Additional features in Brugada Syndrome stratification: frequent PVC and QRS duration

Funding Acknowledgements

Type of funding sources: None.

Introduction

Brugada syndrome (BrS) is a channelopathy with high prevalence of malignant arrhythmic events. The risk stratification in patients (pts) with Brugada electrocardiographic (ECG) pattern is of major importance, to prevent sudden cardiac death (SCD). A higher risk is evidenced in spontaneous type 1 pattern when compared with induced type-1 pattern, as so other electrocardiographic features have been explored aiming to detect additional prognostic factors.

Purpose

To evaluate the association of QRS duration and frequent premature ventricular contractions (PVC) with malignant arrhythmic events.

Methods

Prospective single-center study of consecutive pts with BrS, with spontaneous or induced type 1 pattern included from 2003 to 2021. All pts were enrolled in a protocol including annual non-invasive assessment with ECG and 24-hours Holter monitoring. Primary endpoints were defined as SCD or appropriate shocks in the context of ventricular tachycardia or fibrillation (VT/FV) during follow-up. Cox regression and Kaplan-Meier survival analyses were used to determine the association between the baseline ECG and Holter characteristics and the long-term risk of arrhythmic events.

Results

A total of 117 pts was included, 75 (65%) with a spontaneous type 1 pattern and 44 (33%) with an induced type 1 pattern. The mean age was 47±13years and 38 (32.5%) were male.

During a median follow-up of 4.1±0.3 years, the primary endpoint occurred in 8 (6.8%) pts, with sudden cardiac death in 3 (2.6%) and appropriate shocks due to VT/FV in 5 (4.3%). Pts who suffered arrhythmic events had presented at the study inclusion higher QRS duration (124±18 vs. 108±16ms, p= 0.014) and more frequent PVCs on 24-hour Holter (169±297 vs. 29±198; p = 0.001) - Figure 1. Indeed, the presence of QRS ≥119ms was associated with a 7-fold higher risk (HR: 7.250, 95% CI 1.619-32.461, p = 0.010) and the presence of more than 6 PVC on 24-hour Holter was also associated with a 5-fold higher risk of malignant arrhythmic events (HR 5.376, 95% 1.186-24.260, p = 0.029).

Conclusion

QRS duration and frequent PVC may established themselves as additional risk factors. In our cohort, they were both predictors of arrhythmic events during follow-up and thus can further complement BrS risk stratification.

Apical versus septal pacing - can we chose the localization of ventricular lead in order to prevent upgrade to cardiac resynchronization therapy?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Right ventricular apical pacing (RVAp) may be deleterious to ventricular function and hemodynamics due to pacing induced dyssynchrony. In the last decades, some studies showed that RVAp has been associated with heart failure, deterioration of left ventricular function and high mortality. Some patients (pts) may need, during the follow up (FUP), an upgrade to cardiac resynchronizaon therapy (CRT). New techniques have emerged such as RV lead implantation in the high septum or outflow RV tract (RVOT) and, more recently, His bundle/LB pacing.

Purpose

To compare the need for upgrade to CRT in patients with RVAp versus septal/RVOT pacing.

Methods

Retrospective single-center study of consecutive pts that implanted pacemakers in a tertiary center between January 1995 and December 2020. We collected data regarding pacing indication, RV pacing site (apex versus septum/RVOT) and need for an upgrade to CRT during follow up (FUP).

Our primary endpoint was upgrade to CRT during the FU period. In the model, the impact of localization of the implanted lead on the survival free from upgrade was estimated assuming a neutral effect on mortality. Statistical analysis was performed using T-student test and logistic regression.

Results

We included 8761 pts, 60.2% (n=5275) were male, with a mean age of 76.5±10.7 years. The main indications for pacemaker implantation were (1) complete atrioventricular (AV) block (2239, 25.6%), (2) sick sinus syndrome (2211, 25.2%), (3) atrial fibrillation with AV block or bradycardia with significant pauses (17.4%) and (4) Mobitz II 2nd degree AV block (1467, 16.7%).

RVAp was performed in 1746 (20%) patients and RVOT/septal pacing in 6933 patients (80%; RVOT in 657 (9,5%)). During FUP, 26 (1,5%) RVAp pts and 52 (0,8%) RVOT/septal pacing pts underwent upgrade to CRT, in a total of 78 pts (CRT-P in 54 patients and CRT-D in 24 patients).

We observed that patients with RVAp had twice the risk of CRT upgrade during FUP (OR: 2,0 (IC 95% 1,25-3,21), p=0,004) when compared to patients with RVOT/septal pacing.

Conclusions

Patients with RVAp presented a 2-fold higher risk for upgrade to CRT when compared to patients with RVOT/septal pacing in our center. This retrospective analysis shows that lead implantation in the septum/RVOT should be preferred instead of the apex to reduce pacing induced dyssynchrony and need for CRT upgrade.

Is it possible to predict mortality and recurrence of VT afterablation? PAINESD risk score applicability vs new predictors

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) prevents ventricular tachycardia (VT) recurrences in patients (pts) with structural heart disease (SHD), and might have a favorable outcome, but is associated with severe short-term complications. Identification of pts at high risk of periprocedural acute haemodynamic decompensation has important implications at procedural planning.

The PAINESD risk score is a promising tool to predict VT ablation procedure-related mortality.

Aim

To evaluate the accuracy of the PAINESD risk score to predict short-term mortality after structural VT ablation and to compare it with other conventional clinical predictors.

Methods

Prospective, observational, single-centre study of consecutive pts with SHD (ischemic or nonischemic), referred for VT-CA. High-density substrate maps were collected, through endocardial, epicardial or combined endo-epicardial approaches according to clinical data and operator preference. The primary endpoint was 30-day mortality or hemodynamic decompensation. Univariate Cox regression analysis was used to identify relevant clinical predictors and to compare them with the PAINESD risk score. Multivariable Cox proportional hazards regression models were used to estimate predictors of 30-day mortality.

Results

A total of 102 pts with SHD referred for VT ablation were evaluated(mean age: 67±11 years, 94% male, 78.4% in NYHA class I-II; mean LVEF was 34±11%). The baseline PAINESD risk score was 12.39±5.8, 19.6% at low risk, 36.3% at intermediate risk and 27.5% at high risk of adverse events. Overall 30-day mortality was 4.9%. The PAINESD did not predict 30-days mortality or hemodynamic decompensation (p= 0.93). Indeed, a non- significant trend to higher short and long-term mortality was noticed in high-risk score pts – Figure 1. On univariate analysis age>65 years (p=0.019), LVEF <35% (p=0.049), body mass index<28kg/m2 (p=0.019), CKD (p=0.001) and previous VT ablation (p=0.022) were prognostic predictors. On multivariate analysis, only LVEF<35% (HR2.225; CI95% 1.004-4-774,p=0.038) and CKD (HR 3.35; CI95%: 1.31-8.51, p=0.011) were independent predictors of short-term prognosis.

Conclusions

In our population, LVEF<35% and CKD were the strongest predictors of short-term mortality. PAINESD risk score was not accurate in predicting adverse events. New score systems must be derived for prognostic stratification in this population, incorporating the reduction on the actual short-term event rates after VT ablation.

Predictors of survival in patients submitted to typical atrial flutter ablation

Introduction

Cavo-tricuspid isthmus ablation (CTA) is the first line procedure in patients with typical atrial flutter (AFL) for adequate rhythm and symptoms control with low complication rates and excellent results. Given its apparent simplicity, rarely do we take clinical factors in account before referral.

Aim

To identify predictors of survival after typical AFL ablation.

Methods

Single-center retrospective study of pts with typical AFL submitted to ablation between 2015 and 2019. Pts clinical characteristics were collected. Statistical analysis was performed using Cox regression (for multivariate analysis), Chi-square and Mann-Whitney (for univariate analysis) to identify predictors of survival.

Results

A total of 476 pts (66±12 years, 80% males) underwent CTA. Regarding global clinical characteristics, median body mass index (BMI) 27.3 (IQ 24.5–30.4), median CHA2DS2-VASc score 2 (IQ 1–3), 27.3% with diabetes, 53.9% with dyslipidemia, 69.5% with hypertension, 12% with current tobacco abuse, thyroid disfunction in 10.9%, ischaemic cardiomyopathy in 13.7%, heart failure in 27.8% (3.6% of pts with reduced ejection fraction), chronic kidney disease (CKD) stage 3 or more in 17.7%, obstructive sleep apnea (OSA) in 11.9% and chronic obstructive pulmonary disease (COPD) in 9.5% of pts. Before CTA ablation, 444 pts were under anticoagulation, which was stopped in 293 pts after the procedure. The follow up period was 2.8 years.

In this population, COPD (p=0.005), CKD (p<0.001), heart failure (p=0.0027) and BMI less than 25 (p=0.02) were associated with reduced survival on univariate analysis; patients with BMI between 25 and 30 had better prognosis. On multivariate analysis, CKD was the only independent predictor of reduced survival (HR 0.366; CI95%: 0.132–0.737, p=0.005). There was no difference between genders (p=NS).

A CHA2DS2-VASc score of ≥4 predicted higher mortality (HR: 3.0) in all three groups, although the anti-coagulation suspension had no impact on survival (p=NS).

Conclusion

In this subset of patients, the presence of COPD, heart failure, BMI less than 25 and CHA2DS2-VASc score ≥4 predicted reduced survival, being CKD stage 3 or more an independent predictor. The suspension of anti-coagulation didn't impact on survival. These results can help us to better select pts to the procedure and decide on whether to stop anti-coagulation, although larger studies are still needed.

Funding Acknowledgement

Type of funding sources: None. BMI impact on survivalCKD impact on survival

Cryoablation: safety of same day discharge

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To assess the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive patients admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four patients were included, with a mean age of 61±10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 [178 – 729] days. Most of the patients had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two patients (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p=NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of patients with early discharge and in 8.7% of patients in overnight stay, without statistical significance between the two groups (p=0.61). The most frequent complications were local hematoma (5 patients, 2 in early discharged group), pericardial effusion (3 patients, all in overnight stay), femoral pseudo-aneurism (2 patients, 1 in each group) and arteriovenous fistula (1 patient in overnight stay group). The type of complications did not differ between the two groups (p=0.51). Two patients died during follow up, and this was unrelated to the procedure. In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups (p=NS).

Conclusion

Our study suggests that it is safe to early discharge patients submitted to AF ablation, reducing the hospital stay length in selected patients. Larger studies are needed to confirm this data before routine implementation of this strategy.

Funding Acknowledgement

Type of funding sources: None.

It is possible to predict mortality after ICD implantation?

Introduction

Implantable Cardioverter Defibrillators (ICD) therapy is not recommended in patients who do not have a reasonable expectation of survival for at least 1 year, although specific recommendations regarding clinical or functional status evaluation are lacking.

Purpose

To identify predictors of all-cause mortality in patients who implanted an ICD.

Methods

Prospective single-center study of patients who implanted ICD between 2015 and 2019. Clinical characteristics were evaluated at baseline and mortality was assessed using the national registry of citizens. We performed uni and multivariate analysis to compare clinical characteristics of patients who died and who survived using Cox regression and Kaplan-Meier methods. For the predictor creatinine, we assessed the discrimination power and the best cut-off using the area under the ROC curve (AUC) method.

Results

From 2015–2019, 414 ICDs were implanted (81% male, 62±12 years-old), and 50 (13%) of the patients died after a median follow-up of 23 [11–41] months. Patients who died during the follow-up were older (67±9 vs 61±12, p=0.002), had more diabetes (48% vs 33%, p=0.033) and a higher creatinine (1.23 [0.84–1.86] vs 1.00 [0.84–1.22], p<0.001). The remaining comorbidities were similar between groups (Fig. 1). Patients who died had more frequently an ICD implanted after complication associated with a previous device or as a pacemaker upgrade (6% vs 2%, p=0.030). They also had a higher frequency of ischaemic cardiomyopathy (i-CMP) (82% vs 56%, p=0.002) and of ejection fraction (EF) ≤50% (96% vs 82%, p=0.040). The best cut-off value of creatinine to predict mortality with a sensitivity of 65% and a specificity of 72% was 1.2mg/dl (AUC 0.650; CI95% 0.53–0.77). After adjusting for diabetes, i-CMP, EF ≤50% and upgrade/re-implantation after complication, we found that age (HR 1.033; 95% CI 1.00–1.06, p=0.041) and creatinine ≥1.2mg/dl (HR 2.134; 95% CI 1.09–4.19, p=0.028) were independent predictors of all-cause mortality.

Conclusion

In our cohort of patients who underwent ICD implantation for primary or secondary sudden cardiac death prevention, the all-cause mortality over a median follow-up period of 23 [11–41] months was 13%. We found that in addition to age, a baseline creatinine level ≥1.2mg/dl increases by 2-fold mortality in patients who undergo ICD implantation. Decisions regarding ICD candidacy should not be based on age alone but should also consider creatinine that predisposes to mortality despite ICD implantation.

Funding Acknowledgement

Type of funding sources: None. All cause mortality

Risk stratification in patients with Brugada syndrome: the role of the late potentials evaluated by signal-averaged ECG

Introduction

Brugada syndrome (BS) is a relevant cause of sudden death in individuals without structural heart disease. The accuracy of the available methods for risk stratification is very limited and the investigation of new methodologies to improve the identification of patients at risk is under intensive investigation. Recently the pathophysiological relevance of anomalous, fragmented and prolonged electrograms on the epicardial surface of the right ventricular outflow tract (RVOT) has been described. Therefore, the study of signal-averaged ECG (SA-ECG) has become attractive since it may allow the non-invasive evaluation of these electrical anomalies. In order to maximize the detection capacity and to focus the evaluation in the RVOT, we developed an alternative methodology of electrode positioning directed to this area of interest.

Purpose

To characterize the study of late potentials (LP) by SA-ECG in patients with SB and to evaluate its association with the occurrence of arrhythmia events.

Methods

Prospective single centre study of patients (pts) with BS. LP were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40 ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component (40 microV) of the terminal portion of the QRS (LAS40) in conventional and modified leads (addressed to RVOT). The association of LP with the risk of definite malignant dysrhythmias due to sudden death, ventricular fibrillation, ventricular tachycardia or appropriate shock of the implantable cardioverter defibrillator (ICD) was evaluated and the acuity of the prognostic stratification was determined by the area under the receiver operator characteristic curve (ROC).

Results

A total of 76 pts (69.7% men, age 48±12 years) were studied, of which 33 had a spontaneous type 1 pattern and 43 had a type 1 pattern induced by flecainide. During a median follow-up of 1.6 years, 13 pts (17.1%) had symptoms potentially related to BS and 6 (10.5%) had malignant arrhythmias [including two pts who suffered sudden death (2.6%).

The pts who had malignant dysrhythmias presented higher values of fQRS (125±23 vs. 108±18, p=0.046) and LAS40 (54±13 vs. 40±11, p=0.014), and lower values of RMS40 only in the modified leads (11±5 vs. 22±19, p=0.041). The parameters of the SA-ECG were significant prognostic predictors.

The acuity of each of the parameteres alone was moderate and the parameters that were identified as more powerful predictors of risk were those derived from the modified leads (Figure).

Conclusion

The LP evaluated by SA-ECG may be relevant in the prognostic stratification of patients with BS, since it seems to be associated with the risk of malignant ventricular arrhythmias.

Funding Acknowledgement

Type of funding sources: None.

Predictors of survival and ICD shocks in a population submitted to ventricular tachycardia ablation

Introduction

Sustained monomorphic ventricular tachycardia (VT) is associated with an increased risk of mortality and morbidity in patients with ischemic heart disease (IHD). While implantable cardiac defibrillators (ICD) have been shown to reduce mortality in patients with IHD and are effective in terminating VT, they are unable to prevent recurrent VT. Also, recurrent ICD shocks have been associated with an increase in all-cause mortality, hospitalizations for heart failure and are painful, resulting in impaired quality of life. Therefore, strategies to prevent ICD shocks are needed.

Aim

To evaluate risk factors associated to all cause Mortality and ICD shocks

Methods

We conducted a prospective, observational, single-centre and single-arm study involving patients with IHD, referred for Radiofrequency catheter ablation (RCA) procedure for VT using high-density mapping catheters. Variables selected from the univariate analyses (p<0.10) were entered into multivariable Cox proportional hazards regression models to estimate predictors of ICD shocks recurrence and overall mortality. All analyses were 2-sided and a P-value <0.05 was considered statistically significant. Statistical analysis was performed by using IBM SPSS Statistics 26™.

Results

From June 2015 to June 2020, a total of 64 consecutive patients were referred to our centre for a first RCA procedure using high density mapping for VT. The mean age was 68±9 years, 95% were male. 83% of patients were in NYHA functional class II or I and mean LV ejection fraction was 33±11%. All-cause mortality was 23.4%, an age higher than 70 years (p=0.01) and chronic kidney disease (CKD) were associated with reduced survival on univariate analysis. On multivariate analysis, CKD shown a tendency to reduced survival (HR 0.22; CI95%: 0.41–1.22, p=0.08). No risk factors for ICD shocks were found (table 2).

Conclusions

In our population, age and chronic kidney disease were associated with reduced survival, however no risk factors were associated with ICD shocks.

Funding Acknowledgement

Type of funding sources: None.

Long-Term outcome of ventricular tachycardia catheter ablation in ischemic heart disease patients using a high-density mapping substrate-based approach: a prospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Introduction and objective

Radiofrequency catheter ablation (RCA) for ventricular tachycardia (VT) in patients with ischemic heart disease (IHD) is associated with a reduced risk of VT storm and implantable cardioverter defibrillator (ICD) shocks. We aim to report the long-term outcome after a single RCA procedure for VT in patients with IHD using a high-density substrate-based approach.

Methods

We conducted a prospective, observational, single-centre and single-arm study involving patients with IHD, referred for RCA procedure for VT using high-density mapping catheters. Substrate mapping was performed in all patients. Procedural endpoints were VT noninducibility and local abnormal ventricular activities (LAVAs) elimination. The primary end point was survival free from appropriate ICD shocks and secondary end points included VT storm and all-cause mortality.

Results

Sixty-four consecutive patients were included (68 ± 9 years, 95% male, mean ejection fraction 33 ± 11% , 39% VT storms, and 69% appropriate ICD shocks). LAVAs were identified in all patients and VT inducibility was found in 83%. LAVAs elimination and noninducibility were achieved in 93.8% and 60%, respectively. After a mean follow-up of 25 ± 18 months, 90% and 85% of patients are free from appropriate ICD shocks at 1 and 2 years, respectively. The proportion of patients experiencing VT storm decreased from 39% to 1.6%. Overall survival was 89% and 84% at 1 and 2 years, respectively.

Conclusions

RCA of VT in IHD using a high-density mapping substrate-based approach resulted in a long-term steady freedom of ICD shocks and VT storm. Abstract Figure. Appropriate shock & all cause mortality

Catheter ablation of long-standing persistent atrial fibrillation: the ugly type of AF?

Funding Acknowledgements

Type of funding sources: None.

Introduction

In atrial fibrillation (AF) patients (pts), catheter ablation (CA) by isolating pulmonary veins (PVI) is the most effective therapeutic option in order to maintain sinus rhythm. The success rate of CA relies on type and duration of AF, being more successful in pts with paroxysmal AF and presenting suboptimal success in pts with long-standing persistent AF (LSPAF, >12 months).

Purpose

To evaluate the success of AF ablation, particularly in LSPAF.

Methods

Single-center prospective study of pts submitted to CA between 2004 and 2020. The strategy, regardless of the type of AF, was based on PVI, complemented by cavo-tricuspid isthmus line (CTI) in pts with history of flutter. Additional CA strategies were selectively considered in pts with stable atypical flutter conversion, persistent triggers or no electrograms in the VPs. Pts were monitored with Holter/7-day event loop recorder (3, 6, 12 months and annually up to 5 years). Success was assessed from the 90th day after ablation, with the absence of recurrences of any sustained atrial arrhythmias (> 30 sec). Cox regression and Kaplan-Meier survival were used to compare the success of ablation as a function of the clinical type of AF.

Results

862 pts were submitted to AF ablation (67.3% male, mean age of 58 ± 0.41 years), including 130 pts (15.1%) with LSPAF, 63.3% with paroxysmal AF and 21.6% with short-duration persistent AF (SDPAF). In LSPAF, PVI was performed with irrigated catheter in 26.4%, PVAC in 39.5% and cryoablation in 34.1%. With a mean follow up period of 838 (IQ 159-1469) days, the 3-year success rate after a single procedure was 54.1% in LSPAF, compared to 72.4% in paroxysmal AF and 61.6% in SDPAF (LogRank - p < 0.0001 - figure 1). The risk of arrhythmic recurrence was 37% higher in patients with LSPAF comparing with other groups (HR 0.63 CI 95% 0.43-0.92, p 0.016).

However after a mean of 1.17 procedures/patients, the success difference between groups was not detect (LogRank – p = 0.112 – figure 2). With additional ablation procedures (REDO), the success rate at 3 years was 82.9% LSPAF pts, compared 88.2% in paroxysmal AF pts and 83.6% in SDPAF pts.

In LSPAF pts, different ablation techniques did not predict arrhythmic recurrence. Regarding comorbidities, higher prevalence of peripheral arterial disease (PAD, p = 0.005) a higher NT-proBNP (p = 0.006) and left auricular volume (p = 0.045) were associated with arrhythmic relapse.

Conclusions

AF ablation is more effective when performed earlier in the natural history of the disease. However, even in LSPAF pts, with additional procedures an acceptable rate of success can be achieve, independently from the ablation techniques. Abstract Figures 1 and 2: Success of AF ablation

Comparing single approaches success in index atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial Fibrillation (AF) ablation can be performed by inducing pulmonary vein electrical isolation. There are two widely used approaches: point-by-point and single-shot.  Catheter AF ablation is effective in restoring and maintaining sinus rhythm. However, efficacy is limited by high rate of AF recurrence, after an initially successful procedure.

Purpose

To evaluate AF index ablation successfulness using single-shot techniques and compare them to conventional one (point-by-point using irrigated- tip ablation catheter).

Methods

We analyzed, from a single center, all patients submitted to an index AF ablation procedure and its successfulness. The last was defined as AF, atrial tachycardia or flutter recurrence (with a duration superior to 30seconds) event- free survival, determined by holter and/or event recorder. These exams were performed after 6 and 12months and then annually, until 5years post procedure were accomplished.

Results

From November 2004 to November 2020, 821patients were submitted to first AF ablation (male patients 67,2%(N = 552), mean age of 59 ± 12years old). Paroxysmal AF(PAF) was present in 62,9%(N = 516), with short-duration persistent AF in 21,8%(N = 179) and long-standing persistent in 15,3%(N = 126). Ablation techniques were irrigated tip catheter point-by-point (PbP)ablation in 266 patients (32,4%) and single-shot (SS)techniques on the remaining 555(67,6%), including PVAC in 294(35,8%),225(27,4%) submitted to cryoablation and 36(4,4%) to nMARQ.

Globally, AF ablation had one-year success rate of 72,5%, and 56,2% at 3 years. A significant difference between AF duration type was found: Arrhythmic recurrence risk was 58% higher in persistent AF(PeAF) (HR 1.58;95%IC 1,22-2,04; p < 0.001). In patients presenting with PAF prior to the procedure, success was significantly higher in those submitted to SS technique(HR:0.69;95%CI 0,47-0,90;p = 0.046), while those with PeAF had similar results.

Conclusion

In this single center analysis almost three-quarters had achieved one-year event-free survival, and more than a half reached long-term freedom from atrial arrhythmia. Patients with paroxysmal atrial fibrillation submitted to single-shot procedure presented with a higher success-rate. Moreover, our study confirmed previous data on the importance of atrial fibrillation classification to postprocedural outcomes. Abstract Figure. Survival Curves

Impact of the Covid-19 related lockdown on physical activity, heart rate and arrhythmia burden in a large prospective cohort of CHF patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): BIOTRONIK SE & Co. KG

OnBehalf

BIO|STREAM.HF

Background

At the beginning of the Covid-19 pandemic in spring 2020, governments around the world issued curfews and other stay at home orders (‘lockdown’) to limit the spread of the SARS-CoV19 virus. This may have forced people to decrease their physical activity. Physical inactivity as well as social stress is known to be especially deleterious for heart failure (HF) patients. The BIO|STREAM.HF study enrolled such HF patients into a prospective registry with Home Monitoring.

Purpose

We aimed to evaluate the impact of the lockdown during the first Covid-19 pandemic wave on physical activity and arrhythmia burden of heart failure patients.

Methods

We analysed daily transmitted data of patients enrolled into a large international registry (BIO|STREAM.HF) being implanted with a cardiac resynchronization therapy (CRT) devices. Patients with NYHA ≥ II and LVEF ≤ 40% before CRT implantation were selected.

Intra-individual weekly mean and median values were calculated for the following daily transmitted parameters: physical activity (measured as % of the day during which the patient moves), atrial arrhythmia burden, mean heart rate (at rest), PP variability, PVC burden, and rate of biventricular pacing. Values were calculated for 12 weeks before and 12 weeks after the country-specific effective date of most rigorous restrictions in spring 2020 to visualize the general trend of parameter changes. Moreover, values for intra-individual changes between three 28-days periods (before, during, and after the lockdown) were calculated.

Results

Of 444 patients, 76% were male. They had a mean age of 69 ± 10 years and LVEF of 28.2 ± 6.7%. HF was of ischemic etiology in 42% of cases and they were in NYHA class II (47.5%), III (50.0%) or IV (2.5%).

On average, patients were active for 9% of the day (2 h 10 min). The physical activity decreased by approx. 10% with the onset of the lockdown (figure 1) and recovered within the following eight weeks.

Comparison of the 28-days periods before, during and after the lockdown showed a statistically significant intra-individual decrease in physical activity (mean decrease 9 min per day) during the lockdown compared to pre- and post-lockdown values and a trend toward reduced mean heart rates. In parallel, a significant increase in device detected atrial arrhythmia burden (mean increase 17 min per day) was observed. All other parameters did not change significantly.

Conclusion 

Our results show that patients reduced their physical activity during the Covid-19 related lockdown in spring 2020. This was associated with an increase in atrial arrhythmia burden and a reduction of the mean heart rate. Prognostic implications of these results will further be analysed.

Early discharge after cryoablation procedure: is it safe?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To access the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive pts admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four pts were included, with a mean age of 61 ± 10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 (IQ 178 – 729) days. Most of the pts had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two pts (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p = NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of pts with early discharge and in 8.7% of pts in overnight stay, without statistical significance between the two groups (p = 0.61). The most frequent complications were local hematoma (5 pts, 2 in early discharged group), pericardial effusion (3 pts, all in overnight stay), femoral pseudo-aneurism (2 pts, 1 in each group) and arteriovenous fistula (1 pt in overnight stay group). The type of complications did not differ between the two groups (p = 0.51). Two pts died during the follow up, unrelated with the procedure.

In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups. (p = NS)

Conclusion

Our study suggests that is safe to early discharge pts submitted to AF ablation, reducing the hospital stay length in selected pts. Larger studies are needed to confirm this data before routine implementation of this strategy.

Withdrawal of anti-arrhythmic therapy after cavo-tricuspid isthmus ablation of typical atrial flutter

Funding Acknowledgements

Type of funding sources: None.

Introduction

Medical management of typical atrial flutter (AFL) is sometimes unsuccessful and may have adverse effects. Symptom control using radiofrequency cavo-tricuspid isthmus ablation (CTA) is a feasible alternative, given the fact that it is a simple procedure with a low rate of complications. However, in some patients (pts), new atrial arrhythmias may develop and the decision of anti-arrhythmic therapy (AAT) withdrawal is usually patient-based.

Purpose

To predict the recurrence of atrial arrhythmias (AR) after CTI ablation between pts that suspended AAT and those that maintained AAT.

Methods

Single-center retrospective study of pts with typical AFL submitted to ablation between 2015 and 2019. Pts clinical characteristics, current and follow up therapy were collected. Holter and/or 7-day event loop recorder were performed during the follow up to identify AR. For statistical analysis, we applied Chi-square, Mann-Whitney and Cox regression to identify predictors of AR.

Results

CTA ablation was performed in 476 pts (mean age: 66.3 ± 11.7 years, 79.8% males). At time of ablation most pts were in EHRA II class (70.8%) and 44.6% of pts had at least mild left atrial dilatation on transthoracic echocardiography. The mean follow up time was 2.8 years.

Two-hundred sixty-nine pts (57,6%) were under anti-arrhythmic therapy (AAT) before the ablation. After the procedure, 58 pts withdrawn AAT before AR and 8 pts after AR. During the follow-up period, we observed AR of typical AFL in 17 pts (3.6%), atypical AFL in 35 pts (7.4%) and AF in 118 pts (24.8%).

There were no statistically significant differences regarding AR between pts that maintained and suspended AAT (p = NS). Concerning the pts that suspended AAT, thyroid disfunction (p = 0.012), higher CHADs-VASc score (p = 0.033), ischemic cardiomyopathy (p = 0.001) and tobacco abuse (p = 0.005) were predictors of AR, being the last two also independent predictors (HR 0.243; 95%CI 0.76-0.778, p = 0.017; HR 4.449; 95%CI 1.128-17.553, p = 0.033, respectively). 

Conclusion

After CTA ablation, AF is the most frequent recurrent arrhythmia. Interestingly, the withdrawn of AAT didn’t seem to predict the recurrence of arrhythmic events. The decision of stopping AAT must be individualized regarding patients’ clinical characteristics. Abstract Figure 1: AAT withdrawal and AR

Typical atrial flutter ablation and predictors of events in the follow-up

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cavotricuspid isthmus ablation (CTA) is considered the main treatment for rhythm control in patients (pts) with typical atrial flutter (AFL). Although there is an established risk for embolic events in atrial fibrillation (AF), the results are not standardized for typical AFL. Currently, anticoagulation in AFL pts submitted to ablation is not consensual.

Purpose

To determine the incidence and predictors of major cardiovascular events (MACE) of pts submitted to CTA of typical AFL.

Methods

Single-center retrospective study of patients (pts) submitted to CTA between 2015 and 2019, comprising three groups: I – pts with lone AFL; II – patients with AFL and prior AF submitted to CTA only; and III – patients with AFL and prior AF submitted to IVP and CTA. Clinical records were analyzed to determine the occurrence of MACE during the long-term follow up, defined as death (of cardiovascular or unknown cause), stroke, clinically relevant bleed or hospitalization due to heart failure or arrhythmic events. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses

Results

A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 109 pts (23%) and III – 83 pts (17%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 67 ± 11, 61 ± 11, p < 0.03).

At presentation, the majority of the pts had palpitations (70.4%) and mild symptoms (70.8%). HTN and dyslipidemia were the most frequent cardiovascular risk factors, 69.5% and 53.9%, respectively, and heart failure was not frequent (27.7%) with only 5.4% of pts with LVEF < 30% and 12.4% with left atrium > 50ml/m2.

During a mean follow-up of 2.8 years, the incidence of MACE events was 102 (21,4%). Regarding MACE components: 54 pts (11.5%) died from cardiovascular death, 20 pts had stroke (4.5%), 13 (3.8%) had a clinically relevant bleeding event, and 51 pts (11.4%) were hospitalized due to heart failure or arrhythmic events.

On univariate analysis, arterial peripheric disease (p = 0.018), HTN (p = 0.046), chronic kidney disease (p <0.001), chronic pulmonary disease (p = 0.0024), heart failure (p <0.001), cerebrovascular disease (p 0.029), body mass index (p = 0.01), age (p <0.001), CHADsVASc score (p < 0.001) and left atrial diameter (p= 0.01) were associated with the occurrence of MACE.

However only age (HR 1.073; 95%CI 1.03-1.06, p < 0.001) and chronic kidney disease (HR 0.37; 95%CI 0.186-0.765, p = 0.007) were independent predictors of major events.

Conclusions

In our cohort of pts with AFL, stroke and bleeding occurred in a minority of pts. Age and chronic kidney disease predicted MACE events during follow-up. Abstract Figure. CKD as FLA predictor

P1166Women as candidates for CRT: Are they less but better?

Introduction

 Women have been under-represented in trials of cardiac resynchronization therapy (CRT).  Most available data suggest that CRT has a greater clinical benefit in women than in men. However, further studies are needed to investigate the exact reasons for these results.

Purpose

To compare the prognostic impact and response rate of CRT in women and man.

Methods

Prospective study, single-center study that included pts undergoing CRT implant from 2015 to 2019. Clinical and echocardiographic evaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevations≥10% or LV end-systolic volume (ESV) reductions≥15% were classified as responders. Patients with EF elevations ≥ 20% or ESV reductions≥30% were classified as super-responders. All the parameters were compared between women and man. Prognostic impact of CRT was evaluated as total mortality by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 561 patients were submitted to CRT implant with a follow-up duration of 18.9 ± 15.8 months. From these 148 (26.4%) were female (mean age 72.2 ± 10 years, 22.4% ischemic, LVEF < 30% in 70.2%). The cardiovascular risk factors and comorbidities were similar in both populations (women and men). In the female group, dilated cardiomyopathy was more frequent than in men (71% vs 50.8%, p < 0.01), with ischemic heart disease being the second most frequent etiology of heart failure.

The frequency of LBBB was similar in both groups (63.9% in women and 57.0% in men, p = NS) however the QRS duration was higher in women (164 ± 17 vs 160 ± 24, p = 0.017). The baseline mean EF was similar (30.5 ± 10.3ms in women and 30.3 ± 11.4ms in men) but the ESV was lower (109.7 ± 59.9 vs 138.4 ± 64.6, p < 0.001).

The prevalence of complications and need for surgical revision were similar in both groups.

The rate of CRT responders was similar in both groups, although tendentially higher in women (64.3% in women vs 55.2% in men, p = NS). On the other hand, super-responder rate was statistically significant (38% in women vs 25.1% in men, p = 0.004). The long-term survival was similar in both groups.

Conclusion

The rate of super-responders was higher in women than in men. This may be explained by the higher prevalence of dilated cardiomyopathy in this subgroup of patients and by the fact that women have smaller hearts and a larger QRS duration at baseline, most likely to have a real LBBB. Long-term mortality of CRT was not gender related

Abstract Figure. Long-term survival by gender

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

Introduction

 The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success.

Objectives

 To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping.

Methods

 Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage <1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis.

Results

 We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%.

Conclusions

 High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation.

Abstract Figure.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

Introduction

Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.

Purpose

To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.

Methods

A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups.

In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).

The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).

Conclusion

For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.

Abstract Figure.

P541Cardiac resynchronization therapy: left or non-left bundle branch block? That is the question

Introduction

Cardiac resynchronization therapy (CRT) is associated with reduced mortality and improved quality of life in patients (pts) with low ejection fraction (EF) and conduction delays. Patients with left bundle branch block (LBBB) seem to be the ones who benefit the most from CRT and there is controversy about its efficacy in patients with non-LBBB.

Purpose

To compare the prognostic impact and the response rate to CRT in patients with LBBB and non-LBBB.

Methods

Prospective single-center study of patients who implanted CRT between 2015 and 2019. Clinical, electrocardiographic and echocardiographic evaluations were made before CRT implant and between 6-12 months post-implant. Patients with EF elevation ≥ 10% or left ventricle end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. All the parameters were compared between patients with or without LBBB. Prognostic impact of resynchronization therapy was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 59% had LBBB (69% males, mean age 71.6 ± 10.8 years, 34.5% ischemic, EF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without LBBB), except for diabetes which was more frequent in non-LBBB patients (33% vs 50.6%, p = 0.007). Mean duration of QRS was similar between LBBB vs non-LBBB patients (163 ± 19ms vs 160 ± 22ms, p = NS) and baseline ejection fraction was also equivalent (29.8 ± 13.6% vs 27.9 ± 8.9%).

The prevalence of complications and surgical revisions were similar in both groups.

The response rate according to left ventricle remodelling criteria was higher in LBBB pts (65.9% vs 49.1%, p < 0.05), but the super-responders were similar in both groups (32.5% vs 26.4% p = NS).

The 4-year survival rate of patients with LBBB and non-LBBB was similar (86.5% vs 85.3%).

Conclusion

In our population the response rate to CRT was higher in LBBB pts. However, and despite the actual controversy about the efficacy of CRT in non-LBBB, the long-term mortality was similar in patients with or without LBBB.

Abstract Figure. lon-term survival

P578Multipoint pacing in cardiac resynchronization therapy - how to improve remodeling criteria and its impact in quality of life

Background

Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP.

Purpose

To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients.

Methods

Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT).

Results

 76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS).

At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01).

Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p < 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p < 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS).

Conclusion

In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume.

Abstract Figure.

P1402Isolation of pulmonary veins with duty-cycled circular multi-polar catheter: randomized controlled clinical trial

Introduction

Pulmonary vein isolation (PVI) is the central element in the ablation of atrial fibrillation (AF), and can be obtained with different ablation modalities. The duty-cycled circular multi-pole catheter PVAC® (Medtronic) allows linear application of radiofrequency energy, with the production of circumferential lesions. Conceptually, it can make ablation simpler and faster in patients with favorable anatomy.

Objectives

To evaluate the safety and efficacy of ablation with a PVAC® catheter and to compare it with the conventional technique point-by-point (PbP) with irrigated catheter.

Methods

Clinical trial with single-blinded patients with AF refractory to antiarrhythmic therapy, randomized (1: 1) for ablation with PVAC® or PbP. The ablation strategy consisted of PVI, complemented with ablation of the cavo-tricuspid isthmus in patients with history of concomitant flutter. Monitoring was performed with a 7-day event loop recorder at 3, 6 and 12 months and annually from the 2nd year. Success was defined by AF-free survival or any maintained supraventricular tachycardia (duration > 30seconds).

Results

354 patients (67.5% males, 58 ± 12 years, PbP: 175, PVAC: 179) were included, of which 59.1% had paroxysmal, 26.2% short-standing persistent and 14.7% had long-standing persistent AF. Baseline characteristics were similar between groups. Among patients treated with PVAC, 93.1% of the pulmonary veins were isolated (620/666), similar to the 98.3% immediate success of the PbP group (697/709). Although the complication rate was similar in both groups (PVAC: 4.9% vs. PbP: 7.8%; P = NS), the risk of hemopericardium was lower with PVAC (0% vs. 4.6%; P = 0.013). Two patients treated with PVAC developed stroke (1.13% vs. 0%; P = NS). The duration of the procedure was lower among the patients treated with PVAC [136 (100-180) vs. 230 (188-270) min; P <0.001], with no difference in fluoroscopy time [24.4 (14.5-36.8) vs. 27.1 (17.0-45.0) min]. The success rate after 1st ablation at 36 months was 68%, with no differences between groups. The success rate after multiple ablations increased to 85.8%, with no differences between groups.

Conclusion

The multipolar PVAC catheter can represent an added value in AF ablation, making the procedure simpler and faster, ensuring similar efficacy to the conventional technique and with a lower risk of cardiac tamponade. The present trial suggests the need for clinically manifested stroke risk surveillance, which may be increased with this technique.

Abstract Figure.

42When to implant CRT-P or CRT-D in the elderly?

Introduction

Cardiac resynchronization therapy (CRT) in elder patients is increasingly common. However, the decision to implant a device with defibrillator in these patients is often complex and it can be limited not only by the shorter life expectancy but also by a lower relative risk of arrhythmic compare to non-arrhythmic death due to other comorbidities. Thus, wether CRT is effective in an elderly population (≥75 years old), or if a defibrillator (CRT-D versus CRT-P) influences outcomes is a pivotal concern needing additional data.

Purpose

To compare the prognostic impact of CRT-P vs CRT-D in old patients (≥ 75 years old) and its impact in the response rate to CRT.

Methods

A prospective single-center study was conducted of patients indicated for a CRT implant since 2015. Demographic and clinical criteria were evaluated. Transthoracic echocardiography was performed before CRT implant and between 6-12 months post-implant. Patients with an ejection fraction (EF) elevation ≥ 10% or a LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated using the Cox regression and Kaplan-Meier methods. The decision to implant a CRT-P or CRT-D device was made according to clinical decision. Prognostic impact of CRT-P vs CRT-D was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, follow-up duration 18.9 ± 15.8 months). Among these patients, 53.5% had < 75 years old and 46.5% ≥ 75 years. Baseline clinical characteristics were similar, except for a higher prevalence of chronic kidney disease and atrial fibrillation in the elderly population. The proportion of CRT-D/CRT-P was different between these groups (p < 0.001): in the elderly group, more CRT-P were implanted (67.6% vs 32.4 CRT-D) and in the younger group more CRT-D were implanted (77.9% vs 22.1% CRT-P).

The prevalence of complications due to CRT implant was similar in the two groups (4.7% vs 4.2%, p = NS) but the need for surgical revision was less frequent in the elderly group (11.0% vs 5.7%, p = 0.03). The CRT response rate was equivalent in both groups (40.1% vs 59.9%, p = NS), as was the super-response rate (33% in young vs 26.5% in old patients, p = NS).

In the elderly population, the 4-year survival rate was similar between CRT-P and CRT-D patients (75.4% vs 79.8%).

Conclusion

Patients older than 75 years old have similar benefits from the CRT as patients < 75 years, with equivalent response rates to CRT. However, judging from the similar prognostic impact of CRT-P vs CRT-D in this elder population, the implant of a defibrillator should be personalized.

P1059Recurrence of AF after pulmonary vein isolation: how many times?

Introduction

Ablation of atrial fibrillation (AF) by catheter is an effective therapy, particularly in cases of refractoriness to medical therapy. Pulmonary vein isolation (PVI) has a significative long-term recurrence rate of AF, but the recurrence factors after this procedure are poorly defined.

Purpose

To characterize the causes of AF recurrence after PVI and to evaluate complementary strategies that can optimize the therapeutic efficacy.

Methods

A single centre prospective study of patients (pts) with AF submitted consecutively to PVI since September 2004. The variables responsible for the recurrence of AF, the complementary strategies of optimization of AF ablation and the occurrence of other dysrhythmias were evaluated.

Results

A population of 521 pts were submitted to PVI as a primary strategy for AF treatment - 36.1% for paroxysmal AF, 32.5% for persistent AF <1 year, 14.5% persistent AF> 1 year.

Eighty-three pts needed to perform 2 ablations and 10 pts performed 3 ablations. The higher the number of AF ablations, the higher the incidence of atypical atrial flutter (2% in the 1st AF ablation, 17% in the 2nd and 44% after 3 ablations).

In the pts with recurrence of AF undergoing the 2nd ablation, it was verified that most of the pulmonary veins (PV) were not isolated, with an isolation rate of only 34.1% for the right inferior PV; 29.4% for superior PV right, 29.4% lower left VP, 28.2% upper left PV. In this group, in addition to a new PVI in the pts with re-conduction of PV, 45% performed complementary ablation strategies such as: ablation of the cavo-tricuspid isthmus (52.6%); ablation of the left atrium roof line (29%); mitral isthmus ablation line (26%); applications in the scar zone (26%); posterior atrial left line (8%), atrioventricular nodal reentrant atrioventricular ablation (5%), atrial tachycardia ablation (2.6%).

In the pts submitted to the 3rd ablation, again a low PV isolation rate was confirmed: only 44.4% for the both left PV and upper right PV, and 55.6% for the right lower VP. 33.3% also performed cavo-tricuspid isthmus ablation, 22.2% lower mitral isthmus isolation and 22.2% re-isolation of gaps in the roof or intracicritricial line.

Conclusion

This prospective study demonstrates a high rate of PV re-conduction after PVI and its role in AF recurrence. Therefore, the need for a more effective and definitive IVP technique is evident.

P983Long-standing persistent atrial fibrillation: what can we achieve with ablation?

Introduction

Atrial fibrillation (AF) ablation presents suboptimal results in patients (pts) with persistent long-lasting forms (LSPAF, AF ≥12 months). Recently, the STAR AF-II trial has shown that in these pts complex additional strategies do not improve success compared to only performing pulmonary vein isolation (PVI).

Objectives

To evaluate the success of AF ablation, particularly in long-standing persistent AF

Methods

Single-center prospective study of pts with AF submitted to ablation. The strategy, regardless of the type of AF, was based on PVI, complemented by cavo-tricuspid isthmus line (CTI) in pts with history of flutter. Additional ablation strategies were selectively considered in pts with stable atypical flutter conversion, persistent triggers or no electrograms in the VPs. Pts were monitored with Holter/7-day event loop recorder (3, 6, 12 months and annually up to 5 years). Success was assessed from the 90th day after ablation, with the absence of recurrences of any sustained atrial arrhythmias (>30 sec). Cox regression and Kaplan-Meier survival were used to compare the success of ablation as a function of the clinical type of AF in our population and with pts included in STAR-II AF trial.

Results

620 patients were submitted to AF ablation, 67% male, 58±12 years, including 78 pts (13%) with LSPAF - pts with paroxysmal and persistent short duration AF represented 61% and 26% of the population. In LSPAF, VPI was performed with irrigated catheter (N=33), PVAC (N=44) or nMARQ (N=1), complemented by CTI ablation in 15, linear left atrial lesions in 3, ablation of areas of low voltage in 3 and elimination of fractionated electrograms in 1 patient.

With a median follow-up of 426 days (94–989), the 3-year success rate after a single procedure was 53% in LSPAF, lower than that observed in patients with paroxysmal AF (69%) or short-duration persistent AF (61%) - LogRank P=0.002. The risk of arrhythmias was double in LSPAF vs paroxysmal AF (HR: 2.0; P=0.001). However, after an average of 1.2 procedures/patient, the success rate in LSPAF was 80% at 3 years, comparable to that observed for other types of AF (Log Rank 2.5, p=0.29). Effectively, the long-term success rate of our LSPAF pts treated with PVI and very selective additional strategies was higher than that observed in the STAR-II AF pts treated with PVI and indiscriminate complex ablations (80% vs. 69%, t-test p<0.001, with similar mean follow-up).

Conclusions

AF ablation is more effective if it is performed earlier in the natural history of the disease. However, even in LSPAF, high success rates are achieved through PVI-based ablation strategies, although more procedures are required.

P987Dilated cardiomyopathy - a group that does not benefit from ICD?

Introduction

The prevalence of sudden death in patients with heart failure with reduced ejection fraction has been declining in the last decade, not only due to better optimization of pharmacological therapy, but also due to the high rate of cardiac resynchronization responders. Overall, based on recent studies demonstrating a lack of improvement in mortality in some patients with dilated cardiomyopathy, the CRT-P/CRT-D implantation ratio has been increasing across Europe.

Objective

To evaluate the evolution of the CRT-P/CRT-D implantation ratio and to evaluate the impact on mortality of dilated cardiomyopathy (DCM) patients who underwent resynchronization therapy.

Methods

A single-center prospective study of non-randomized patients who underwent CRT implantation since 2015. Demographic and clinical data from patients with dilated cardiomyopathy were assessed. The mortality of these patients and the predictors of mortality by the Cox and Kaplan-Meier regression method were evaluated.

Results

486 CRTs were implanted since 2015 (male 73.9%, age 72.06±9.9 years, median follow-up time of 487 days IIQ [175, 749].) During the last 3 years, occurred an increased in CRT-P/CRT-D ratio with the CRT-P implant rate increasing from 36% of the total devices in 2015 to 47% in 2018. Of the patients submitted to CRT implantation, 256 (55%) had dilated cardiomyopathy as the etiology of heart failure. In this population, by multivariate Cox analysis, age (HR 1.1, 95% CI 1.0–1.1, p=0.003) and GFR <60ml/min/1.73m2 (HR 1.8 IC 95% 1, 2–2.6, p=0.01) were independent predictors of mortality. In addition, CRT-D implantation in these patients was associated with a significant reduction in all-cause mortality (HR 0.33 95% CI 0.15–0.73, p<0.01) with a required number to treat only 10 patients. Similar results were obtained in the subgroup of patients aged ≥59 years.

Mortality in DMC – CRT-P vs CRT-D

Conclusion

The CRT-P implant rate has been increasing at the expense of the CRT-D implant after some studies suggest no benefit in the population aged ≥59 years. However, in our population of patients with DCM, CRT-D implantation demonstrated a 67% mortality reduction. These results may demonstrate a good selection of patients for this therapy, but should also motivate further studies in the evaluation of mortality in this subgroup of patients.

Reduction in the severity of early onset severe preeclampsia during gestation may be associated with changes in endothelial cell activation: A pathological case report

Early severe preeclampsia with changes consistent with the Hemolysis elevated liver enzymes low platelet count (HELLP) variant and severe fetal growth restriction rarely resolves prior to delivery. Established clinical disease is preceded by endothelial dysfunction and inflammation. Endothelial activation is reported in vitro to be raised in the presence of necrotic trophoblastic debris which is deported into the maternal circulation in preeclampsia. We report on an early severe preeclamptic patient admitted at 24 weeks gestation. Maternal serum was taken at day 2, 16, 30 of admission and 45 days postpartum. 20% maternal serum or trophoblastic debris from first trimester placental explants that had been cultured with 10% maternal serum was exposed to endothelial cells. Endothelial cell activation was quantified by the cell surface ICAM-1 expression and U937 monocyte adhesion assay. The clinical condition of this patient improved including the blood pressure, liver function, and platelet count by the 3rd day after antihypertensive treatment and remained normal until delivery at 37 weeks. ICAM-1 expression and U937 moncyte adhesion assay of endothelial cells was significantly increased following exposure of the endothelial cells to the maternal serum or trophoblastic debris from placentae treated with maternal serum drawn on day 2. However, ICAM-1 expression and the monocyte adhesion assay were significantly reduced following exposure of endothelial cells to maternal serum or trophoblastic debris from placenta treated with maternal serum drawn on day 16 or 30. Our data suggest unknown factor(s) in the maternal serum triggered endothelial cell activation when the clinical symptoms were present. The improvement in the clinical condition occurred along with the changes in endothelial cell activation.