Conduction system disease management in patients candidate and/or treated for the aortic valve disease: an Italian Survey promoted by Italian Association of Arrhythmology and Cardiac Pacing (AIAC)

BACKGROUND

Conduction system disorders represent a frequent complication in patients undergoing surgical (surgical aortic valve replacement, SAVR) or percutaneous (transcatheter aortic valve implantation, TAVI) aortic valve replacement. The purpose of this survey was to evaluate experienced operators approach in this clinical condition.

METHODS

This survey was independently conducted by the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and it consisted of 24 questions regarding the respondents' profile, the characteristics of participating centres, and conduction disease management in different scenarios.

RESULTS

Fifty-five physicians from 55 Italian arrhythmia centres took part in the survey. Prophylactic pacemaker implantation is rare. In case of persistent complete atrioventricular block (AVB), 49% and 73% respondents wait less than one week before implanting a definitive pacemaker after SAVR and TAVI, respectively. In case of second degree AVB, the respondents wait some days more for definitive implantation. Respondents consider bundle branch blocks, in particular pre-existing left bundle branch block (LBBB), the worst prognostic factors for pacemaker implantation after TAVI. The implanted valve type is considered a relevant element to evaluate. In patients with new-onset LBBB and severe/moderate left ventricular systolic dysfunction, respondents would implant a biventricular pacemaker in 100/55% of cases, respectively.

CONCLUSIONS

Waiting time before a definitive pacemaker implantation after aortic valve replacement has reduced compared to the past, and it is anticipated in TAVI vs. SAVR. Bundle branch blocks are considered the worse prognostic factor for pacemaker implantation after TAVI. The type of pacemaker implanted in new-onset LBBB patients without severe left ventricular systolic dysfunction is heterogeneous.

A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy

At the beginning of the COVID-19 emergency, non-urgent surgical procedures had to be deferred, but also emergencies were reduced. To assess the global trend of pacemaker (PM) and implantable cardiac-defibrillator (ICD) procedures performed in Italy before, during, and after the first COVID-19 emergency, all the Italian hospital discharge records related to PM/ICD procedures performed between 2012 and 2021, sent to the National Institute of Health, were reviewed. Compared to 2019, in 2020, there was a reduction of first PM implants (52,216 to 43,962, -16%; p < 0.01), but not replacements (16,591 to 17,331, + 4%; p = 0.16). In particular, in April 2020, there was a drop of first implants (- 53,4% vs the average value of April 2018 and April 2019; p < 0.01), while the reduction of replacements was less evident (-32.6%; p = NS). In 2021, PM procedures increased to values similar to the pre-pandemic period. A reduction of ICD procedures was observed in 2020 (22,355, -7% toward 2019), mainly in April 2020 (- 46% vs April 2018/April 2019; p = 0.03). In 2021, the rate of ICD procedures increased (+ 14% toward 2020). A non-significant reduction of "urgent" procedures (complete atrioventricular block for PM and ventricular fibrillation for ICD), even in April 2020, was observed. In 2020, there was a reduction of first PM implants and ICDs, offset by increased activity in 2021. No decrease in PM replacements was observed, and the drop in "urgent" PM and ICD procedures was not statistically significant.

REducing INFectiOns thRough Cardiac device Envelope: insight from real world data. The REINFORCE project

AIMS

Infections resulting from cardiac implantable electronic device (CIED) implantation are severely impacting on patients' and on health care systems. The use of TYRXTM absorbable antibiotic-eluting envelope has proven to decrease major CIED infections within 12 months of CIED surgery. The aim is to evaluate the impact of the envelope use on infection-related clinical events in a real-world contemporary patient population.

METHODS AND RESULTS

Data on patients undergoing CIED surgery were collected prospectively by participating centers of the One Hospital ClinicalService project. Patients were divided into two groups according to whether TYRXTM absorbable antibiotic-eluting envelope was used or not. Out of 1819 patients, 872 (47.9%) were implanted with an absorbable antibiotic-eluting envelope and included in the Envelope group and 947 (52.1%) patients who did not receive an envelope were included in the Control group. Compared to control, patients in the Envelope group had higher thrombo-embolic or hemorrhagic risk, higher BMI, lower LVEF and more comorbidities. During a mean follow-up of 1.4 years, the incidence of infection-related events was significantly higher in the control compared to the Envelope group (2.4% vs. 0.8%, P = 0.007). The five-year cumulative incidence of infection-related events was 8.1% in the control and 2.1% in the Envelope group (HR: 0.34, 95%CI: 0.14-0.80, P = 0.010).

CONCLUSION

In our analysis, the use of an absorbable antibiotic-eluting envelope in the general CIED population was associated with a lower risk of systemic and pocket infection.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Report 2022]

BACKGROUND

The Pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the voluntary Italian collaborating centers.

METHODS

For the year 2022 main data about national PM and ICD implantation activity were obtained on the basis of European Cards and subsequently analyzed to create a standard report.

RESULTS

PM Registry: data about 17 800 PM implantations were collected (14 191 first implants and 3609 replacements). The number of collaborating centers was 152. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). Main ECG indications included atrioventricular conduction disorders in 46.0% of first PM implants, sick sinus syndrome in 17.7%, atrial fibrillation plus bradycardia in 7.7%, other unspecified ECG and electrophysiological abnormalities in 43.0%. For first PM implants, pacing in DDDR mode was reported in 42.2%, followed by DDD mode (20.6%), VVIR mode (25.1%), VVI mode (11.1%) and finally VDD-VDDR (5.1%). Median value of longevity of explanted PMs was 8.3 years. ICD Registry: data about 5210 ICD implantations were obtained (3656 first implants and 1554 replacements). The number of collaborating centers was 301. Median age of treated patients was 72 years (63 quartile I; 79 quartile III). Primary prevention indication was reported in 72.4% of first implants, secondary prevention in 27.6% (cardiac arrest in 4.6% of records). A single-chamber ICD was used in 30.3% of first implants, dual-chamber ICD in 30.0% and biventricular ICD in 39.7%. Median value of longevity of explanted ICDs was 7.0 years.

CONCLUSIONS

In the calendar year 2022, the Italian PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The ICD Registry documented a large use of prophylactic and biventricular ICDs, reflecting a favorable adherence in clinical practice to trials and guidelines. The ICD longevity and the number of recalls demonstrated a favorable trend.

HeartInsight: from SELENE HF to implementation in clinical practice

There is strong evidence that remote monitoring in cardiac implantable electronic devices can detect device malfunctions earlier than conventional monitoring and that it can be useful for detecting cardiac arrhythmias, while little data are available for an improved management of heart failure (HF). HeartInsight is a new remote monitoring algorithm developed and validated in the SELENE HF study that combines information from a diverse set of sensors integrated into one alert to detect worsening HF with promising accuracy. However, the shift from detecting technical issues or arrhythmia episodes to early predicting clinical events underscores the need to understand how to properly integrate these tools into the clinical workflow by defining an organizational model and shared guidelines for the management of HF alerts. Here, we critically discuss issues that will be raised by the implementation of this 'enhanced' remote monitoring approach to HF care in daily clinical practice.

Temporal association between drops in thoracic impedance and malignant ventricular arrhythmia: A longitudinal analysis of remote monitoring trends

INTRODUCTION

Thoracic impedance (TI) drops measured by implantable cardioverter-defibrillators (ICDs) have been reported to correlate with ventricular tachycardia/fibrillation (VT/VF). The aim of our study was to assess the temporal association of decreasing TI trends with VT/VF episodes through a longitudinal analysis of daily remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds).

METHODS AND RESULTS

Retrospective data from 2384 patients were randomized 1:1 into a derivation or validation cohort. The TI decrease rate was defined as the percentage of rolling weeks with a continuously decreasing TI trend. The derivation cohort was used to determine a TI decrease rate threshold for a ≥99% specificity of arrhythmia prediction. The associated risk of VT/VF episodes was estimated in the validation cohort by dividing the available follow-up into 60-day assessment intervals. Analyses were performed separately for 1354 ICD and 1030 CRT-D patients. During a median follow-up of 2.0 years, 727 patients (30.4%) experienced 3298 confirmed VT/VF episodes. In the ICD group, a TI decrease rate of >60% was associated with a higher risk of VT/VF episode in a 60-day assessment interval (stratified hazard ratio, 1.42; 95% confidence interval (CI), 1.05-1.92; p = .023). The TI decrease preceded (40.8%) or followed (59.2%) the VT/VF episodes. In the CRT-D group, no association between TI decrease and VT/VF episodes was observed (p = .84).

CONCLUSION

In our longitudinal analysis, TI decrease was associated with VT/VF episodes only in ICD patients. Preventive interventions may be difficult since episodes can occur before or after TI decrease.

[2020 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing]

BACKGROUND

This report describes the findings of the 2020 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

METHODS

Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers.

RESULTS

A total of 10 378 ablation procedures were performed by 66 institutions. Most centers (70%) have an electrophysiology laboratory, and 23% a hybrid cardiac surgery laboratory. All centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3.5 and 3, respectively. An electrophysiology technician was involved in 35% of all centers. In 88.2% of cases, catheter ablation was performed for supraventricular arrhythmias; the most frequently treated arrhythmia was atrial fibrillation (39.4%), followed by atrioventricular nodal reentrant tachycardia (18.6%), and common atrial flutter (10.6%). In 72.9% of patients, catheter ablation was performed using a 3D mapping system, with a "near-zero" fluoroscopic approach in 37.7% of all patients.

CONCLUSIONS

The 2020 Italian Catheter Ablation Registry confirmed that the electrophysiology activity was markedly affected by the COVID-19 pandemic; atrial fibrillation is the most frequently treated arrhythmia with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Report 2021]

BACKGROUND

The Pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the voluntary Italian collaborating centers.

METHODS

For the year 2021 main data about national PM and ICD implantation activity were obtained on the basis of European Cards and subsequently analyzed to create a standard report.

RESULTS

PM Registry: data about 18 631 PM implantations were collected (15879 first implants and 2752 replacements). The number of collaborating centers was 121. Median age of treated patients was 82 years (76 quartile I; 87 quartile III). Main ECG indications included atrioventricular conduction disorders in 26.8% of first PM implants, sick sinus syndrome in 12.2%, atrial fibrillation plus bradycardia in 9.6%, other unspecified ECG and electrophysiological abnormalities in 43.0%. For first PM implants, pacing in DDDR mode was reported in 46.5%, followed by DDD mode (20.6%), VVIR mode (15.0%), VVI mode (9.0%) and finally VDD-VDDR (5.8%). Median value of longevity of explanted PMs was 8.9 years. ICD Registry: data about 6878 ICD implantations were obtained (4708 first implants and 2170 replacements). The number of collaborating centers was 345. Median age of treated patients was 72 years (70 quartile I; 75 quartile III). Primary prevention indication was reported in 86.3% of first implants, secondary prevention in 13.7% (cardiac arrest in 4.4% of records). A single-chamber ICD was used in 32.1% of first implants, dual-chamber ICD in 30.3% and biventricular ICD in 37.6%. Median value of longevity of explanted ICDs was 6.9 years.

CONCLUSIONS

In the calendar year 2021, the Italian PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The ICD Registry documented a large use of prophylactic and biventricular ICDs, reflecting a favorable adherence in the clinical practice to trials and guidelines. The ICD longevity and the number of recalls demonstrated a favorable trend. In order to increase and optimize the cooperation of Italian PM and ICD implanting centers, the online data entry (https://www.aiac.it/riprid) should be adopted at large scale.

Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

Ventricular Arrhythmias and Implantable Cardioverter-Defibrillator Therapy in Women: A Propensity Score-Matched Analysis

BACKGROUND

Causes of sex differences in incidence of sustained ventricular arrhythmias (SVAs) are poorly understood.

OBJECTIVES

This study aims to investigate sex-specific risk of SVAs and device therapies by balancing sex groups in relation to several baseline characteristics with the propensity score (PS).

METHODS

We used a large remote monitoring dataset from implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds). Study endpoints were time to the first appropriate SVA, time to the first device therapy for SVA, and time to the first ICD shock. Results were compared between females and a PS-matched male subgroup.

RESULTS

In a cohort of 2,532 patients with an ICD or CRT-D (median age, 70 years), 488 patients (19.3%) were women. After selecting 488 men PS-matched for 19 variables relative to baseline demographics, implant indications, principal comorbidities, and concomitant therapy, yet the SVA rate at the 2.1-year median follow-up was significantly lower in women than in man (adjusted HR: 0.65; 95% CI: 0.51-0.81; P < 0.001). Women also showed a reduced risk of any device therapy (HR: 0.59; 95% CI: 0.45-0.76; P < 0.001) and shocks (HR: 0.66; 95% CI: 0.47-0.94; P = 0.021). Differences in sex-specific SVA risk profile were not confirmed in CRT-D patients (HR: 0.78; 95% CI: 0.55-1.09; P = 0.14) nor in those with an ejection fraction <30% (HR: 0.80; 95% CI: 0.52-1.23; P = 0.31).

CONCLUSIONS

After matching demographics, indications, principal comorbidities, and concomitant therapy, women still exhibited a lower SVA risk profile than men, except in the subgroups of CRT-D or/and ejection fraction <30%.

Ventricular arrhythmias and implantable cardioverter-defibrillator therapy in women: a propensity score-matched analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

The implantable cardioverter-defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death in selected patients. Although current guidelines apply to both women and men, there is a growing awareness that the incidence of cardiac arrhythmias and device interventions is influenced by sex.

Purpose

To investigate sex-specific risk of sustained ventricular arrhythmias (SVAs) and device therapies, using remote monitoring data from ICDs and cardiac resynchronization therapy defibrillators (CRT-Ds).

Methods

Study endpoints were time to the first appropriate SVA, time to the first appropriate device therapy for SVA, and time to the first ICD shock. Appropriateness of device-detected SVAs was adjudicated by three expert electrophysiologists. Results were compared between women and a 1:1 propensity score (PS)-matched subgroup of men.

Results

In a cohort of 2,532 patients with an ICD or CRT-D (median age, 70 years), 488 patients (19.3%) were women. As compared to men, women more frequently had a CRT-D (51% vs. 40%, p&lt;0.001), and nonischemic cardiomyopathy (65% vs. 45%, p&lt;0.001). After a median follow-up of 2.1 years, SVAs occurred in 123 women (25.2%) and in 174 of the 488 PS-matched men (35.6%) with an adjusted hazard ratio (HR) of 0.65 (95% confidence interval [CI], 0.51-0.81; p&lt;0.001). Women also showed a reduced risk of any device therapy (HR, 0.59; CI, 0.45-0.76; p&lt;0.001) and shocks (HR, 0.66; CI, 0.47-0.94, p=0.021). Differences in sex-specific SVA risk profile were not confirmed in CRT-D patients (HR, 0.78; CI, 0.55-1.09; p=0.14) and in those with an ejection fraction &lt;30% (HR, 0.80; CI, 0.52-1.23; p=0.31).

Conclusion

In our analysis of remote monitoring data, women exhibited a lower SVA risk profile than PS-matched men in the subgroup of patients with an ICD or/and ejection fraction ≥30%.

The value of wearable cardioverter defibrillator in adult patients with recent myocardial infarction: Economic and clinical implications from a health technology assessment perspective

AIMS

Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness.

METHODS & RESULTS

Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis - based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276.

CONCLUSION

WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Report 2020]

BACKGROUND

The Pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers.

METHODS

For the year 2020, the main data about national PM and ICD implantation activity were obtained on the basis of European Cards and subsequently analyzed to create a standard report.

RESULTS

PM Registry: data about 22 080 PM implantations were collected (18 027 first implants and 3803 replacements). The number of collaborating centers was 142. Median age of treated patients was 82 years (75 quartile I; 87 quartile III). ECG indications included atrioventricular conduction disorders in 31.0% of first PM implants, sick sinus syndrome in 13.8%, atrial fibrillation plus bradycardia in 9.9%, other unspecified ECG and electrophysiological abnormalities in 36.6%. Use of single-chamber PMs was reported in 29.0% of first implants, of dual-chamber PMs in 68.2%, of PM with cardiac resynchronization therapy (CRT) in 2.7%. ICD Registry: data about 11 931 ICD implantations were obtained (8266 first implants and 3665 replacements). The number of collaborating centers was 330. Median age of treated patients was 72 years [63 quartile I; 79 quartile III]. Primary prevention indication was reported in 85.0% of first implants, secondary prevention in 15.0% (cardiac arrest in 4.2%). A single-chamber ICD was used in 30.2% of first implants, dual-chamber ICD in 31.2% and biventricular ICD in 38.6%.

CONCLUSIONS

In the calendar year 2020, the Italian PM Registry showed stable ECG and symptom indications, with an important prevalence of dual-chamber pacing. The ICD Registry documented a large use of prophylactic and biventricular ICDs, reflecting a favorable adherence in clinical practice to trials and guidelines. The ICD longevity and the number of recalls demonstrated a favorable trend. In order to increase and optimize the cooperation of Italian PM and ICD implanting centers, the online data entry (https://www.aiac.it/riprid) should be adopted at large scale.

[2019 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing]

BACKGROUND

This report describes the findings of the 2019 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

METHODS

Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers.

RESULTS

A total of 15 201 ablation procedures were performed by 91 institutions. Most (78%) of the centers has one electrophysiology laboratory, and 17% of them has a hybrid cardiac surgery laboratory. Almost all (98%) centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3 and an electrophysiology technician was involved in 30% of all centers. In 88.4% of cases, ablations were performed for supraventricular arrhythmias, and among these the most frequently treated arrhythmia was atrial fibrillation (32.9%), followed by atrioventricular nodal reentrant tachycardia (23.9%), and common atrial flutter (11.7%). In 10 256 (67.4%) patients catheter ablation was performed by means of a 3D mapping system, with a "near-zero" fluoroscopic approach in 4626 (30.4%) of all patients.

CONCLUSIONS

The 2019 Italian Catheter Ablation Registry confirmed that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

One-year mortality after implantable defibrillator implantation: do risk stratification models help improving clinical practice?

PURPOSE

The purpose of this study was to assess the available mortality risk stratification models for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients.

METHODS

We conducted a review of mortality risk stratification models and tested their ability to improve prediction of 1-year survival after implant in a database of patients who received a remotely controlled ICD/CRT-D device during routine care and included in the independent Home Monitoring Expert Alliance registry.

RESULTS

We identified ten predicting models published in peer-reviewed journals between 2000 and 2021 (Parkash, PACE, MADIT, aCCI, CHA2DS2-VASc quartiles, CIDS, FADES, Sjoblom, AAACC, and MADIT-ICD non-arrhythmic mortality score) that could be tested in our database as based on common demographic, clinical, echocardiographic, electrocardiographic, and laboratory variables. Our cohort included 1,911 patients with left ventricular dysfunction (median age 71, 18.3% female) from sites not using any risk stratification score for systematic patient screening. Patients received an ICD (53.8%) or CRT-D (46.2%) between 2011 and 2017, after standard physician evaluation. There were 56 deaths within 1-year post-implant, with an all-cause mortality rate of 2.9% (95% confidence interval [CI], 2.3-3.8%). Four predicting models (Parkash, MADIT, AAACC, and MADIT-ICD non-arrhythmic mortality score) were significantly associated with increased risk of 1-year mortality with hazard ratios ranging from 3.75 (CI, 1.31-10.7) to 6.53 (CI 1.52-28.0, p ≤ 0.014 for all four). Positive predictive values of 1-year mortality were below 25% for all models.

CONCLUSION

In our analysis, the models we tested conferred modest incremental predicting power to ordinary screening methods.

The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.

Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation

Aims

There are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation.

Methods and results

We retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse‐probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P < 0.001), more frequently male (82.5% vs. 75.5%, P = 0.02), and had higher heart rate (75.7 vs. 71.0 b.p.m., P < 0.001). Of the 229 AF patients, 162 (70.7%) received suboptimal CRT (<98%) and 67 (29.3%) had adequate CRT (≥98%). During a median follow‐up of 24 months, total mortality did not differ between AF and SR groups (propensity‐score‐weighted hazard ratio, HR 1.32 [95% confidence interval, 0.82–2.15], P = 0.25). The risk of appropriate shocks was significantly higher in the AF group with <98% CRT than in the SR group (weighted‐HR, 1.99 [1.21–3.26], P = 0.006) and was similar in the AF group with ≥98% CRT versus the SR group (1.29 [0.66–2.53], P = 0.45). During follow‐up, sinus rhythm was recovered in 23 patients in the AF group (10%) after a median time of 106 (42–256) days. The rate of sinus rhythm recovery in the AF group was 4.5 (95% CI, 2.8–6.7) per 100 patient‐years; the rate of permanent AF occurrence in the SR group was 2.5 (95% CI, 1.9–3.3) per 100 patient‐years.

Conclusions

Although mortality was similar across patient groups, patients with permanent AF and suboptimal CRT had twofold higher risk of appropriate shocks than SR patients or AF patients with CRT ≥ 98%.

Impact of COVID-19 Pandemic on Remote Monitoring of Cardiac Implantable Electronic Devices in Italy: Results of a Survey Promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

The COVID-19 pandemic has had a profound impact on the organisation of health care in Italy, with an acceleration in the development of telemedicine. To assess the impact of the COVID-19 pandemic on the spread of remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) in Italy, a survey addressed to cardiologists operating in all Italian CIED-implanting centres was launched. A total of 127 cardiologists from 116 Italian arrhythmia centres took part in the survey, 41.0% of all 283 CIED-implanting centres operating in Italy in 2019. All participating centres declared to use RM of CIEDs. COVID-19 pandemic resulted in an increase in the use of RM in 83 (71.6%) participating centres. In a temporal perspective, an increase in the median number of patients per centre followed up by RM was found from 2012 to 2017, followed by an exponential increase from 2017 to 2020. In 36 participating centres (31.0%) a telehealth visits service was activated as a replacement for in-person outpatient visits (in patients with or without CIED) during the COVID-19 pandemic. COVID-19 pandemic has caused an acceleration in the use of RM of CIEDs and in the use of telemedicine in the clinical practice of cardiology.

Combining Home Monitoring temporal trends from implanted defibrillators and baseline patient risk profile to predict heart failure hospitalizations: results from the SELENE HF study

AIMS

We developed and validated an algorithm for prediction of heart failure (HF) hospitalizations using remote monitoring (RM) data transmitted by implanted defibrillators.

METHODS AND RESULTS

The SELENE HF study enrolled 918 patients (median age 69 years, 81% men, median ejection fraction 30%) with cardiac resynchronization therapy (44%), dual-chamber (38%), or single-chamber defibrillators with atrial diagnostics (18%). To develop a predictive algorithm, temporal trends of diurnal and nocturnal heart rates, ventricular extrasystoles, atrial tachyarrhythmia burden, heart rate variability, physical activity, and thoracic impedance obtained by daily automatic RM were combined with a baseline risk-stratifier (Seattle HF Model) into one index. The primary endpoint was the first post-implant adjudicated HF hospitalization. After a median follow-up of 22.5 months since enrolment, patients were randomly allocated to the algorithm derivation group (n = 457; 31 endpoints) or algorithm validation group (n = 461; 29 endpoints). In the derivation group, the index showed a C-statistics of 0.89 [95% confidence interval (CI): 0.83-0.95] with 2.73 odds ratio (CI 1.98-3.78) for first HF hospitalization per unitary increase of index value (P < 0.001). In the validation group, sensitivity of predicting primary endpoint was 65.5% (CI 45.7-82.1%), median alerting time 42 days (interquartile range 21-89), and false (or unexplained) alert rate 0.69 (CI 0.64-0.74) [or 0.63 (CI 0.58-0.68)] per patient-year. Without the baseline risk-stratifier, the sensitivity remained 65.5% and the false/unexplained alert rates increased by ≈10% to 0.76/0.71 per patient-year.

CONCLUSION

With the developed algorithm, two-thirds of first post-implant HF hospitalizations could be predicted timely with only 0.7 false alerts per patient-year.

Circadian periodicity affects the type of ventricular arrhythmias and efficacy of implantable defibrillator therapies

INTRODUCTION

Factors influencing malignant arrhythmia onset are not fully understood. We explored the circadian periodicity of ventricular arrhythmias (VAs) in patients with implantable cardioverter and cardiac resynchronization defibrillators (ICD/CRT-D).

METHODS

Time, morphology (monomorphic/polymorphic), and mode of termination (anti-tachycardia pacing [ATP] or shock) of VAs stored in a database of remote monitoring data were adjudicated. Episodes were grouped in six 4-h timeslots from 00:00 to 24:00. Circadian distributions and adjusted marginal odds ratios (ORs), with 95% confidence interval (CI), were analyzed using mixed-effect models and logit generalized estimating equations, respectively, to account for within-subject correlation of multiple episodes.

RESULTS

Among 1303 VA episodes from 446 patients (63% ICD and 37% CRT-D), 120 (9%) self-extinguished, and 842 (65%) were terminated by ATP, 343 (26%) by shock. VAs clustered from 08:00 to 16:00 with 44% of episodes, as compared with 22% from 00:00 to 08:00 (p < .001) and 34% from 16:00 to 24:00 (p = .005). Episodes were more likely to be polymorphic at night with an adjusted marginal OR of 1.66 (CI, 1.15-2.40; p = .007) at 00:00-04:00 versus other timeslots. Episodes were less likely to be terminated by ATP in the 00:00-04:00 (success-to-failure ratio, 0.67; CI, 0.46-0.98; p = .039) and 08:00-12:00 (0.70; CI, 0.51-0.96; p = .02) timeslots, and most likely to be terminated by ATP between 12:00 and 16:00 (success-to-failure ratio 1.42; CI, 1.06-1.91; p = .02).

CONCLUSION

VAs did not distribute uniformly over the 24 h, with a majority of episodes occurring from 08:00 to 16:00. Nocturnal episodes were more likely to be polymorphic. The efficacy of ATP depended on the time of delivery.

[The unmet needs of sudden cardiac death. The role of the wearable cardioverter defibrillator when the risk is transient or uncertain]

Sudden cardiac death is defined as a natural death due to termination of cardiac activity associated with loss of consciousness, spontaneous breathing and circulation. Nowadays, the prevention of sudden cardiac death represents a major issue and many areas of uncertainty are not met by current evidences. Among those, reliable tools for risk stratification are still lacking, as well as solution for patients in which the risk of sudden cardiac death is due to a transient or correctable condition.The concept of the wearable cardioverter defibrillator is based on a potential solution for such grey areas. It merges long-term monitoring capabilities, shockable rhythm discrimination and shock delivery without the need for bystander assistance or invasive procedures. The present review aims to summarize current problems in dealing with this insidious condition, and to discuss potential options for patients in whom sudden cardiac death could be prevented more safely and cost-effectively.

Organization and procedures in contemporary catheter ablation centres: data from the 2018 Italian Catheter Ablation Registry

AIMS

This report describes the findings of the 2018 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

METHODS

The Italian Catheter Ablation Registry systematically collects data on the ablation procedures performed in Italy. Data collection was retrospective. A standardized questionnaire was completed by participating centres.

RESULTS

We collected data on 15 714 catheter ablation procedures performed in Italy during 2018 in 94 electrophysiology centres. In most centres (75/94, 80%), a single electrophysiology laboratory was available, and a hybrid electrophysiology laboratory was available in 15% (14/94) of centres. In most (93%) centres, at least two electrophysiologists were involved in the catheter ablation procedures. In only 13 out of 94 (14%) electrophysiology laboratories, an anaesthesiologist assists every electrophysiology procedure; in most cases (74/94, 79%), an on-demand anaesthesiology service was available. On-site cardiothoracic surgery was reported in 43 out of 94 (46%) centres.Nonfluoroscopic navigation systems were available in most centres (88/94, 93%). Intracardiac echocardiography was used in 59 out of 94 (63%) electrophysiology laboratories. Atrial fibrillation (31%) was the most frequently treated ablation target, followed by atrioventricular nodal re-entrant tachycardia (20%) and cavo-tricuspid isthmus (15%). In 61.7% of all procedures, a 3D mapping system was used. In about one-third of procedures, a near-zero approach was performed.

CONCLUSION

In most Italian electrophysiology centres, a single electrophysiology laboratory was available and at least two electrophysiologists were involved in the ablation procedures. An increasing number of procedures were performed by means of a nonfluoroscopic mapping system with a near-zero approach.

Home Monitoring trends during COVID-19 infection

BACKGROUND

Cardiac implantable electronic device (CIED) recipients could have an unfavorable prognosis if infected with the novel coronavirus (COVID-19). We aimed to analyze the data daily transmitted by the Home Monitoring (HM) system (BIOTRONIK, Berlin, Germany) of CIEDs during the infection.

METHODS

We identified CIED patients followed with the HM who experienced COVID-19 clinical manifestations. The daily trends of the following HM variables were analyzed: mean heart rate (HR), physical activity, thoracic impedance (TI), ventricular and atrial arrhythmic burden.

RESULTS

The study cohort included 10 CIED patients (median age 90 [84-92] years, male 90%) with acute respiratory syndrome. The HR showed an increase of a value ranging from 10 to 30 bpm well in advance of the severe clinical manifestations. The physical activity was generally low during the entire infection course. The TI decreased in patients presented with pulmonary edema, but increased significantly (8 to 25 Ω) in most COVID-19 patients (8 out of 10) suggesting an association with pulmonary fibrosis. Arrhythmic complications were also found in half of the patients.

CONCLUSION

The trends of HR and TI in CIEDs recipients infected by the COVID-19 often showed early recurrent patterns before adverse clinical manifestations.

Sinergy between drugs and devices in the fight against sudden cardiac death and heart failure

The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.

Change in the use of remote monitoring of cardiac implantable electronic devices in Italian clinical practice over a 5-year period: results of two surveys promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

AIMS

The aim of this study was to evaluate the use of remote monitoring in Italian clinical practice and its trend over the last 5 years.

METHODS

In 2012 and 2017, two surveys were conducted. Both were open to all Italian implanting centres and consisted of 25 questions on the characteristics of the centre, their actual use of remote monitoring, applied organizational models and administrative and legal aspects.

RESULTS

The questionnaires were completed by 132 and 108 centres in 2012 and 2017, respectively (30.6 and 24.7% of all Italian implanting centres). In 2017, significantly fewer centres followed up fewer than 200 patients by remote monitoring than in 2012, while more followed up more than 500 patients (all P < 0.005). In most of the centres (77.6%) that responded to both surveys, the number of patients remotely monitored significantly increased from 2012 to 2017.In both surveys, remote monitoring was usually managed by physicians and nurses. Over the period, primary review of transmissions by physicians declined, while it was increasingly performed by nurses; the involvement of technicians rose, while that of manufacturers' technical personnel decreased. The percentage of centres in which transmissions were submitted to the physician only in critical cases rose (from 28.3 to 64.3%; P < 0.001). In 86.7% of centres, the lack of a reimbursement system was deemed the main barrier to implementing remote monitoring.

CONCLUSION

In the last 5 years, the number of patients followed up by remote monitoring has increased markedly. In most Italian centres, remote monitoring has increasingly been managed through a primary nursing model. The lack of a specific reimbursement system is perceived as the main barrier to implementing remote monitoring .

Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March-April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.

[Position paper of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) on driving by patients with cardiac implantable electronic devices]

In patients with cardiac implantable electronic devices (CIEDs) (implantable cardioverter-defibrillators [ICDs] and pacemakers [PMs]), the potential risk of suddenly being unable to drive, and hence of causing road accidents, is higher than in the general population. In ICD patients, this risk stems from the possibility that an arrhythmic event leading to loss of consciousness may occur while driving. In PM patients, it may be the result of a device malfunction in a PM-dependent patient. To determine a CIED patient's ability to drive, two variables must be taken into account: (i) the risk of events, which depends on the type of underlying heart disease (ICD patients have a higher risk than PM patients); (ii) the time spent driving and the type of vehicle driven (professional drivers are at higher risk than private drivers). This position paper reports the recommendations of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) regarding driving by patients with CIEDs, on the basis of the available literature and the European reference recommendations.

Telecardiology during the Covid-19 pandemic: past mistakes and future hopes

Covid-19 has caused a striking global impact on public health services. The inevitable suspension of all scheduled visits without urgency and non-urgent hospitalizations has resulted in relevant modifications in our management of cardiac patients. Our goal should be to maintain high standards in the treatment of cardiovascular diseases, reducing the risk of esposure to Covid-19 for patients and healthcare professionals. Our Division of Cardiology follows 300 patients in a Heart Failure Ambulatory and almost all of these, as CIEDs' carriers, are monitored by remote monitoring; in addition, we follow more than 2000 CIEDs' carriers using remote monitoring. The purpose of telemedicine, using telecommunications technology, must be to optimize the clinical management of heart failure patients at home, in order to improve their quality of life, reducing hospitalization and emergency department access, also promoting self-management. The evolution of technology has led to the development and refinement of telemedicine and remote monitoring and even more in pandemic times these methods are to be considered a cornerstone. So that telemedicine can really become a well-structured reality, the following are fundamental: the uniform recognition of a reimbursement for this type of medical service, the creation of an organizational model with an adequately structured team, a valid integration with the territorial reality.

Direct oral anticoagulants for patients aged over 80 years in nonvalvular atrial fibrillation: the impact of frailty

AIMS

In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy.

METHODS

We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18).

RESULTS

The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate).

CONCLUSION

Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.

853Could baseline electrical parameters be a marker of arrhythmia occurrence and poorer prognosis in implantable cardioverter defibrillator patients?

Funding Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background/Introduction: Parameters routinely measured during cardiac devices implantation also depend on bioelectrical properties of the myocardial tissue.

Purpose

To explore the potential association of electrical parameters with clinical outcomes in implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy defibrillators (CRT-D) recipients.

Methods

In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA) and atrial high rate episode lasting ≥7 days (7day-AHRE).

Results

In a cohort of 2,976 patients (58.1% ICD) with a median follow-up of 25 months, events rates were 3.1/100 patient-years for all-cause mortality,  18.1/100 patient-years for VA and 8.9/100 patient-years for 7day-AHRE.

At univariate analysis baseline shock impedance was consistently lower in groups with events than in those without, with a 40 Ohm cut-off  better identifying patients at high risk, but at multivariable analysis the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint.

Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 7-day AHRE as compared to those without (2.40 [IQ: 1.62-3.71] Vs 3.50 [IQ: 2.35-4.66] mV, p &lt; 0.01). The adjusted-HR for 7-day AHRE in patients with atrial sensing &gt;1.5 mV versus those with values ≤1.5 mV was 0.44 (95% CI:0.27-0.72), p = 0.001.

Conclusion

Despite in patients with events a lower baseline shock impedance was observed at univariate analysis, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of long-lasting atrial arrhythmia.

Abstract Figure. AHRE occurrence by atrial sensing

P531Cardiac resynchronization therapy in patients with permanent atrial fibrillation: insights from the HMEA database

Funding Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Background/Introduction: The benefits of cardiac resynchronization therapy with defibrillator (CRT-D) in heart failure are well established. However, a gap of evidence is still present for patients with permanent atrial fibrillation (perm-AF)

Purpose

To investigate outcomes of CRT-D patients with perm-AF in terms of appropriate shock for ventricular arrhythmia and all-cause mortality in a long-term time horizon. 

Methods

We used the Home Monitoring Expert Alliance (HMEA) database, a nationwide data repository of daily remote monitoring transmissions. The episodes with delivered shock were adjudicated by a board of 3 electrophysiologists.

Results

Among 1226 CRT-D patients (mean age 71.2 ± 10.0 years; 75.5% males), 276 (22.5%) had perm-AF at device implantation. These patients had more frequently rate responsive function (19.7% vs 64.1%) and higher basic rate (median value 60 bpm vs 70 bpm) as compared to all other patients (p &lt; 0.001). The CRT pacing percentage calculated over the first 2 months was slightly lower for perm-AF patients (median value 96.0% vs 98.8%, p &lt; 0.001).

At 5-year appropriate shock incidence was 34.2% (95% confidence interval [CI], 25.1%-45.3%) for perm-AF and 19.9% (15.6%-25.1%) for all other patients. All-cause mortality was 27.7% (17.7%-41.8%) for perm-AF and 15.6% (12.2%-19.9%) for all other patients. 

The age- and sex-adjusted hazard ratio between perm-AF and all other patients was 1.81 (95% CI: 1.25-2.64, p = 0.002) for appropriate shock and 0.92 (95% CI: 0.57-1.50, p = 0.748) for all-cause mortality.

Conclusion

Although a higher incidence of appropriate shock, perm-AF at the time of CRT-D implantation was not associated with increased long-term mortality,

Abstract Figure. Appropriate shock and mortality

[Quality and performance in cardiac pacing and electrophysiology. An update to the 2010 Italian Association of Arrhythmology and Cardiac Pacing (AIAC) - Italian Federation of Cardiology (IFC) Document 'Structure and functional organization of Arrhythmology']

In the last decade the field of cardiac pacing and electrophysiology underwent major advancements thanks to both new ways of arrhythmia management and technological innovations. At the same time, the clinical competence and the procedural qualitative level of Cardiac Rhythm Centers have increased significantly. In 2010 an ad hoc Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and the Italian Federation of Cardiology (FIC) published a consensus document on the organization of Cardiac Rhythm Centers and on the standards of professional practice in pacing and electrophysiology in Italy. In particular, this document focused on the minimal requirements of a Center to be qualified as suitable to perform first, second and third-level cardiac pacing and electrophysiology activities. However, most of these indicators have been overcome over time. Thus, an update of the previously published organizational model appeared necessary. In this document several new requirements and indicators about the organization and performance of both operators and Cardiac Arrhythmia Centers have been introduced. These include: (i) "structural and procedural requirements" (types of diagnostic and therapeutic procedures performed, logistic structures, healthcare staff and technologies), (ii) "activity indicators" (number of procedures performed); (iii) "appropriateness indicators" (adherence to guideline recommendations); (iv) "outcome indicators" (procedural success and complications); and (v) "quality of care indicators" (management and continuity of care levels). By applying these requirements and indicators, each center can optimize its procedures, increasing its performance and effectiveness. Finally, a new model for the organization of the Italian network of Cardiac Arrhythmia Centers is also suggested.

Atrial signal amplitude predicts atrial high-rate episodes in implantable cardioverter defibrillator patients: Insights from a large database of remote monitoring transmissions

BACKGROUND

Parameters measured during implantable cardioverter defibrillator (ICD) implant also depend on bioelectrical properties of the myocardium. We aimed to explore their potential association with clinical outcomes in patients with single/dual-chamber ICD and cardiac resynchronization therapy defibrillator (CRT-D).

METHODS

In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by the occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA), and atrial high-rate episode lasting ≥24 hours (24 h AHRE).

RESULTS

In a cohort of 2976 patients (58.1% ICD) with a median follow-up of 25 months, event rates were 3.1/100 patient-years for all-cause mortality, 18.1/100 patient-years for VA, and 9.3/100 patient-years for 24 h AHRE. At univariate analysis, baseline shock impedance was consistently lower in groups with events than without, with a 40 Ω cutoff that better identified high-risk patients. However, at multivariable analysis, the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 24 h AHRE than in those without (2.45 [IQR: 1.65-3.85] vs 3.51 [IQR: 2.37-4.67] mV, P < .01). The adjusted HR for 24 h AHRE in patients with atrial sensing >1.5 mV vs those with values ≤1.5 mV was 0.52 (95% CI: 0.33-0.83), P = .006.

CONCLUSIONS

Although lower baseline shock impedance was observed in patients with events, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of atrial arrhythmia.

Effects of remote monitoring of cardiac implantable electronic devices after stroke or transient ischemic attack

AIMS

Cardiac implantable electronic device (CIED) recipients who experienced an ischemic cerebral event may particularly benefit from continuous remote monitoring. We aimed to assess the effect of remote monitoring on the occurrence of 1-year serious adverse events in CIED recipients after ischemic stroke or transient ischemic attack (TIA).

METHODS

Patients were eligible if they suffered a TIA/stroke. Study endpoints were all-cause mortality, all-cause hospitalization, and TIA/stroke recurrence. Patients were retrospectively divided according to the presence of remote monitoring for CIED follow-up.

RESULTS

From January 2011 to December 2017, 71 CIED recipients were hospitalized in our institution for TIA/stroke: pacemaker (76%), cardiac resynchronization therapy device (17%), or implantable cardioverter defibrillator (7%). Among them, 26 (37%) were remotely monitored (RM-ON), whereas 45 (63%) were followed with conventional in-hospital visits (RM-OFF). No significant differences were found in baseline characteristics between groups. The all-cause mortality and hospitalization rates were significantly lower in the RM-ON group [2.2; 95% confidence interval (CI) 0.8-4.8, and 5.8; 95% CI 3.3-9.4 per 100 patient-months] as compared with the RM-OFF group (8.1; 95% CI 5.2-11.9, and 9.7; 95% CI 6.5-13.9 per 100 patient-months). Despite a similar incidence of new diagnosis of atrial fibrillation, the median time from the arrhythmic episode to the physician evaluation was dramatically lower in the RM-ON as compared with the RM-OFF group [2 (1-3) vs. 78 (64-92) days; P = 0.002].

CONCLUSION

We found that remote monitoring as compared with conventional in-hospital visits may contribute to a better outcome in CIED recipients who had suffered from an ischemic cerebral event.

P2592Combining home monitoring temporal trends and baseline patient risk profile for predicting impending heart failure hospitalizations. Results from the SELENE HF (BIO.Detect HF IV) study

Background/Introduction

The lack of a validated method to efficiently combine information provided by Remote Monitoring (RM) of implantable defibrillators (ICD) and patient clinical profile has limited the use of RM in the prevention of worsening heart failure episodes.

Purpose

Our objective was to develop and validate an index combining RM temporal trends and a baseline risk score for predicting the first HF hospitalization after device implantation.

Methods

We prospectively enrolled 918 patients (81% male, median age 69, interquartile interval [QI], 61/76; Seattle Heart Failure Score [SHFS], 0.17, QI, −0.40/0.75) with indication to ICD (56%), or ICD with cardiac resynchronization therapy (44%). The Home Monitoring (HM) system was activated in all patients after implant to collect several technical and HF-related variables daily. Investigators were blinded to HM reports, and only received automatic alerts for critical technical issues. The primary endpoint was the first adjudicated HF hospitalization. The cohort was a posteriori 1:1 randomized in derivation and validation groups stratified by device type and primary endpoint occurrence. The SHFS was used for baseline risk assessment.

Results

During a median follow-up of 23 months (QI, 14/36), 62 first HF hospitalizations were adjudicated. In the derivation group, the index was constructed by combining the SHFS and temporal trends of 24-hour and rest mean heart rates, ventricular ectopic beat frequency, arrhythmic atrial burden, heart rate variability, physical exercise, and thoracic impedance. Variable selection was based on an automatic stepwise procedure, after applying appropriate transformations in variable-specific time frames to maximize the area under the receiver operating characteristics curve (AUC). The resulting index was associated to an AUC of 0.88 and an Odds Ratio of 2.72 (confidence interval [CI] 1.97–3.75, p<0.001) for index unitary increase. In the index validation test, first HF hospitalizations were predicted with a sensitivity of 73.3% (CI, 54.1%-87.7%), a median alerting time of 55 days (QI, 20/68), false alert rate of 0.75 (CI, 0.70–0.81) patient-year, and 95.1% false-alert-free days.

Conclusion

HM temporal trends of selected variables and the SHFS may be combined to timely and efficiently predict the first HF hospitalization after implant, with less than 1 expected per-patient false alert per year.

Acknowledgement/Funding

BIOTRONIK SE & Co. KG, Berlin, Germany

[2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing]

BACKGROUND

This report describes the findings of the 2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).

METHODS

Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers.

RESULTS

A total of 15 601 ablation procedures were performed by 91 institutions, with a mean of 184 ± 213 procedures per center. The most frequently treated arrhythmia was atrial fibrillation (34%), followed by atrioventricular nodal reentrant tachycardia (25%) and common atrial flutter (14%). About 10% of overall ablation procedures were performed in patients with ventricular arrhythmias. On-site cardiothoracic surgery was available in 42% of the centers performing ablation and in 49% of the centers performing atrial fibrillation ablation. In most patients, the ablation procedure was guided by a three-dimensional mapping system, and in 15% of patients a near-zero X-ray strategy was used.

CONCLUSIONS

The Italian Catheter Ablation Registry systematically collected 1-year data on ablation procedures performed in Italy, revealing that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of patients treated for ventricular tachycardia.

P6556Prevention of long-lasting atrial fibrillation through device therapy in dual-chamber pacemakers: analysis on 1384 patients of the role of Reactive ATP and atrial preventive pacing

Background

Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in clinical practice and it is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. Moreover AF management is a huge cost for healthcare systems. AF is irregular, typically originates from the pulmonary veins, and as such, requires cardioversion to terminate persistent episodes. AF is not susceptible to pace-termination, however, the MINERVA trial has shown that AF may transform in slower organized rhythms such as atrial flutter or atrial tachycardia, which can often be terminated by atrial anticahycardia pacing (ATP); in particular by Reactive ATP, a specific ATP feature which can be re-armed when atrial arrhythmias get slower or more regular. The MINERVA trial showed that the combination of ATP, preventive atrial pacing algorithms and minimal ventricular pacing (MVP) was associated with lower progression to persistent and permanent AF, compared with standard DDD pacing mode and to MVP mode, in pacemaker patients with clinical history of AF.

Purpose

We aimed to confirm MINERVA trial results in real-world clinical practice and to evaluate whether AF prevention was associated with preventive atrial pacing or solely with ATP. Indeed in our project atrial preventive pacing algorithms were not enabled and the pacing mode (DDD or MVP) was chosen according to patients' AV conduction characteristics.

Methods

Consecutive dual-chamber pacemaker patients with sinus node disease and device detected AT/AF were prospectively followed by 30 Italian cardiologic centers in an observational research. Clinical and device data were collected and reviewed by expert cardiologists to assess AT/AF occurrence through in clinic visit and/or remote transmissions of device data.

Results

A total of 239 patients (73 years old, 56% male) wearing a dual-chamber pacemaker with Reactive ATP were included in the project, followed for a median observation period of 13 months and compared with 1145 patients included in the MINERVA trial followed for a median observation period of 34 months and programmed with DDD pacing mode (383 patients), MVP (389 patients) and MVP+Reactive ATP+preventive algorithms (373 patients). As shown in the following figure incidence of 7 consecutive days of AF in the patients treated by DDD/MVP+Reactive ATP in real-world clinical practice was very similar to that found in the MINERVA trial arm programmed with MVP+Reactive ATP+preventive algorithms.

Incidence of AF longer than 7 days

Conclusions

Our analysis performed in a population of sinus node disease patients with dual-chamber pacemakers confirmed MINERVA trial results in terms of prevention of long-lasting AF episodes. In particular these results confirm the benefit associated with the use of Reactive ATP, rather than preventive atrial pacing algorithms.

Are Atrial High-Rate Episodes Associated With Increased Risk of Ventricular Arrhythmias and Mortality?

OBJECTIVES

This study evaluated the temporal association between atrial high-rate episodes (AHREs) and sustained ventricular arrhythmias (VAs) in a remotely monitored cohort with implantable cardioverter-defibrillators (ICD) with and/or without cardiac resynchronization therapy with a defibrillator (CRT-D).

BACKGROUND

Clinical relevance of AHREs in terms of VA rate and survival has not been outlined yet.

METHODS

This study analyzed data of patients with ICDs and CRT-Ds from the nationwide Home Monitoring Expert Alliance network. The cohort included 2,435 patients with a median follow-up of 25 months (interquartile range: 13 to 42 months) and age 70 years (range 61 to 77 years); 19.7% were women, 51.4% had coronary artery disease, and 45.2% had a CRT-D. There were 3,410 appropriate VA episodes; 498 (14.6%) were preceded by AHREs within 48 h; in 85.5% of this group, AHREs were still ongoing at episode onset.

RESULTS

In a longitudinal analysis, the odds ratios (ORs) of experiencing any VA in a 30-day interval with AHREs versus intervals without AHREs were 2.35 (95% confidence interval [CI]: 1.86 to 2.97; p < 0.001) for ventricular tachycardia (VT), 3.06 (95% CI: 2.35 to 3.99; p < 0.001) for fast VT, 1.84 (95% CI: 1.36 to 2.48; p < 0.001) for self-extinguishing ventricular fibrillation (VF), and 2.31 (95% CI: 1.17 to 4.57; p = 0.01) for VF. ORs decreased with increasing AHRE burden. Patients with AHREs 48 h before VAs were more likely to experience VA recurrences (adjusted hazard ratio [HR]: 1.78; 95% CI: 1.41 to 2.24; p < 0.001) and had higher overall mortality (HR: 2.67; 95% CI: 1.68 to 4.23; p < 0.001).

CONCLUSIONS

AHREs were not uncommon 48 h before VAs, which tended to be distributed around intervals with AHREs. Temporal connection between AHREs and VAs was a marker of increased risk of VA recurrence and a poorer prognosis.

Reduction in pulmonary artery pressures with use of sacubitril/valsartan

Pulmonary hypertension due to left heart disease (PH-LHD) frequently complicates heart failure with reduced ejection fraction (HFrEF). Specific therapies for PH have not offered an advantage in patients with PH-LHD. The combined angiotensin receptor blocker-neprilysin inhibitor (ARNI), sacubitril/valsartan, is a novel therapy that can increase levels of natriuretic peptides (NPs). The resulting action on natriuresis and vasodilation may play an important role in the reduction of pulmonary pressures. Here, we report how the use of ARNI in two patients with HFrEF has resulted in an improvement in PH and, consequently, in clinical status and prognosis. <Learning objective: Sacubitril/valsartan (ARNI) is the newest neurohormonal agent approved for therapy in heart failure with reduced ejection fraction (HFrEF). Pulmonary hypertension (PH) due to left heart disease (PH-LHD) is frequent in patients with HFrEF and is associated with a reduced functional class and poor prognosis. The use of ARNI has been associated with a relevant reduction in pulmonary pressures in two cases of PH-LHD.>.

Lead choice in cardiac implantable electronic devices: an Italian survey promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing)

Background: Few data are available regarding lead preferences of electrophysiologists during cardiac implantable electronic devices (CIEDs) implantation. Aim of this survey is to evaluate the leads used, and the reasons behind these choices, in a large population of implanters. Methods: A questionnaire was sent to all 314 Italian centers with experience in CIED implantation. Results: 103 operators from 100 centers (32% of centers) responded. For atrium, passive leads represented first choice for pacemakers and defibrillators (71% and 64% of physicians, respectively), mainly for safety. For right ventricle, active fixation was preferred (61% and 93% operators in pacemaker and defibrillator patients), for higher versatility in positioning and lower dislodgement risk. For left ventricular stimulation, quadripolar leads were preferred by more than 80% of respondents, for better phrenic nerve and myocardial threshold management; active-fixation leads represent a second choice, in order to prevent or manage dislodgement (78% and 17% of respondents, respectively), but 44% of operators considered them dangerous. Conclusions: The choice of leads is heterogeneous. Trends are toward active-fixation right ventricular leads and passive-fixation atrial leads (particularly in pacemaker patients, considered frailer). For left ventricular stimulation, operators' majority want to disposition all kind of leads, although quadripolar leads are the favorites.

Rate-responsive pacing and atrial high rate episodes in cardiac resynchronization therapy patients: Is low heart rate the key?

BACKGROUND

The role of atrial rate-responsive (RR) pacing in cardiac resynchronization therapy (CRT) is unclear due to the favorable effect of rate lowering in systolic heart failure. Atrial high rate episodes (AHREs) in CRT recipients are particularly worrisome since they cause loss of CRT, beyond representing a stroke risk factor.

HYPOTHESIS

The presence of an association between RR and the incidence of AHREs.

METHODS

Daily remote transmissions from 836 CRT recipients were analyzed. AHREs were classified by duration: ≥15 minutes, ≥5 hours, and ≥ 24 hours. Variables possibly associated to AHREs were included in time-dependent proportional-hazard models, averaging over 30-day periods and adjusting for main baseline variables.

RESULTS

After a median follow-up of 23.9 (12.2-36.0) months, 507 (60.6%) patients experienced at least one 15-minute AHRE. RR function was programmed in 166 (19.8%) patients and was associated with an increased AHRE occurrence rate with hazard ratio (HR) ranging from 1.45 to 1.78 for the 3 cutoffs of episode duration. The negative effect of RR function was not observed in the subset of patients with low mean heart rate (<68 bpm). Higher mean heart rates increased AHRE risk (HR:1.02, P = .01), while CRT amount decreased it (HR:0.98, P < .01). The extent of atrial pacing did not predict AHRE occurrence.

CONCLUSIONS

RR pacing in CRT recipients is associated with increased AHRE occurrence, especially when an average heart rate > 68 bpm is attained.

Long-term outcomes after prophylactic ICD and CRT-D implantation in nonischemic patients: Analysis from a nationwide database of daily remote-monitoring transmissions

INTRODUCTION

Clinical trials did not provide conclusive evidence concerning the benefit of prophylactic implantable cardioverter-defibrillators (ICDs) in patients with severe nonischemic cardiomyopathy (NICM). We aimed to compare incidence of appropriate sustained ventricular arrhythmia (SVA) and device therapy in ischemic cardiomyopathy (ICM) vs NICM ICD and/or cardiac resynchronization therapy (CRT-D) patients.

METHODS AND RESULTS

We analyzed remote-monitoring data from devices of the Home Monitoring Expert Alliance network. SVA recordings were adjudicated by three independent electrophysiologists. Our cohort included 1,946 patients who received either an ICD (55%) or a CRT-D (45%) for primary prevention of sudden cardiac death. Median (interquartile range) age was 70 (62-77) years, 81% were male, and 52% were in the ICM group. Patients were remotely monitored for a maximum follow-up of 5 years. The 5-year product-limit estimate of SVA incidence in patients with an ICD was 47.3% (95% confidence interval [CI], 41.0%-53.9%) in the ICM group and 44.7% (36.9%-53.3%) in the NICM group. In patients with a CRT-D, SVA incidence was 45.7% (37.3%-55.0%) in ICM patients and 49.2% (40.4%-58.7%) in NICM patients. The adjusted hazard ratio for SVA in the ICM vs NICM group was 0.96 (95% CI: 0.70-1.30, P = .77) in ICD patients and 0.85 (95% CI: 0.61-1.18, P = .34) in CRT-D patients. SVAs triggered appropriate device therapies with similar incidence in all groups.

CONCLUSION

In a large cohort of remotely monitored ICD and CRT-D recipients, SVA incidence did not significantly differ in ICM and NICM patients.

Organizational model and reactions to alerts in remote monitoring of cardiac implantable electronic devices: A survey from the Home Monitoring Expert Alliance project

BACKGROUND

This survey aimed to describe the organizational workflow of cardiac implantable electronic devices (CIEDs) remote monitoring (RM) service in ordinary practice.

METHODS

A questionnaire was designed for our purpose and completed by 49 sites participating to the Italian Home Monitoring Expert Alliance.

RESULTS

A dedicated organizational model for RM was set up for 86% of centers. The median RM team consisted of 2 (Interquartile range [IQR]: 1-3) physicians and 1 (IQR: 0-2) nurse. RM service was available in working hours and the median percentage of patients included was 100% (IQR: 10%-100%) for implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) recipients and 5% (IQR:0%-30%) for pacemakers. In-office follow-up was performed every 12 and 6 months for pacemaker and ICD/CRT recipients, respectively. More than 90% of sites used to activate all technical alerts, with a prompt reaction in case of an out-of-range parameter. The threshold for atrial fibrillation (AF) daily burden notification in most cases ranged from 2.4 to 7.2 hours. All ventricular arrhythmias alerts were usually switched on: an inappropriate therapy or more than one appropriate episode triggered an urgent in-hospital visit. Concerning heart failure, low CRT percentage pacing alert was always used, while the other available notifications were less frequently switched on.

CONCLUSIONS

This survey showed that RM service was usually set up with a primary nursing model including on average two responsible physicians and one nurse and mainly offered to ICD/CRT patients. Technical, AF and ventricular arrhythmia alerts triggered prompt reactions, while heart failure related indexes were generally less applied.

Prediction of mortality in patients with implantable defibrillator using CHADS2 score: data from a prospective observational investigation

BACKGROUND

CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke/TIA) score has been validated as a risk stratification score to predict stroke in patients with atrial fibrillation (AF). The objective of this analysis was to assess whether patient risk factors, in particular CHADS2 score, identified patients at risk of mortality.

METHODS

821 patients with an implantable cardioverter defibrillator were prospectively followed-up in 11 cardiology centers. Patients were grouped in 3 groups according to pre-specified risk classes: low (CHADS2 = 0), moderate (CHADS2 = 1, 2), and high (CHADS2 = 3-6). Information on clinical status and events, were collected during scheduled and unscheduled follow-up visits. Deaths were retrieved from medical records, or through the Regional Office of Vital Statistics.

RESULTS

Over a mean follow-up of 44±26 months, 135 deaths occurred in the overall population: 6 (7.7%) in the low-risk population, 69 (13.8%) in moderate-risk patients and 60 (24.6%) in high-risk patients. Kaplan-Meier estimated of patient survival were significantly different in 3 patients groups (93.0%, 90.1%, 78.5% in low, moderate and high risk patients respectively, at 4 years P<0.001). A sub-analysis on patients without history of AF showed similar results. Multivariate regression analysis adjusted for baseline characteristics confirmed the high risk status (HR 1.88, 95% CI 1.27-2.80; P = 0.002) as an independent predictor of mortality adjusted for the baseline characteristics.

CONCLUSIONS

In our multicenter research, the long-term mortality was higher in patients with high CHADS2 score than in those with lower risk score regardless the presence of history of AF. CHADS2 score could be considered a toll to predict all causes mortality.

Seasonal trend of ventricular arrhythmias in a nationwide remote monitoring database of implantable defibrillators and cardiac resynchronization devices

BACKGROUND

The occurrence of sustained ventricular arrhythmias (SVA) may be influenced by environmental factors. We aimed to investigate annual periodic trends of SVA from the intracardiac electrograms (IEGMs) stored in the implantable defibrillators (ICDs) or cardiac resynchronization therapy (CRT-D) recipients.

METHODS

Data from the Home Monitoring Expert Alliance project, a pooled repository of remote monitoring transmissions were analyzed. All IEGMs stored were independently adjudicated by three cardiac electrophysiologists. Periodicity of SVA was evaluated with Generalized Estimating Equations (GEE) models, including periodic terms depending on months in a year.

RESULTS

A total of 2936 ICD/CRT-D patients (median age 70 years, 79.6% male) were followed for a median period of 25[13-44] months. Most prevalent structural heart diseases were ischemic (50.8%) and idiopathic dilated (30.6%) cardiomyopathies. Overall, 942 (32.1%) patients experienced a total of 4824 SVA. At GEE analysis, we found a significant periodic component (p = 0.048) when considering both shocked and non-shocked episodes. SVA less frequently occurred in Junes and Julies (3.7 × 1000 patient-month). No evidence of significant periodicity was collected in the subgroup of ischemic patients.

CONCLUSIONS

In this RM-based cohort of ICD/CRT-T patients, we observed an annual periodicity of SVA occurrence, with a lower incidence in summer months.