A hybrid clinical and electrocardiographic score to predict the origin of outflow tract ventricular arrhythmias

BACKGROUND

To predict the outflow tract ventricular arrhythmias (OTVA) site of origin (SOO) before the ablation procedure has important practical implications. The present study sought to prospectively evaluate the accuracy of a clinical and electrocardiographic hybrid algorithm (HA) for the prediction of OTVAs-SOO, and at the same time to develop and to prospectively validate a new score with improved discriminatory capacity.

METHODS

In this multicenter study, we prospectively enrolled consecutive patients referred for OTVA ablation (N = 202), and we divided them in a derivation sample and a validation cohort. Surface ECGs during OTVA were analyzed to compare previous published ECG-only criteria and to develop a new score.

RESULTS

In the derivation sample (N = 105), the correct prediction rate of HA and ECG-only criteria ranged from 74 to 89%. R-wave amplitude in V3 was the best ECG parameter for discriminating LVOT origin in V3 precordial transition (V3PT) patients, and was incorporated to the novel weighted hybrid score (WHS). WHS correctly classified 99 (94.2%) patients, presenting 90% sensitivity and 96% specificity (AUC 0.97) in the entire population; WHS mantained a 87% sensitivity and 91% specificity (AUC 0.95) in patients with V3PT subgroup. The high discriminatory capacity was confirmed in the validation sample (N = 97): the WHS exhibited an AUC (0.93), and a WHS ≥ 2 allowed a correct prediction of LVOT origin in 87 (90.0%) cases, yielding a sensitivity of 87% and specificity of 90%; moreover, the V3PT subgroup showed an AUC of 0.92, and a punctuation ≥ 2 predicted an LVOT origin with a sensitivity of 94% and specificity of 78%.

CONCLUSIONS

The novel hybrid score has proved to accurately anticipate the OTVA's origin, even in those with a V3 precordial transition. A Weighted hybrid score. B Typical examples of the use of the weighted hybrid score. C ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the derivation cohort. D ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the V3 precordial transition OTVA subgroup.

Risk of cardiac complications during pregnancy in patients with cardiac devices

Background

Pregnant women with cardiac devices (pacemaker or defibrillators [ICD]) are increasing in developed countries. Risk stratification in these patients is challenging, since presence of cardiac devices are not considered specifically neither in mWHO nor CARPREG II scales. In addition, the previous evidence is scarce and heterogeneous, based mostly on observational studies published years ago.

Purpose

To describe the intrinsic risk for cardiovascular complications of pregnant women with cardiac devices.

Methods

We designed a prospective study including all pregnancies under follow-up in our Heart Disease and Pregnancy Unit between January 2013 and December 2020, selecting those patients with an intracardiac device at the time of pregnancy. Following institutional review board approval, data were collected from medical records in order to classify the patients according to the type of heart disease and the mWHO scale. CARPREG II scale was calculated retrospectively from 2014 to 2018 and prospectively afterwards. All cardiological complications were identified during each pregnancy and puerperium, defined as the appearance of heart failure, arrhythmias or thrombotic complications.

Since our patients were classified in mWHO groups 2 or 2–3, we compared the incidence of complications between our cohort of patients with devices and the rest of the pregnancies of mWHO 2–3 patients without devices. We also included in the analysis patients with an unspecified mWHO. A mWHO IV patient was excluded from analysis.

Results

A total of 323 pregnancies were identified, of which 15 were in patients with devices (4.6%) and 135 in mWHO 2–3 patients without devices (41.8%). There were 9 pregnancies in 6 pacemaker carriers and 6 in 6 ICD carriers. The mean age was 34.3 years. None of them had other cardiovascular risk factors. A total of 2 cardiac complications were identified: one patient in the pacemaker group and another in the ICD group presented with a lead thrombosis at 25 and 30 weeks respectively. In both patients, anticoagulation with weight-adjusted enoxaparin was started. In the other hand, in the mWHO 2–3 patients without devices we identified 2 complications in the form of heart failure episodes: one during third trimester and another in puerperium.

When comparing our device patient group (n=14) with the mWHO 2–3 patients without devices (n=135), we observed a statistically significant higher incidence of complications in the device group (14.3% vs 1.5%, p=0.002).

Conclusions

Pregnant women with cardiac devices have a higher risk of complications than pregnant women with a similar risk profile according to the mWHO scale, mainly in the form of lead thrombosis.

Funding Acknowledgement

Type of funding sources: None.

Spanish registry of cardiac resynchronization therapy in adults with congenital heart disease (RETRACCA): clinical outcomes at one year follow-up

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Spanish Society of Cardiology

Background

There are limited data about the impact of cardiac resynchronization therapy (CRT) in adults with congenital heart disease (CHD) with conflicting results in patients (P) with systemic right ventricle (SRV).

Objectives

We analyzed the one-year outcomes of adults with CHD implanted with CRT and the impact of CRT in P with SRV as compared with systemic left ventricle (SLV).

Methods

Data were analyzed from the Spanish Registry of CRT in adults with CHD (RETRACCA). This is an observational, ambispective (66 % retrospective), multicenter Registry, including 74 adults with CHD implanted with a CRT device from 6 Spanish centers from 2007 to 2021. Ventricular function was assessed by echocardiography and graded on a four-point ordinal scale. Response to CRT was defined as an improvement in NYHA functional class and/or systemic ventricular ejection fraction by at least one category. In addition to changes in functional class and ventricular function, other outcomes analyzed included mortality, heart transplantation and CRT-related complications.

Results

68 P completed one year of follow-up. Table 1 shows the baseline characteristics of the P prior to CRT. The two main indications for CRT were depressed systolic function of the systemic ventricle with more than 40 % ventricular pacing (69 %) and severely depressed systolic function of systemic ventricle, NYHA FC II-IV and QRS > 150 (18 %). Sixty percent of P received a CRT-ICD, whereas 40 % received a CRT-pacemaker. The approach for CRT system implantation was transvenous in 70 % of the patients, mixed in 21 % and fully epicardial in 9 %. Overall, 43 out of 68 patients (75 %) responded to CRT either by improvement of NYHA FC (56 %) and/or systemic ventricular function (41 %). Compared with baseline, CRT was associated with significant improvement in NYHA FC (p<0.001; figure 1), QRS duration (169±31 vs 150±29; p=0.005), and systemic ventricle systolic function (severe or moderate 80 % vs 58 %; p=0.04). Percentage of responders was similar among patients with a SLV (73 %) and with SRV (81 %; p=0.51). Only pre-implant NYHA FC III-IV was predictive of a positive response in the univariate analysis (OR 3.82; 95 % CI 1.03-14.18). Seven complications occurred at implant (10 %). During the follow-up, there were 8 complications in 7 P: 2 P had heart transplantation, 3 P required hospital admission for decompensation of heart failure, 2 P presented pocket infections and 1 lead malfunction. No differences in complication rates were observed between the systemic LV and systemic RV subgroups.

Conclusions

In this series, at one-year follow-up, CRT resulted in improvement in functional class and/or systemic ventricular function in 75 % of P with adult CHD. The percentages of responders and complications were similar among patients with SLV or SRV.

Predictors of positive electrophysiological study in patients with syncope and bundle branch block: PR interval and type of conduction disturbance

BACKGROUND

Electrophysiological study (EPS) is indicated in patients with syncope and bundle branch block (BBB). Data about predictors of positive EPS in these patients is scarce.

OBJECTIVE

To assess clinical and electrocardiographic (ECG) predictors of positive EPS in patients with syncope and BBB.

METHODS

Observational single-center study that included all consecutive patients with syncope and BBB that underwent EPS from January 2011 to June 2017. Results of EPS were considered positive according to current ESC syncope guidelines.

RESULTS

During study period, 271 patients were included (64.9% male, age: 73.9 ± 12.2 years, number of syncopal episodes: 2.4 ± 2.5, LVEF: 56.1 ± 9.9%). Type of BBB: RBBB + LAFB/LPFB in 39.8%, isolated LBBB in 38.7% and isolated RBBB in 18.5% of the patients. Duration of QRS and PR interval were 141.9 ± 16.7 and 182.8 ± 52.2 milliseconds. EPS was positive in 41.7% of the patients. In multivariate analysis, conduction disturbance pattern and long PR interval (OR 8.6; 2.9-25; P < 0.0001) were predictors of positive EPS. Conduction disturbance patterns related with positive EPS were: BBB different than isolated RBBB (OR 15.2; 2.2-23.4; P = 0.005), LBBB or RBBB+long PR + left fascicular block (OR 4.5; 1.06-20.01; P < 0.042), and RBBB+left fascicular block compared with LBBB (OR 4.8; 1.2-16.7; P = 0.025). Clinical factors and syncope characteristics were not related with EPS result.

CONCLUSIONS

Diagnostic yield of EPS in patients with syncope and BBB is moderate (41%). Type of conduction disturbance pattern and PR interval are associated with the electrophysiological (EP) test result. Patients with LBBB or bifascicular block have the highest rate of positive EP test. Long PR interval increases the proportion of positive EPS in all conduction disturbance patterns.

Life-threatening and life-saving inappropriate implantable cardioverter defibrillator shocks

An implantable cardioverter defibrillator (ICD) lead dislodgement into the right atrium is a dangerous situation, particularly in patients in atrial fibrillation because atrial fibrillation can be sensed as ventricular fibrillation and true ventricular fibrillation induced with an inappropriate shock. In the presence of shocks, ICD interrogation should be performed as soon as possible.

A Risk Score to Predict the Absence of Left Ventricular Reverse Remodelling: Implications for the Timing of ICD Implantation in Primary Prevention

Collapse