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Dijkshoorn LA, Smeding L, Pepplinkhuizen S, de Veld JA, Knops RE, Olde Nordkamp LRA. Fifteen years of subcutaneous implantable cardioverter-defibrillator therapy: Where do we stand, and what will the future hold? Heart Rhythm 2024:S1547-5271(24)02741-3. [PMID: 38908460 DOI: 10.1016/j.hrthm.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/14/2024] [Accepted: 06/15/2024] [Indexed: 06/24/2024]
Abstract
The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a feasible alternative to the transvenous ICD in the treatment of ventricular tachyarrhythmias in patients without indications for pacing or cardiac resynchronization therapy. Since its introduction, numerous innovations have been made and clinical experience has been gained, leading to its adoption in current practice and preference in certain populations. Moreover, emerging technologies like the extravascular ICD and the combination of the S-ICD with the leadless pacemaker offer new possibilities for the future. These advancements underscore the evolving role of the S-ICD in management of ventricular tachyarrhythmia. This review outlines implantation considerations, patient selection, and troubleshooting advancements in the last 15 years and provides insights into future perspectives.
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Affiliation(s)
| | - Lonneke Smeding
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Jolien A de Veld
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Reinoud E Knops
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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ElRefai M, Abouelasaad M, Conibear I, Wiles BM, Dunn AJ, Coniglio S, Zemkoho AB, Morgan J, Roberts PR. Using artificial intelligence and deep learning to optimise the selection of adult congenital heart disease patients in S-ICD screening. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00073-1. [PMID: 38871179 DOI: 10.1016/j.ipej.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/27/2024] [Accepted: 06/10/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION The risk of complications associated with transvenous ICDs make the subcutaneous implantable cardiac defibrillator (S-ICD) a valuable alternative in patients with adult congenital heart disease (ACHD). However, higher S-ICD ineligibility and higher inappropriate shock rates-mostly caused by T wave oversensing (TWO)- are observed in this population. We report a novel application of deep learning methods to screen patients for S-ICD eligibility over a longer period than conventional screening. METHODS Adult patients with ACHD and a control group of normal subjects were fitted with a 24-h Holters to record their S-ICD vectors. Their T:R ratio was analysed utilising phase space reconstruction matrices and a deep learning-based model to provide an in-depth description of the T: R variation plot for each vector. T: R variation was compared statistically using t-test. RESULTS 13 patients (age 37.4 ± 7.89 years, 61.5 % male, 6 ACHD and 7 control subjects) were enrolled. A significant difference was observed in the mean and median T: R values between the two groups (p < 0.001). There was also a significant difference in the standard deviation of T: R between both groups (p = 0.04). CONCLUSIONS T:R ratio, a main determinant for S-ICD eligibility, is significantly higher with more tendency to fluctuate in ACHD patients when compared to a population with normal hearts. We hypothesise that our novel model could be used to select S-ICD eligible patients by better characterisation of T:R ratio, reducing the risk of TWO and inappropriate shocks in the ACHD patient cohort.
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Affiliation(s)
- Mohamed ElRefai
- Cardiology Department, University Hospital of Cambridge, Cambridge, United Kingdom.
| | - Mohamed Abouelasaad
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Isobel Conibear
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Anthony J Dunn
- School of Mathematical Sciences, University of Southampton, United Kingdom; Decision Analysis Services Ltd, Basingstoke, United Kingdom
| | | | - Alain B Zemkoho
- School of Mathematical Sciences, University of Southampton, United Kingdom
| | - John Morgan
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Paul R Roberts
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Budrejko S, Zienciuk-Krajka A, Daniłowicz-Szymanowicz L, Kempa M. Comparison of Preoperative ECG Screening and Device-Based Vector Analysis in Patients Receiving a Subcutaneous Implantable Cardioverter-Defibrillator. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2186. [PMID: 38138289 PMCID: PMC10745078 DOI: 10.3390/medicina59122186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) provide protection against sudden cardiac death from outside the cardiovascular system. ECG screening is a prerequisite for implantation, but the reproducibility of its results post-operatively in the device is only partial. We aimed to compare the results of ECG screening with device-based sensing vector analysis. Materials and Methods: We screened the hospital records of all S-ICD recipients in our clinic. All of them had pre-operative ECG screening performed (primary, secondary, and alternate vectors). The results were compared with device-based vector analysis to determine the relation of the pre- and post-operative vector availability. Results: Complete ECG screening and device-based vector analysis were obtained for 103 patients. At least two acceptable vectors were found in 97.1% of the patients pre-operatively and in 96.1% post-operatively. When comparing vectors in terms of agreement (OK or FAIL) pre- and post-operatively, in 89.3% of the patients, the result for the primary vector was the same in both situations; for the secondary, it was in 84.5%, and for the alternate, it was in 74.8% of patients, respectively. In 55.3% of patients, all three vectors were labeled the same (OK or FAIL); in 37.9%, two vectors had the same result, and in 6.8%, only one vector had the same result pre- and post-operatively. The number of available vectors was the same pre- and post-operatively in 62.1% of patients, while in 15.5%, it was lower, and in 22.3% of patients, it was higher than observed during screening. Conclusions: Routine clinical pre-operative screening allowed for a good selection of candidates for S-ICD implantation. All patients had at least one vector available post-operatively. The final number of vectors available in the device-based analysis in most patients was at least the same (or higher) than during screening. The repeatability of the positive result for a single vector was high.
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Affiliation(s)
- Szymon Budrejko
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland; (A.Z.-K.); (L.D.-S.); (M.K.)
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Kohli U, von Alvensleben J, Srinivasan C. Subcutaneous Implantable Cardioverter Defibrillators in Pediatrics and Congenital Heart Disease. Card Electrophysiol Clin 2023; 15:e1-e16. [PMID: 38030336 DOI: 10.1016/j.ccep.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Subcutaneous implantable cardioverter defibrillators (S-ICDs) are being used with increased frequency in children and patients with congenital heart disease. Vascular access complexities, intracardiac shunts, and specific anatomies make these devices particularly appealing for some of these patients. Alternative screening, implantation, and programming techniques should be considered based on patient size, body habitus, anatomy, procedural history, and preference. Appropriate and inappropriate shock rates are generally comparable to those seen with transvenous devices. Complications such as infection can occur, although their severity is likely to be less than that seen with transvenous devices. Technical advances are likely to further broaden S-ICD applicability.
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Affiliation(s)
- Utkarsh Kohli
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University School of Medicine and West Virginia University Children's Heart Center, 64 Medical Center Drive, Robert C. Byrd Health Science Center, PO Box 9214, Morgantown, WV 26506-9214, USA.
| | - Johannes von Alvensleben
- Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045 720-777-1234, USA
| | - Chandra Srinivasan
- The Children's Hospital of Philadelphia; University of Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Kakarla J, Denham NC, Ishikita A, Oechslin E, Alonso-Gonzalez R, Nair K. Risk Stratification for Sudden Cardiac Death in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:414-425. [PMID: 38161672 PMCID: PMC10755789 DOI: 10.1016/j.cjcpc.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 01/03/2024]
Abstract
There has been significant progress in the prevention of sudden cardiac death in repaired tetralogy of Fallot. Contemporary cohorts report greater survival attributable to improved surgical techniques, heart failure management, and proactive strategies for risk stratification and management of ventricular arrhythmias including defibrillator implantation and ablation technology. Over the last 25 years, our understanding of predictive risk factors has also improved from invasive and more limited measures to individualized risk prediction scores based on extensive demographic, imaging, electrophysiological, and functional data. Although each of these contemporary scoring systems improves prediction, there are important differences between the study cohorts, included risk factors, and imaging modalities that can significantly affect interpretation and implementation for the individual patient. In addition, accurate phenotyping of disease complexity and anatomic repair substantially modulates this risk and the mechanism of sudden death. Routine implementation of risk stratification within repaired tetralogy of Fallot management is important and directly informs primary prevention defibrillator implantation as well as consideration for proactive invasive strategies including ventricular tachycardia ablation and pulmonary valve replacement. Assessment and risk stratification by a multidisciplinary team of experts in adult congenital heart disease are crucial and critical. Although we have increased understanding, reconciliation of these complex factors for the individual patient remains challenging and often requires careful consideration and discussion with multidisciplinary teams, patients, and their families.
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Affiliation(s)
- Jayant Kakarla
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Nathan C. Denham
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Ayako Ishikita
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Krishnakumar Nair
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
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Jacquemyn X, Kutty S, Manlhiot C. The Lifelong Impact of Artificial Intelligence and Clinical Prediction Models on Patients With Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:440-452. [PMID: 38161675 PMCID: PMC10755786 DOI: 10.1016/j.cjcpc.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/24/2023] [Indexed: 01/03/2024]
Abstract
Medical advancements in the diagnosis, surgical techniques, perioperative care, and continued care throughout childhood have transformed the outlook for individuals with tetralogy of Fallot (TOF), improving survival and shifting the perspective towards lifelong care. However, with a growing population of survivors, longstanding challenges have been accentuated, and new challenges have surfaced, necessitating a re-evaluation of TOF care. Availability of prenatal diagnostics, insufficient information from traditional imaging techniques, previously unforeseen medical complications, and debates surrounding optimal timing and indications for reintervention are among the emerging issues. To address these challenges, the integration of artificial intelligence and machine learning holds great promise as they have the potential to revolutionize patient management and positively impact lifelong outcomes for individuals with TOF. Innovative applications of artificial intelligence and machine learning have spanned across multiple domains of TOF care, including screening and diagnosis, automated image processing and interpretation, clinical risk stratification, and planning and performing cardiac interventions. By embracing these advancements and incorporating them into routine clinical practice, personalized medicine could be delivered, leading to the best possible outcomes for patients. In this review, we provide an overview of these evolving applications and emphasize the challenges, limitations, and future potential for integrating them into clinical care.
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Affiliation(s)
- Xander Jacquemyn
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Shelby Kutty
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Cedric Manlhiot
- Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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7
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Budrejko S, Zienciuk-Krajka A, Olędzki S, Daniłowicz-Szymanowicz L, Kempa M. How likely is the sense-B-noise to affect patients with subcutaneous implantable cardioverter-defibrillators and can we solve that problem in every case? Pacing Clin Electrophysiol 2023; 46:1472-1477. [PMID: 37864812 DOI: 10.1111/pace.14853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Sense-B-noise is a newly reported possible cause of inappropriate shocks in patients with subcutaneous implantable cardioverter-defibrillators (S-ICDs). The nature of that noise is unknown, it is not related to mechanical failure of the S-ICD system. Reprogramming to the secondary sensing vector is suggested by the producer as a possible solution. METHODS We analyzed the medical records of S-ICD recipients from two university clinical centers (Gdansk and Szczecin, Poland). Our aim was to determine the rate of sense-B-noise, and whether the secondary sensing vector would be available for reprogramming if such a problem occurred in our patients. RESULTS The sense-B-noise issue affected three patients in our cohort (3%), which corresponds to the incidence of 0.012 events per patient-year of follow-up. The primary vector was permanently used in 47 patients (52%), secondary in 28 (31%), and alternate in 16 (17%), respectively. Therefore, the total number of patients potentially vulnerable to sense-B noise (with the primary or alternate vector programmed permanently) was 63 (69%). Among those 63 patients, 51 individuals (81%) had also the secondary vector available for permanent use. CONCLUSION The sense-B-noise affected 3% of patients in our cohort, with an incidence of 0.012 per patient-year of follow-up. Most patients potentially vulnerable to sense-B noise could be reprogrammed to the secondary sensing vector, if necessary. Further investigation of the sense-B-noise issue is needed.
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Affiliation(s)
- Szymon Budrejko
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Agnieszka Zienciuk-Krajka
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Szymon Olędzki
- Department of Cardiology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | | | - Maciej Kempa
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
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Harris L, Burg MR, Mah DY. Subcutaneous ICD in Congenital Heart Disease: Will Skin Deep Cut It? J Am Coll Cardiol 2023; 82:600-602. [PMID: 37558372 DOI: 10.1016/j.jacc.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Louise Harris
- University Health Network Toronto General Hospital, Peter Munk Cardiac Centre, Toronto, Ontario, Canada.
| | - Melanie R Burg
- University Health Network Toronto General Hospital, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Russo V, Ciabatti M, Brunacci M, Dendramis G, Santobuono V, Tola G, Picciolo G, Teresa LM, D'Andrea A, Nesti M. Opportunities and drawbacks of the subcutaneous defibrillator across different clinical settings. Expert Rev Cardiovasc Ther 2023; 21:151-164. [PMID: 36847583 DOI: 10.1080/14779072.2023.2184350] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
INTRODUCTION The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an established therapy for the prevention of sudden cardiac death (SCD) and an alternative to a transvenous implantable cardioverter-defibrillator system in selected patients. Beyond randomized clinical trials, many observational studies have described the clinical performance of S-ICD across different subgroups of patients. AREAS COVERED Our review aimed to describe the opportunities and drawbacks of the S-ICD, focusing on their use in special populations and across different clinical settings. EXPERT OPINION The choice to implant S-ICD should be based on the patient's tailored approach, which takes into account the adequate S-ICD screening at rest or during stress, the infective risk, the ventricular arrhythmia susceptibility, the progressive nature of the underlying disease, the work or sports activity, and the risk of lead-related complications.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, University of Campania 'Luigi Vanvitelli' - Monaldi Hospital, Naples, Italy
| | | | | | | | | | | | | | | | | | - Martina Nesti
- Cardiology Unit, San Donato Hospital, Arezzo (FI), Italy
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Fortune JD, Coppa NE, Haq KT, Patel H, Tereshchenko LG. Digitizing ECG image: A new method and open-source software code. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 221:106890. [PMID: 35598436 PMCID: PMC9286778 DOI: 10.1016/j.cmpb.2022.106890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/07/2022] [Accepted: 05/12/2022] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVE We aimed to develop and validate an open-source code ECG-digitizing tool and assess agreements of ECG measurements across three types of median beats, comprised of digitally recorded simultaneous and asynchronous ECG leads and digitized asynchronous ECG leads. METHODS We used the data of clinical studies participants (n = 230; mean age 30±15 y; 25% female; 52% had the cardiovascular disease) with available both digitally recorded and printed on paper and then scanned ECGs, split into development (n = 150) and validation (n = 80) datasets. The agreement between ECG and VCG measurements on the digitally recorded time-coherent median beat, representative asynchronous digitized, and digitally recorded beats was assessed by Bland-Altman analysis. RESULTS The sample-per-sample comparison of digitally recorded and digitized signals showed a very high correlation (0.977), a small mean difference (9.3 µV), and root mean squared error (25.9 µV). Agreement between digitally recorded and digitized representative beat was high [area spatial ventricular gradient (SVG) elevation bias 2.5(95% limits of agreement [LOA] -7.9-13.0)°; precision 96.8%; inter-class correlation [ICC] 0.988; Lin's concordance coefficient ρc 0.97(95% confidence interval [CI] 0.95-0.98)]. Agreement between digitally recorded asynchronous and time-coherent median beats was moderate for area-based VCG metrics (spatial QRS-T angle bias 1.4(95%LOA -33.2-30.3)°; precision 94.8%; ICC 0.95; Lin's concordance coefficient ρc 0.90(95%CI 0.82-0.95)]. CONCLUSIONS We developed and validated an open-source software tool for paper-ECG digitization. Asynchronous ECG leads are the primary source of disagreement in measurements on digitally recorded and digitized ECGs.
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Affiliation(s)
| | | | - Kazi T Haq
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, OR, United States
| | - Hetal Patel
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, OR, United States; Chicago Medical School at Rosalind Franklin University, IL, United States
| | - Larisa G Tereshchenko
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, OR, United States; Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Larisa Tereshchenko, 9500 Euclid Ave, JJN3-01. , Cleveland, OH 44195, United States.
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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ElRefai M, Abouelasaad M, Wiles BM, Dunn AJ, Coniglio S, Zemkoho AB, Roberts PR. Deep learning-based insights on T:R ratio behaviour during prolonged screening for S-ICD eligibility. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01245-6. [PMID: 35551558 DOI: 10.1007/s10840-022-01245-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND A major predictor of eligibility of subcutaneous implantable cardiac defibrillators (S-ICD) is the T:R ratio. The eligibility cut-off of the T:R ratio incorporates a safety margin to accommodate for fluctuations of ECG signal amplitudes. We introduce a deep learning-based tool that accurately measures the degree of T:R ratio fluctuations and explore its role in S-ICD screening. METHODS Patients were fitted with Holters for 24 h to record their S-ICD vectors. Our tool was used to assess the T:R ratio over the duration of the recordings. Multiple T:R ratio cut-off values were applied, identifying patients at high risk of T-wave oversensing (TWO) at each of the proposed values. The purpose of our study is to identify the ratio that recognises patients at high risk of TWO while not inappropriately excluding true S-ICD candidates. RESULTS Thirty-seven patients (age 54.5 + / - 21.3 years, 64.8% male) were recruited. Fourteen patients had heart-failure, 7 hypertrophic cardiomyopathy, 7 had normal hearts, 6 had congenital heart disease, and 3 had prior inappropriate S-ICD shocks due to TWO. 54% of patients passed the screening at a T: R of 1:3. All patients passed the screening at a T: R of 1:1. The only subgroup to wholly pass the screening utilising all the proposed ratios are the participants with normal hearts. CONCLUSION We propose adopting prolonged screening to select patients eligible for S-ICD with low probability of TWO and inappropriate shocks. The appropriate T:R ratio likely lies between 1:3 and 1:1. Further studies are required to identify the optimal screening thresholds.
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Affiliation(s)
- Mohamed ElRefai
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Mohamed Abouelasaad
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Benedict M Wiles
- Cardiology Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony J Dunn
- School of Mathematical Sciences, University of Southampton, Southampton, UK
| | - Stefano Coniglio
- School of Mathematical Sciences, University of Southampton, Southampton, UK
| | - Alain B Zemkoho
- School of Mathematical Sciences, University of Southampton, Southampton, UK
| | - Paul R Roberts
- Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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Sudden cardiac death in adults with congenital heart disease: Lessons to Learn from the ATROPOS registry. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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14
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OUP accepted manuscript. Eur Heart J 2022; 43:2103-2115. [DOI: 10.1093/eurheartj/ehac104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/22/2022] [Accepted: 01/03/2022] [Indexed: 11/14/2022] Open
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Helman SM, Herrup EA, Christopher AB, Al-Zaiti SS. The role of machine learning applications in diagnosing and assessing critical and non-critical CHD: a scoping review. Cardiol Young 2021; 31:1770-1780. [PMID: 34725005 PMCID: PMC8805679 DOI: 10.1017/s1047951121004212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Machine learning uses historical data to make predictions about new data. It has been frequently applied in healthcare to optimise diagnostic classification through discovery of hidden patterns in data that may not be obvious to clinicians. Congenital Heart Defect (CHD) machine learning research entails one of the most promising clinical applications, in which timely and accurate diagnosis is essential. The objective of this scoping review is to summarise the application and clinical utility of machine learning techniques used in paediatric cardiology research, specifically focusing on approaches aiming to optimise diagnosis and assessment of underlying CHD. Out of 50 full-text articles identified between 2015 and 2021, 40% focused on optimising the diagnosis and assessment of CHD. Deep learning and support vector machine were the most commonly used algorithms, accounting for an overall diagnostic accuracy > 0.80. Clinical applications primarily focused on the classification of auscultatory heart sounds, transthoracic echocardiograms, and cardiac MRIs. The range of these applications and directions of future research are discussed in this scoping review.
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Affiliation(s)
- Stephanie M Helman
- Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth A Herrup
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Adam B Christopher
- Division of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Salah S Al-Zaiti
- Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
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16
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Howell S, Stivland TM, Stein K, Ellenbogen K, Tereshchenko LG. Response to cardiac resynchronisation therapy in men and women: a secondary analysis of the SMART-AV randomised controlled trial. BMJ Open 2021; 11:e049017. [PMID: 34706949 PMCID: PMC8552143 DOI: 10.1136/bmjopen-2021-049017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There is a controversy about whether both sexes' response to cardiac resynchronisation therapy (CRT) is similar. We aimed to assess a causal effect of sex on CRT response. DESIGN Secondary analysis of a randomised controlled trial (RCT) data. Doubly robust augmented-inverse-probability-weighted (AIPW) estimation of sex effect on CRT response. SETTING The SmartDelay Determined Atrioventricular (AV) Optimisation (SMART-AV) RCT. PARTICIPANTS The SMART-AV RCT enrolled New York Heart Association class III-IV patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35% despite optimal medical therapy and QRS duration ≥120 ms, in sinus rhythm. After exclusion of those with missing outcome or covariates, 741 participants (age 66±11 years; 33% female; 78% white; LVEF 28%±9%; 58% ischaemic cardiomyopathy; 75% left bundle branch block; left ventricular end-systolic volume index (LVESVI) 65±30 mL/m2) were included. INTERVENTIONS Implanted CRT defibrillator with randomly assigned AV delay as either (1) fixed at 120 ms, or (2) echocardiography-determined, or (3) SmartDelay algorithm-programmed. OUTCOME A composite of freedom from death and HF hospitalisation and a >15% reduction in LVESVI at 6 month post-CRT was the endpoint. RESULTS The primary endpoint was met by 337 patients (45.5%); 134 were women (55.6% response) and 203 were men (40.6% response); p<0.0001. After conditioning for 33 covariates that included baseline demographic, clinical, ECG, echocardiographic and biomarker characteristics, known predictors of CRT response, logistic regression showed a higher probability for composite CRT response for women versus men (OR 1.79; 95% CI 1.08 to 2.98; p<0.0001), whereas AIPW estimation showed no difference in CRT response (average treatment effect 0.88; 95% CI 0.41 to 1.89; p=0.739). After removing colliders from the model, both logistic regression (OR 1.00; 95% CI 0.69 to 1.44) and AIPW (ATE 1.06; 95% CI 0.96 to 1.16) reported similar results. CONCLUSIONS Both sexes' response to CRT is similar. Sex differences in HF substrate, treatment and comorbidities explain sex disparities in CRT outcomes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier; NCT00677014.
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Affiliation(s)
- Stacey Howell
- Department of Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | | | - Kenneth Stein
- Boston Scientific Corp, Marlborough, Massachusetts, USA
| | - Kenneth Ellenbogen
- Department of Medicine, Medical College of Virginia, Richmond, Virginia, USA
| | - Larisa G Tereshchenko
- Department of Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Zormpas C, Silber-Peest AS, Eiringhaus J, Hillmann HAK, Hohmann S, Müller-Leisse J, Westhoff-Bleck M, Veltmann C, Duncker D. Author reply: S-ICD eligibilities in adults with congenital heart disease. ESC Heart Fail 2021; 8:3444-3446. [PMID: 34121341 PMCID: PMC8318500 DOI: 10.1002/ehf2.13467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Christos Zormpas
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Jörg Eiringhaus
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Henrike A K Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johanna Müller-Leisse
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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18
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Wang L, Haq KT, Tereshchenko LG. To the editor: S-ICD eligibility in adult congenital heart disease. ESC Heart Fail 2021; 8:3440-3441. [PMID: 34036723 PMCID: PMC8318419 DOI: 10.1002/ehf2.13449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/08/2021] [Accepted: 05/16/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Linda Wang
- Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN62, Portland, OR, USA
| | - Kazi T Haq
- Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN62, Portland, OR, USA
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN62, Portland, OR, USA
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Haq KT, Howell SJ, Tereshchenko LG. Applying Artificial Intelligence to ECG Analysis: Promise of a Better Future. Circ Arrhythm Electrophysiol 2020; 13:e009111. [PMID: 32809878 DOI: 10.1161/circep.120.009111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Kazi T Haq
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
| | - Stacey J Howell
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
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