at the time of LVAD implant were performed in 4 patients (Group U = 3; Group C = 1). All underwent endocardial VT ablation for recurrent VT (Group U 2.0 ± 2.8 months vs. Group C 12.3 ± 7.5 months post-LVAD).
Results: Intraoperative VT surgical and cryo-ablation successfully terminated incessant VT in 2 patients. Radiofrequency ablation achieved acute procedural success in all cases. One patient developed heart block requiring permanent pacemaker. 6-month VT-free survival was observed in 2 patients (Group U). Five patients had recurrence within 30 days of procedure. At a mean follow-up of 26 months, transplant-free survival was observed in 4 patients (Group U 3 vs. Group C 1). The cause of death was non-arrhythmia-related.
Conclusion: High-risk (INTERMACS I) patients receiving LVAD implant and hybrid approach of intraoperative cryoablation followed by endocardial VT ablation appear to have favorable VT- and transplant-free survivals than their low-risk counterparts who did not receive intraoperative ablation procedure.
SUPPORTING DOCUMENTS
| Intraoperative cryoablation | 6-month VT free survival | Transplant free survival *mean follow-up of 26 months | |
| Group U (n = 4) | 3 | 2 | 3 |
| Group C (n = 4) | 1 | 0 | 1 |
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