Safety and Efficacy of Transcatheter Aortic Valve Replacement With Continuation of Vitamin K Antagonists or Direct Oral Anticoagulants

OBJECTIVES

This study investigated whether transcatheter aortic valve replacement (TAVR) with peri-procedural continuation of oral anticoagulation is equally safe and efficacious as TAVR with peri-procedural interruption of anticoagulation.

BACKGROUND

A significant proportion of patients undergoing TAVR have an indication for long-term oral anticoagulation. The optimal peri-procedural management of such patients is unknown.

METHODS

Consecutive patients on oral anticoagulation who underwent transfemoral TAVR at 5 European centers were enrolled. Oral anticoagulation was either stopped 2 to 4 days before TAVR or continued throughout the procedure. Primary safety outcome was major bleeding. Secondary efficacy endpoints included vascular complications, stroke, and mortality.

RESULTS

Of 4,459 patients, 584 patients were treated with continuation of anticoagulation and 733 with interruption of anticoagulation. At 30 days, major or life-threatening bleedings occurred in 66 (11.3%) versus 105 (14.3%; odds ratio [OR]: 0.86; 95% confidence interval [CI]: 0.61 to 1.21; p = 0.39) and major vascular complications in 64 (11.0%) versus 90 (12.3%; OR: 0.89; CI: 0.62 to 1.27; p = 0.52) of patients with continuation and with interruption of anticoagulation, respectively. Transfusion of packed red blood cells was less often required in patients with continuation of anticoagulation (80 [13.7%] vs. 130 [17.7%]; OR: 0.59; 95% CI: 0.42 to 0.81; p = 0.001). Kaplan-Meier estimates of survival at 12 months were 85.3% in patients with continuation of anticoagulation and 84.0% in patients with interruption of anticoagulation (hazard ratio: 0.90; 95% CI: 0.73 to 1.12; p = 0.36).

CONCLUSIONS

Continuation of oral anticoagulation throughout TAVR did not increase bleeding or vascular complication rates. Moreover, packed red blood cell transfusions were less often required in patients with continuation of oral anticoagulation.

Predictors of paravalvular leak following implantation of the ACURATE neo transcatheter heart valve: the PREDICT PVL study

Objectives

Report predictors and the natural course of paravalvular leak (PVL) following implantation of the ACURATE neo transcatheter heart valve (THV).

Background

Understanding the mechanisms of PVL may help to improve patient selection, patient outcomes and the design of next-generation THVs.

Methods

A total of 30 patients (mean age 81±5 years, 47% women) undergoing transcatheter aortic valve replacement with the ACURATE neo were enrolled in the PREDICT PVL study. The effective regurgitant orifice area (EROA, in mm²) of PVL was assessed by transthoracic and transoesophageal echocardiography before discharge and at 6 months follow-up.

Results

PVL was none/trace in 10 (33%), mild in 18 (60%) and moderate in 2 (7%) patients and occurred in distinct locations with largest EROAs in the area of the left coronary cusp and its adjacent commissures. Independent predictors for EROA were implantation depth (r coefficient −1.9 mm² per mm implantation depth, p=0.01), leaflet calcification (6.2 mm² per calcification grade, p=0.03) and THV size L (7.6 mm² more than size S or M, p=0.01). At 6 months follow-up, EROA decreased by 29% from 13.7±9.7 mm² to 9.5±7.9 mm² (p<0.01). Patients with smaller EROAs were more likely to be in New York Heart Association class 1 than patients with larger EROAs (p<0.01).

Conclusions

PVL occurred predominantly in the region of the left coronary cusp and decreased by 29% during 6 months of follow-up. Our results underscore the importance of adequate patient selection and optimal implantation depth.

Improved Procedural Efficiency of Atrial Fibrillation Ablation Using a Dedicated Ablation Protocol and Lean Management

OBJECTIVES

In this study the authors hypothesized that "Lean management" within a dedicated ablation protocol could standardize the pulmonary vein isolation (PVI) procedure and improve quality.

BACKGROUND

There is a large variability in safety, effectiveness, and efficiency of PVI.

METHODS

This was a single-center prospective study with inclusion of all consecutive PVI procedures from 2017 to 2019. A 3-step intervention was introduced based on Lean management: step 1) simplification (CLOSE protocol); step 2) waste elimination (higher power shorter duration); and step 3) improved standardization (Lab Optimization Tool [LOT]). PVI was divided into steps that were tracked (in minutes) using LOT. Parameters were compared in 6-month intervals.

RESULTS

Overall, 295 patients (146 patients with LOT) were analyzed. Step 1 reduced skin-to-skin procedure duration (2017: 119 ± 21 min vs. 2018: 77 ± 15 min; p < 0.001) and variance (from 2018 to 2019 p = 0.024). Step 2 reduced the radiofrequency time (2017: 38 ± 6 min vs. 2018: 20 ± 3 min; p < 0.001) and variance (from 2018 to 2019 p < 0.001). Analysis of step 3 demonstrated that only 53% of the entire procedure length (143 ± 22 min) was used for treatment (skin-to-skin time 77 ± 16 min), the remaining time being devoted for setup (42 ± 12 min, 29%); left atrial access (16 ± 7 min, 12%); respiratory gating, left atrial map, and pseudo-circle annotation (10 ± 6 min, 7%); ablation (39 ± 10 min, 27%); and bilateral block validation (10 ± 8 min, 7%).

CONCLUSIONS

Standardization of PVI using a dedicated ablation protocol and Lean management can help to reduce procedure and radiofrequency ablation duration and variance, and increase procedural efficiency without compromising safety. To improve health care utilization, increased efficiency should become an accepted goal in addition to procedural safety and effectiveness.

MIDCAB vs OPCAB for severe coronary artery disease: a comparative study

Background/Introduction

MIDCAB (minimally invasive direct coronary artery bypass surgery) ± PCI/DES was compared to classical “off pump” coronary artery bypass surgery (OPCAB) for the treatment of severe coronary artery disease.

Purpose

We hypothesized that MIDCAB is associated with reduced perioperative morbidity and mortality.

Methods

Preoperative and postoperative clinical data were collected prospectively in 329 consecutive patients with severe coronary artery disease undergoing either a MIDCAB procedure ± PCI/DES (MIDCAB group), n=118 patients, or classical OPCAB (OPCAB group), n=211 patients, at our institution from January 2017 to July 2019. A matched analysis using the EuroSCORE II (81 patients per group) was done.

Results

The median of EuroSCORE II was 1.05 in both groups, p=1. All MIDCAB patients underwent a left-sided mini-thoracotomy and received a single LIMA-LAD graft, OPCAB patients received median 3 distal anastomoses, p&lt;0.001. Operative time was shorter in MIDCAB patients, 160min vs. 240min, p&lt;0.001. Maximum postoperative Troponin levels were lower in MIDCAB compared to OPCAB, 105 μg/l vs. 260 μg/l, p&lt;0.001. Intubation time was shorter in MIDCAB, 7.0 h vs. 9.3 h, p=0.04, as was ICU time, p=0.02. Chest tube drainage after 24 hours was lower in MIDCAB patients, 405 mL vs. 555 mL, p&lt;0.001. Transfusions of blood, platelets and fresh frozen plasma were rarely needed. Transfusion of erythrocytes were more common in OPCAB, 19%, vs. MIDCAB, 2.5%, p=0.001. A transient neurological deficit showed one (1.2%) patient in the OPCAB group, non in MIDCAB, p=0.3. A hybrid procedure was performed in 18 MIDCAB patients (22%) and 5 OPCAB patients (6.2%). In-hospital mortality was 0% in the MIDCAB group, and 1.2% in OPCAB patients, p=0.3.

Conclusions

MIDCAB is a good and safe option to treat severe coronary artery disease. MIDCAB is not only less invasive, but associated with reduced perioperative risk compared to standard OPCAB surgery even if a hybrid procedure is needed.

Funding Acknowledgement

Type of funding source: None

Thebesian Veins Draining to the Left Ventricle, Mimicking Left Ventricular Noncompaction

Left ventricular noncompaction cardiomyopathy (LVNC) was diagnosed in a 59-year-old woman, based on echocardiography. Later, diagnostic criteria were also found positive by cardiac magnetic resonance (CMR). However, coronary angiography revealed thebesian veins were causing the noncompacted appearance. The complementary role of CMR and echocardiography criteria, including flow assessment in the recesses, is discussed. (Level of Difficulty: Advanced.).

Association of biomarkers of inflammation with hospitalization for heart failure and death in patients with atrial fibrillation

Background

Hospitalization for heart failure and death are among the most common adverse clinical outcomes in patients with atrial fibrillation (AF). The underlying mechanisms are poorly understood.

Purpose

We hypothesised that inflammation, quantified by plasma levels of C-reactive protein (CRP) and interleukin 6 (IL-6), is independently associated with hospitalization for heart failure and death in a large, contemporary cohort of AF patients.

Methods

Patients with established AF and 65 years of age or older were enrolled in two large, prospective, multicentre cohort studies in Switzerland. Plasma levels of high-sensitivity (hs) CRP and IL-6 were measured from frozen EDTA plasma samples obtained at baseline. Using these two biomarkers, we calculated an inflammation score ranging from 0 to 4 (1 point for each biomarker between the 50th and 75th percentile, 2 points for each biomarker above the 75th percentile). We constructed multivariable Cox proportional hazards models to quantify the associations of hs-CRP, IL-6 and the inflammation score with time to first hospitalization for heart failure and time to all-cause mortality, respectively.

Results

A total of 3,784 patients with AF (median age 72 years, 28% women, 24% with a prior history of heart failure and 84% anticoagulation use at baseline) were followed for a median (interquartile range [IQR]) of 4.0 (2.9–5.1) years. The median (IQR) plasma levels of hs-CRP and IL-6 at baseline were 1.64 (0.81–3.69) mg/L and 3.42 (2.14–5.60) pg/mL, respectively. The incidence rates of hospitalization for heart failure and death were 3.04 and 2.80 per 100 person-years, respectively. After multivariable adjustment, both biomarkers were significantly associated with the risk of hospitalization for heart failure (per increase in 1 standard deviation [SD], adjusted hazard ratio [aHR] 1.22, 95% confidence interval [CI] 1.11–1.34 for log-transformed hs-CRP, and aHR 1.48, 95% CI 1.35–1.62 for log-transformed IL-6) and death (per increase in 1 SD, aHR 1.40, 95% CI 1.27–1.54 for log-transformed hs-CRP, and aHR 1.67, 95% CI 1.53–1.81 for log-transformed IL-6). Incidence rates of hospitalization for heart failure increased from 1.34 to 7.31 per 100 person-years across categories of the inflammation score (Figure 1). A strong relationship persisted after multivariable adjustment. Similar findings were observed for all-cause mortality.

Conclusions

Inflammation is a strong predictor of hospitalization for heart failure and death in patients with AF. Targeting inflammation may be a promising treatment strategy to improve outcomes in these patients at high risk for adverse outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation

Bioresorbable scaffold versus drug coated balloon for treatment of in-stent-restenosis – long-term outcomes of the randomized ABSORB-ISR trial

Background

Observational studies showed promising results after treatment of coronary instent-restenosis (ISR) using the everolimus-eluting bioresorbable vascular scaffold (BVS) Absorb®.

Purpose

We compared long-term outcomes after treatment of ISR with BVS versus the paclitaxel-eluting drug coated balloon (PE-DCB) SeQuent® Please, which is commonly used for treatment of ISR.

Methods

This was randomized-controlled trial of Absorb® BVS versus SeQuent® Please PE-DCB in an all-comers population with clinically relevant ISR. The patients were randomized in a 1:1 fashion. The angiographic primary endpoint was late lumen loss (LLL) at 9 months. Clinical follow-ups (FU) up to 48 months were conducted.

Results

Totally, 53 patients and lesions were enrolled. The mean age was 66.7±9.8 years, 23 (43.4%) had an acute coronary syndrome (ACS) and 16 (30.2%) were diabetic. PCI was successful in all patients. After 9 months, the mean LLL did not significantly differ between patients treated with BVS versus PE-DCB (median 0.41 (interquartile range (IQR) 0.15; 1.23)mm versus 0.27 (IQR 0.13; 0.66)mm, p=0.86). Moreover, mean lumen area on optical coherence tomography (OCT) did not significantly differ (median 5.47 (IQR 4.44; 7.69)mm2 versus 6.70 (IQR 5.00; 7.82)mm2, p=0.24). Rates of significant ISR (angiographic stenosis &gt;70%) were similar with BVS versus PE-DCB (7 (30.4%) versus 6 (27.3%), p=0.81). The target vessel revascularization rates were 9 (33.3%) versus 9 (34.6%) using the BVS versus PE-DCB (p=0.72), also highlighted in the Figure below). No stent/ scaffold thrombosis occurred during FU. The study was prematurely stopped due to withdrawal of the Absorb® BVS in September 2017.

Conclusions

In this randomized pilot study, we found no significant difference in angiographic, OCT and clinical endpoints after treatment of ISR lesions using the Absorb BVS versus SeQuent® Please PE-DCB during long-term follow-up (≥48months). However, rates of target vessel revascularization were very high in both groups (&gt;30%).

TVR and TLF with BVS or PE-DCB for ISR

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Abbott Vascular

The Admit-AF risk score: a clinical risk score for predicting hospital admissions in patients with atrial fibrillation

Background

Patients with atrial fibrillation (AF) have a high risk of hospital admissions, but there is no validated prediction tool to identify those at highest risk.

Purpose

To develop and externally validate a risk score for all-cause hospital admissions in patients with AF.

Methods

We used a prospective cohort of 2387 patients with established AF as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator (LASSO) method fit to a Cox regression model. The developed risk score was externally validated in a separate prospective, multicenter cohort of 1300 AF patients.

Results

In the derivation cohort, 891 patients (37.3%) were admitted to the hospital over a median follow-up 2.0 years. In the validation cohort, hospital admissions occurred in 719 patients (55.3%) during a median follow-up 1.9 years. The most important predictors for admission were age (75–79 years: adjusted hazard ratio [aHR], 1.33; 95% confidence interval [95% CI], 1.00–1.77; 80–84 years: aHR, 1.51; 95% CI, 1.12–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.35–2.61), prior pulmonary vein isolation (aHR, 0.74; 95% CI, 0.60–0.90), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.18; 95% CI, 1.02–1.37), prior stroke/TIA (aHR, 1.28; 95% CI, 1.10–1.50), heart failure (aHR, 1.21; 95% CI, 1.04–1.41), peripheral artery disease (aHR, 1.31; 95% CI, 1.06–1.63), cancer (aHR, 1.33; 95% CI, 1.13–1.57), renal failure (aHR, 1.18, 95% CI, 1.01–1.38), and previous falls (aHR, 1.44; 95% CI, 1.16–1.78). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in AF patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

The Admit-AF risk score

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation (Grant numbers 33CS30_1148474 and 33CS30_177520), the Foundation for Cardiovascular Research Basel and the University of Basel

Temporal trends in treatment and outcomes of patients with acute coronary syndrome and concomitant moderate to severe renal failure

Introduction

Limited information about the management and outcomes of patients with acute coronary syndromes (ACS) and moderate to severe renal failure (RF) is available owing to underrepresentation of this population in most studies.

Methods

We evaluated the use of guideline-recommended therapies and in-hospital outcomes of totally 49'191 ACS patients with normal-mild renal failure (RF) (defined as eGFR &gt;45ml/min/m2) versus moderate-severe RF (eGFR &lt;45ml/min/m2) enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2002 and 2019 according to 2-year periods.

Results

Overall, 3'478 (7.1%) patients had moderate-severe RF. They were older (65.2+12.9 versus 77.2+10.6 years) and had significantly more comorbidities (including heart failure, cerebrovascular and peripheral vascular disease). Moderate-severe RF patients received less frequently guideline-recommended drugs, including P2Y12 inhibitors, ACEI/ARBs and statins (p&lt;0.0001). Between the first and last 2-year periods, the number of patients with moderate-severe RF and number of performed percutaneous coronary interventions (PCI) increased in this cohort (p-for-trend=0.001). At the same time, in-hospital mortality significantly decreased among ACS patients with and without RF (17.5% to 10.5% and 6.0% to 3.9%, respectively, p-for-trend=0.001 for both, see Figure). Similar trends were observed for other complications, namely cardiogenic shock and reinfarction. However, major bleedings increased significantly over time in patients with and without RF (p-for-trend=0.038 and &lt;0.001, respectively).

Conclusions

Outcomes of ACS patients with moderate to severe RF improved over the last two decades. Even though the rate of PCI increased in ACS patients with moderate-severe RF, they were less likely to receive guideline-recommended therapies and still suffer a high in-hospitality mortality (&gt;10%). With respect to the increasing burden of ACS patients with RF, our study implicates that more efforts should be undertaken to further improve outcomes of those patients.

Funding Acknowledgement

Type of funding source: None

Effect of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization in women with acute heart failure

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ between women and men. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes.

Purpose

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

Results

Among 788 patients randomized, 781 completed the trial and were eligible for the primary end point analysis. Of these 288 (36.9%) were women. The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 34 female patients (23.0%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.9%; adjusted hazard ratio, 1.67 [95% CI: 1.08–2.59]; P=0.02). Clinically significant adverse events with early intensive and sustained vasodilation vs usual care included hypotension (8% vs 2%).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Cox Proportional Hazard Curve

Funding Acknowledgement

Type of funding source: None

Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry

AIMS

We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS).

METHODS AND RESULTS

We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission.

CONCLUSIONS

Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.

Use of the wearable cardioverter-defibrillator - the Swiss experience

INTRODUCTION

Sudden cardiac death caused by malignant arrhythmia can be prevented by the use of defibrillators. Although the wearable cardioverter defibrillator (WCD) can prevent such an event, its role in clinical practice is ill defined. We investigated the use of the WCD in Switzerland with emphasis on prescription rate, therapy adherence and treatment rate.

MATERIALS AND METHODS

The Swiss WCD Registry is a retrospective observational registry including patients using a WCD. Patients were included from the first WCD use in Switzerland until February 2018. Baseline characteristics and data on WCD usage were examined for the total study population, and separately for each hospital.

RESULTS

From 1 December 2011 to 18 February 2018, a total of 456 patients (67.1% of all WCDs prescribed in Switzerland and 81.1% of all prescribed in the participating hospitals) were included in the registry. Up to 2017 there was a yearly increase in the number of prescribed WCDs to a maximum of 271 prescriptions per year. The mean age of patients was 57 years (&plusmn; 14), 81 (17.8%) were female and mean left ventricular ejection fraction (EF) was 32% (&plusmn; 13). The most common indications for WCD use were new-onset ischaemic cardiomyopathy (ICM) with EF &le;35% (206 patients, 45.2%), new-onset nonischaemic cardiomyopathy (NICM) with EF &le;35% (115 patients, 25.2%), unknown arrhythmic risk (83 patients, 18.2%), bridging to implantable cardioverter-defibrillator implantation or heart transplant (37 patients, 8.1%) and congenital/inherited heart disease (15 patients, 3.3%). Median wear duration was 58 days (interquartile range [IQR] 31&ndash;94) with a median average daily wear time of 22.6 hours (IQR 20&ndash;23.2). Seventeen appropriate therapies from the WCD were delivered in the whole population (treatment rate: 3.7%) to a total of 12 patients (2.6% of all patients). The most common underlying heart disease in patients with a treatment was ICM (13/17, 76.5%). There were no inappropriate treatments.

CONCLUSION

The use of WCDs has increased in Switzerland over the years for a variety of indications. There is high therapy adherence to the WCD, and a treatment rate comparable to previously published registry data. &nbsp.

Evaluation of comprehensive geriatric assessment in older patients undergoing pacemaker implantation

Background

This study evaluated the use of comprehensive geriatric assessment (CGA) in older patients undergoing pacemaker implantation.

Methods

In this prospective cohort, CGA was performed in 197 patients ≥75 years at pacemaker implantation and yearly thereafter. CGA embraced the following domains: cognition, mobility, nutrition, activities of daily living (ADLs), and falls (with or without loss of consciousness). Based on comorbidities, the Charlson comorbidity index (CCI) was calculated. For predictive analysis, logistic regression was used.

Results

During a mean follow-up duration of 2.4 years, the incidence rates of syncope decreased from 0.46 to 0.04 events per year (p < 0.001), and that of falls without loss of consciousness from 0.27 to 0.15 (p < 0.001) before vs. after implantation. Sixty-three patients (32.0%) died. Impaired mobility (OR 2.60, 95%CI 1.22–5.54, p = 0.013), malnutrition (OR 3.26, 95%CI 1.52–7.01, p = 0.002), and a higher CCI (OR per point increase 1.25, 95%CI 1.04–1.50, p = 0.019) at baseline were significant predictors of mortality. Among 169 patients who survived for more than 1 year and thus underwent follow-up CGA, CGA domains did not deteriorate during follow-up, except for ADLs. This decline in ADLs during follow-up was the strongest predictor of later nursing home admission (OR 9.29, 95%CI 1.82–47.49, p = 0.007). Higher baseline age (OR per year increase 1.10, 95%CI 1.02–1.20, p = 0.018) and a higher baseline CCI (OR per point increase 1.32, 95%CI 1.05–1.65, p = 0.017) were associated with a decline in ADLs during follow-up.

Conclusions

CGA is useful to detect functional deficits, which are associated with mortality or nursing home admission after pacemaker implantation. The present study seems to support the use of CGA in older patients undergoing pacemaker implantation as functional deficits and falls are amenable to geriatric interventions.

Heart Rate Variability Triangular Index as a Predictor of Cardiovascular Mortality in Patients With Atrial Fibrillation

Background

Impaired heart rate variability (HRV) is associated with increased mortality in sinus rhythm. However, HRV has not been systematically assessed in patients with atrial fibrillation (AF). We hypothesized that parameters of HRV may be predictive of cardiovascular death in patients with AF.

Methods and Results

From the multicenter prospective Swiss‐AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1922 patients who were in sinus rhythm or AF. Resting ECG recordings of 5‐minute duration were obtained at baseline. Standard parameters of HRV (HRV triangular index, SD of the normal‐to‐normal intervals, square root of the mean squared differences of successive normal‐to‐normal intervals and mean heart rate) were calculated. During follow‐up, an end point committee adjudicated each cause of death. During a mean follow‐up time of 2.6±1.0 years, 143 (7.4%) patients died; 92 deaths were attributable to cardiovascular reasons. In a Cox regression model including multiple covariates (age, sex, body mass index, smoking status, history of diabetes mellitus, history of hypertension, history of stroke/transient ischemic attack, history of myocardial infarction, antiarrhythmic drugs including β blockers, oral anticoagulation), a decreased HRV index ≤ median (14.29), but not other HRV parameters, was associated with an increase in the risk of cardiovascular death (hazard ratio, 1.7; 95% CI, 1.1–2.6; P=0.01) and all‐cause death (hazard ratio, 1.42; 95% CI, 1.02–1.98; P=0.04).

Conclusions

The HRV index measured in a single 5‐minute ECG recording in a cohort of patients with AF is an independent predictor of cardiovascular mortality. HRV analysis in patients with AF might be a valuable tool for further risk stratification to guide patient management.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02105844.

Symptoms and quality of life in patients with coexistent atrial fibrillation and atrial flutter

Aims

Atrial fibrillation (AF) and atrial flutter (AFL) are two of the most common atrial arrhythmias and often coexist. Many patients with AF or AFL are symptomatic, which impacts their quality of life (QoL). The purpose of this study was to determine whether coexistent AFL represents an added burden for AF patients.

Methods

We combined baseline data from two large prospective, observational, multicenter cohort studies (BEAT-AF and Swiss-AF). All 3931 patients included in this analysis had documented AF. We obtained information on comorbidities, medication, and lifestyle factors. All participants had a clinical examination and a resting ECG. Symptom burden and QoL at the baseline examination were compared between patients with and without coexistent AFL using multivariable adjusted regression models.

Results

Overall, 809 (20.6%) patients had a history of AFL. Patients with coexistent AFL more often had history of heart failure (28% vs 23%, p = 0.01), coronary artery disease (30% vs 26%, p = 0.007), failed therapy with antiarrhythmic drugs (44% vs 29%, p < 0.001), and more often underwent AF-related interventions (36% vs 17%, p < 0.001). They were more often symptomatic (70% vs 66%, p = 0.04) and effort intolerant (OR: 1.14; 95% CI: 1.01-1.28; p = 0.04). Documented AFL on the baseline ECG was associated with more symptoms (OR: 2.30; 95% CI: 1.26-4.20; p = 0.007).

Conclusion

Our data indicates that patients with coexistent AF and AFL are more often symptomatic and report poorer quality of life compared to patients suffering from AF only.

P956Improved quality of life and symptomatic atrial fibrillation reduction in patients treated with a standardized ablation index workflow

Background/Introduction

The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied.

Purpose

To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study.

Methods

329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI.  An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits.

Results

Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively.

Conclusion

PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM.

AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire

1242The flexibility, ease of using, and leaving curve of a standardized ablation index workflow for catheter ablation of paroxysmal atrial fibrillation

Background/Introduction

The ‘CLOSE’ protocol, incorporating standardized ablation index (AI) targets in conjunction with defined inter-tag distance (ITD) has been shown to improve the acute and long-term success of pulmonary vein isolation (PVI) when treating paroxysmal atrial fibrillation (PAF). The reproducibility and learning curve for this protocol has not been studied.

Purpose

To assess the acute and long-term efficacy of CLOSE PVI across multiple operators (n = 37) in the 17-centre European study ‘VISTAX’.

Methods

329 patients with PAF (61.8% male, 61.3 ± 10.1 years) underwent PVI according to the CLOSE protocol, with target AI values for each lesion of ≥400 on the posterior wall and ≥550 on the anterior wall, and target ITD of ≤6mm. Each 3-dimensional electroanatomic map was evaluated at a core lab where adherence to each of these criteria was assessed. 281/329 patients (85.1%) fulfilled all standardized workflow requirements and were adjudicated as having their PVI per-protocol (PP). First pass PVI and acute effectiveness (adenosine-proof first pass PVI at 30-minute challenge) were recorded. Clinical effectiveness was assessed as freedom from atrial arrhythmia recurrence through 12 months recorded via transtelephonic monitoring (weekly and symptomatically), in addition to holter and electrocardiogram monitoring during 3,6,12 month follow up visits. Learning curve analysis was evaluated on all investigators.

Results

First pass PVI rates were similar in the overall (86%) and PP cohorts (85%), as was acute effectiveness (82% in both cohorts). Freedom from atrial arrhythmia at 12 months too was identical for both cohorts (79%). Total procedure time and total ablation time decreased by an average 8 minutes and 10 minutes respectively after the first procedure and then showed further steady decreases over the number of ablations performed by the investigator (Figure).  The procedural efficiencies and clinical success were reproducible across different centers. No significant deviations were found from individual sites.

Conclusion

The standardized CLOSE workflow is reproducible across centres, and is ‘forgiving’ without impacting on high efficacy of almost 80%. The learning curve is short, suggesting that the excellent clinical results can be replicated widely and easily.

Abstract Figure. Learning Curves- Procedure & Ablation

Increasing Mortality From Premature Coronary Artery Disease in Women in the Rural United States

Background

Previous reports have described a leveling off of mortality from premature coronary artery disease (CAD). In recent years, the prevalence of cardiovascular risk factors has increased in rural communities and young adults.

Methods and Results

We extracted CAD mortality rates from the Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research (CDC WONDER) database from 1999 to 2017, focusing on mortality from premature CAD (defined as <65 years of age in women) and urban–rural differences. Variations in mortality rates over time, assessed with Joinpoint regression modeling, are expressed as estimated annual percentage change (95% CI) and stratified by urbanization, sex, age, and race. Age‐adjusted mortality rates decreased for women and men. Stratification by urbanization revealed that premature CAD mortality is stagnating among women in rural areas. However, this stagnation conceals a statistically significant increase in CAD mortality rates since 2009 in women aged 55 to 64 years (estimated annual percentage change: +1.4%; 95% CI, +0.3% to +2.5%) and since 1999 in women aged 45 to 54 years (estimated annual percentage change: +0.6%; 95% CI, +0.2% to 1.0%). Since 1999, mortality has been stagnating in the youngest group (aged 35–44 years; estimated annual percentage change: +0.2%; 95% CI, −0.4% to +0.8%). Stratification by race indicated an increase in mortality rates among white rural women. Premature CAD mortality remains consistently higher in the rural versus urban United States, regardless of sex, race, and age group.

Conclusions

Premature CAD mortality rates have declined over time. However, stratification by sex and urbanization reveals disparities that would otherwise remain concealed: CAD mortality rates have increased among women from rural areas since at least 2009.

Associations of symptoms and quality of life with outcomes in patients with atrial fibrillation

OBJECTIVE

We aimed to investigate changes in atrial fibrillation (AF)-related symptoms and quality of life (QoL) over time, and their impact on prognosis.

METHODS

We prospectively followed 3836 patients with known AF for a mean of 3.7 years. Information on AF-related symptoms and QoL was obtained yearly. The primary end point was a composite of stroke or systemic embolism. Main secondary end points included stroke subtypes, all-cause mortality, cardiovascular death, hospitalisation for congestive heart failure (CHF), myocardial infarction and major bleeding. We assessed associations using multivariable, time-updated Cox proportional hazards models.

RESULTS

Mean age was 72 years, 72% were male. Patients with AF-related symptoms (66%) were younger (70 vs 74 years, p<0.0001), more often had paroxysmal AF (56% vs 37%, p<0.0001) and had lower QoL (71 vs 72 points, p=0.009). The incidence of the primary end point was 1.05 and 1.02 per 100 person-years in patients with and without symptoms, respectively. The multivariable adjusted HR (aHR) (95% CIs) for the primary end point was 1.11 (0.77 to 1.59; p=0.56) for AF-related symptoms. AF-related symptoms were not associated with any of the secondary end points. QoL was not significantly related to the primary end point (aHR per 5-point increase 0.98 (0.94 to 1.03; p=0.37)), but was significantly related to CHF hospitalisations (0.92 (0.90 to 0.94; p<0.0001)), cardiovascular death (0.90 (0.86 to 0.95; p<0.0001)) and all-cause mortality (0.88 (0.86 to 0.90; p<0.0001)).

CONCLUSIONS

AF-related symptoms were not associated with adverse outcomes and should therefore not be the basis for prognostic treatment decisions. QoL was strongly associated with CHF, cardiovascular death and all-cause mortality.

The Admit-AF risk score: A clinical risk score for predicting hospital admissions in patients with atrial fibrillation

Aims

To develop and externally validate a risk score for all-cause hospital admissions in patients with atrial fibrillation.

Methods and results

We used a prospective cohort of 2387 patients with established atrial fibrillation as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator method fit to a Cox model. The risk score was validated in a separate prospective cohort of 1300 atrial fibrillation patients. The incidence of all-cause hospital admission was 19.1 per 100 person-years in the derivation cohort and it was 26.1 per 100 person-years in the validation cohort. The most important predictors for admission were age (75–79 years: adjusted hazard ratio (aHR), 1.34; 95% confidence interval (CI), 1.01–1.78; 80–84 years: aHR, 1.50; 95% CI, 1.11–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.36–2.62), prior pulmonary vein isolation (aHR, 0.72; 95% CI, 0.58–0.88), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.17; 95% CI, 1.02–1.36), prior stroke/transient ischaemic attack (aHR, 1.26; 95% CI, 1.18–1.47), heart failure (aHR, 1.19; 95% CI, 1.03–1.39), peripheral artery disease (aHR, 1.35; 95% CI, 1.08–1.67), cancer (aHR, 1.33; 95% CI, 1.12–1.57), renal failure (aHR, 1.17; 95% CI, 0.99–1.37) and previous falls (aHR, 1.40; 95% CI, 1.13–1.74). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in atrial fibrillation patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

Relevance of New Conduction Disorders After Implantation of the ACURATE Neo Transcatheter Heart Valve in the Aortic Valve Position

The ACURATE neo transcatheter heart valve has been associated with very low rates of new conduction disorders (CDs). We assessed the clinical relevance of new CDs in patients undergoing transcatheter aortic valve replacement (TAVR) with this valve. Data of consecutive patients without a pre-existing left bundle branch block (LBBB) or a permanent pacemaker (PPM) undergoing TAVR with the ACURATE neo were analyzed from the prospective SwissTAVI registry. Patients with new CDs were compared with patients with an unchanged electrocardiogram (ECG). ACURATE neo was implanted in 203 patients (mean age 82 ± 6 years, 63% women), CDs occurred in 28 patients (22 [11%] developed a LBBB, 6 [3%] required a PPM). New CDs resulted in a longer median duration of hospitalization (7 vs 5 days, interquartile range 4 to 13 vs 3 to 8 days, p = 0.04). At 1-year follow-up, left ventricular ejection fraction was significantly lower in patients with new CDs comparedwith patients with an unchanged ECG (54% ± 13% vs 61% ± 9%, p <0.01). Kaplan-Meier estimates of survival at 1-year were 89% in patients with new CDs and 95% in patients with an unchanged ECG (hazard ratio 2.0, 95% confidence interval 0.7 to 6.2, p = 0.22). After TAVR with the self-expanding ACURATE neo valve, the rate of new CDs, including complete LBBB was low and very few patients required a new PPM. However, new CDs prolonged initial hospitalization and increased the risk for left ventricular-dysfunction at 1-year follow-up. Patients without new CDs had excellent outcomes with a very high survival rate at 1-year follow-up.