Evaluation of a multisensory algorithm to prevent acute decompensation of heart failure in patients implanted with a cardioverter defibrillator: rationale and design

Background

Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs [1–4]. HeartLogic is an algorithm incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing preemptive treatment of congestion to prevent acute decompensation [5–7].

Objectives

We aim to provide real-world data on the impact of pre-emptive HF management, guided by the HeartLogic index on unscheduled HF hospitalizations in a substantial cohort of patients.

Methods

The HeartLogic French Study is an investigator-initiated, prospective, multi-centre, non-randomized study. All in all, 310 patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic index calculation will be included across 10 French centers. The HeartLogic index will be monitored remotely on a weekly basis for 12 months and in case of HeartLogic index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, and unscheduled hospitalizations for ventricular or atrial arrhythmia. Blood samples will be collected for biobanking, and quality of life will be assessed. A blind and independent committee will adjudicate the events.

Conclusions

The HeartLogic French Cohort Study will provide robust real-world data on HF hospitalization in a cohort of patients managed with the HeartLogic algorithm allowing preemptive treatment of congestion.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Infection and infective endocarditis after cardiac implantable electronic device implantation: a contemporary nationwide cohort study

Funding Acknowledgements

Type of funding sources: None.

Aims

To determine the contemporary incidence and risk factors of infection and infective endocarditis (IE) following implantation of a first-time, permanent, cardiac implantable electronic device (CIED).

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals from January 1, 2010 to December 31, 2019, who underwent a de novo permanent pacemaker (PM) or implantable cardioverter defibrillator (ICD) implantation were identified together with the occurrence of post-implantation infection and IE-events during follow-up.

Results

In total 688,007 CIED patients with de novo implants were identified (single-chamber pacemaker 18.8%, dual-chamber pacemaker 64.9%, cardiac resynchronization therapy [CRT]pacemaker 3.2%, single-chamber ICD 4.3%, dual-chamber ICD 3.4%, CRT ICD 5.5%). Follow-up was 2.6±2.6 years (median 1.9, IQR 0.2-4.3 years) and total follow-up time was 1,788,166person-years (PYs). There were 9,804 patients with CIED-related infection during follow-up (incidence rate 5.48 per 1000 patient.year) among whom 2,658 had IE (incidence rate 1.49 per 1000 patient.year).

The incidence rate (per 1000 PYs) of CIED-related infection and IE in the different subgroups of patients with pacemakers and ICD (single-chamber, dual-chamber, CRT) are in table 1. Incidence rates were higher in patients with an ICD than in those with a pacemaker, and higher in those with CRT. Incidence rates of CIED-related infection and IE were not different in single-chamber vs dual-chamber CIEDs(table 1).

In multivariable analysis, ICD (vs pacemaker, HR: 1.59; 95% CI 1.40-1.80) and CRT (vs no CRT, HR: 1.21; 95% CI: 1.07-1.37) were independent risk factors for CIED-related infection. Dual-chamber pacemakers were not associated with a higher risk of CIED-related infection than single-chamber pacemakers. Similarly, dual-chamber ICDs were not associated with a higher risk of CIED-related infection than single-chamber ICDs (table). There were similar findings when analysing the risk of IE during FU. ICD (vs pacemaker, HR: 1.31; 95% CI 1.23-1.40) and CRT (vs no CRT, HR: 1.24; 95% CI: 1.16-1.32) were independent risk factors for IE. Dual-chamber pacemakers were not associated with a higher risk of IE than single-chamber pacemakers and dual-chamber ICDs were not associated with a higher risk of IE than single-chamber ICDs (table).

Results were similar when one considered separately the periods 2010-2014 and 2015-2019

Conclusion

The risk of CIED-related infection and IE was significantly higher in patients with ICDs than in those with pacemakers and significantly higher with CRT than with no CRT. By contrast, there was no statistical difference in the risk of CIED-related infection and IE in patients with single-chamber or dual-chamber CIEDs in this contemporary analysis at a nationwide level.

Are the results of the RATE-AF trial reproducible in daily practice? Clinical outcomes with digoxin vs beta-blocker for heart rate control in permanent atrial fibrillation

Background

There is little evidence to support selection of heart rate control therapy in patients with permanent atrial fibrillation (AF), in particular those with coexisting heart failure. In the recent RATE-AF trial that included patients with permanent AF and symptoms of heart failure, treatment with low-dose digoxin or bisoprolol did not result in statistically significant difference in quality of life at 6 months. The purpose of the study was to analyse whether the clinical outcomes may differ among unselected patients with permanent AF treated with digoxin or beta-blocker seen in daily practice.

Methods

All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. Among them 1,787 patients had the RATE-AF criteria of inclusion (permanent AF, age ≥60 and NYHA ≥2), of whom 512 patients (29%) were treated with beta-blocker alone, 425 (24%) were treated with digoxin alone and 237 (13%) were treated with both a beta-blocker and digoxin. Outcomes in patients treated with beta-blocker alone or digoxin alone were compared after 1:1 propensity-score matching.

Results

After propensity score matching, 270 patients treated with beta-blocker were matched 1:1 with 270 patients treated with digoxin. In these patients (age 79±8 years, CHA2DS2VASc score 4.0±1.3), 125 deaths were recorded during a follow-up of 2.2±2.7 years (median 1.1, interquartile 0.1–3.5 years, yearly rate of death 10.4%) including 72 cardiovascular deaths (yearly rate 6.0%). Major clinical events (all-cause death, myocardial infarction, ischemic stroke or major bleeding) were recorded in 192 patients (yearly rate 19.1%). In this matched analysis, risk was not statistically significant in the 2 groups for all-cause death (HR 0.95, 95% CI 0.67–1.35 for beta-blocker use vs digoxin use), cardiovascular death (HR 1.23, 95% CI 0.77–1.96 for beta-blocker use vs digoxin use) or major clinical events (HR 0.98, 95% CI 0.74–1.31 for beta-blocker use vs digoxin use).

Conclusion

Our analysis included more patients and had a longer follow-up than in the RATE-AF trial, resulting in a 10-fold higher number of clinical events. We found that among patients with permanent AF and symptoms of HF, there was no statistically significant difference in the risk of all-cause death, cardiovascular mortality and major clinical events between those treated with digoxin or beta-blocker. Concerns regarding the use of digoxin, such as the narrow therapeutic window and drug interactions, were not issues resulting in worse clinically relevant cardiovascular outcomes with the approach used in the current study.

Funding Acknowledgement

Type of funding sources: None.

Benefits for clinical outcomes associated with dual-chamber pacing versus ventricular pacing in patients with sinus-node dysfunction: a nationwide matched control study

Introduction

Evidence from randomized trials suggests that, in patients with sinus-node dysfunction (SND), physiologic pacing (dual-chamber, DDD) may be superior to single-chamber (ventricular, VVI) pacing because it is associated with lower risks of atrial fibrillation and stroke, better exercise capacity and lower risk of pacemaker syndrome. However, benefits on mortality and risk of heart failure have not been demonstrated and these issues have not been fully evaluated in large “real life” analyses. The aim of our study was to assess and compare clinical outcomes within the first 30 days and during a longer-term follow-up with the two types of pacing at a nationwide level for patients with SND.

Methods

Using the administrative hospital database in France 2010–2020, 52,974 patients with SND were included in the analysis: 4,069 patients had VVI pacing and 48,905 had DDD pacing. Patients with leadless VVI pacemakers were excluded of the analysis. After propensity score matching 2,213 patients with VVI pacemaker were matched 1:1 with 2,213 patients treated with DDD pacemaker.

Results

In the matched analysis, patients with DDD pacemakers had a lower rate of all-cause (hazard ratio HR 0.711, 95% CI 0.61–0.828) and cardiovascular death (HR 0.628, 95% CI 0.48–0.818) within the 30 days after implantation. There were no significant differences for incidence of tamponade (HR 0.666, 95% CI 0.11–3.992), pneumothorax (HR 1.000, 95% CI 0.32–3.105), hemothorax (HR 0.800, 95% CI 0.21–2.982), major bleeding (HR 0.824, 95% CI 0.68–1.005) and transfusion (HR 1.016, 95% CI 0.83–1.243). During subsequent follow-up (mean: 3.0±2.8 years), risk of all-cause death in the matched population was significantly lower in the DDD group than in the VVI pacemaker group (HR 0.683, 95% CI 0.60–0.784). Patients with SND treated DDD pacemakers also had a lower risk of cardiovascular death (HR 0.569, 95% CI 0.44–0.732), new-onset atrial fibrillation (HR 0.638, 95% CI 0.58–0.706), ischemic stroke (HR 0.685, 95% CI 0.53–0.887) and hospitalization for heart failure (HR 0.758, 95% CI 0.68–0.850) than those treated VVI pacemakers, whilst risk of endocarditis was not significantly different (HR 0.986, 95% CI 0.50–1.951).

Conclusion

Patients with SND treated with DDD pacemakers had better clinical outcomes compared to those treated with VVI pacemakers. DDD pacing was associated with lower risks of death, cardiovascular death, new-onset atrial fibrillation, ischemic stroke, hospitalization for heart failure. DDD pacing was neither associated with a higher risk of complication on the short-term nor of endocarditis on the longer-term.

Funding Acknowledgement

Type of funding sources: None.

Long-term clinical outcomes in patients after catheter ablation for atrial fibrillation or atrioventricular node ablation: a French nationwide cohort study

Background

Catheter ablation of atrial fibrillation (AF) has become a therapy of choice to treat symptomatic AF in current practice. As an alternative, atrioventricular node (AVN) ablation is an older but efficient procedure to control ventricular rate.

Purpose

To assess long-term clinical outcomes of AF ablation and AVN ablation in large cohort of patients with AF and to compare these two procedures.

Methods

This French multicentric retrospective study enrolled all patients hospitalized with a primary or secondary diagnosis of AF from 1st January 2010 to 31st December 2019, using an administrative hospital-discharge database. Clinical outcomes were analyzed in overall population and in propensity-matched samples.

Results

During follow-up (mean [SD] 2.0 [2.2], median [IQR] 1.0 [0.1–3.3] years), 2,438,015 patients were analysed (No ablation 2,360,833, AF ablation 62,490 and AVN ablation 14,692). Compared to patients treated without ablation, incidence of all-cause death was lower in patients treated with AF ablation (hazard ratio (HR) 0.272, 95% confidence interval (CI) 0.259–0.287, p<0.0001) or AVN ablation (HR 0.762, 95% CI 0.734–0.791, p<0.0001). After propensity-score matching, in patients treated with AF ablation, incidence of all-cause death (HR 0.662, 95% CI 0.557–0.788, p<0.0001), cardiovascular death (HR 0.617, 95% CI 0.471–0.807, p<0.0001) and hospitalization for heart failure (HF) (HR 0.732, 95% CI 0.620–0.865, p<0.0001) were lower compared to patients treated with AVN ablation, unlike incidence of ischemic stroke (HR 1.447, 95% CI 1.122–1.865, p<0.0001).

Conclusion

AF ablation and AVN ablation may be associated with better survival compared to non-invasive strategy. Compared to AVN ablation, AF ablation is associated with lower risk of all-cause death, cardiovascular death and hospitalization for HF, but higher incidence of ischemic stroke.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics matched cohortMain results

Conventional transvenous or leadless ventricular permanent pacemakers: post-operative complications and mid-term follow-up

Introduction/Background

Leadless ventricular permanent pacemakers (leadless VVI, LPM) were designed to reduce lead-related complications of conventional VVI pacemakers (CPM).

Purpose

The aim of our study was to assess and compare real-life clinical outcomes within the first 30 days and during a mid-term follow-up with the two techniques at a nationwide level.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2017 to September 1, 2020, who underwent a first LPM or CPM implantation were included. Importantly, patients with dual chamber pacemaker were not included in our study.

Results

Of 42,315 patients included in the cohort, 40,828 patients (96%) had a CPM and 1,487 had a LPM. Using propensity score, 1,344 patients with CPM were adequately matched in a 1:1 fashion with LPM patients.

Clinical outcomes at day 30

In the unmatched population, within the 30 days after implantation, patients with LPM had a lower rate of all-cause mortality (OR: 0.635, 95% CI: 0.527–0.765, p<0.0001) and from a cardiovascular cause (OR: 0.568, 95% CI: 0.405–0.797, p=0.001). They also had lower rates of major bleeding and need for transfusion. There was no significant difference between groups regarding tamponade, pneumothorax or hemothorax.

In the matched population, LPM implantation was still significantly associated with a lower rate of all-cause death (OR: 0.583, 95% CI: 0.456–0.744, p<0.0001), cardiovascular death (OR: 0.413, 95% CI: 0.271–0.629, p<0.0001), major bleeding (OR: 0.523, 95% CI: 0.348–0.786, p=0.002) or transfusion (OR: 0.481, 95% CI: 0.296–0.780, p<0.0001). However, tamponade, pneumothorax or hemothorax were not significantly different between the two groups.

Clinical outcomes during mid-term follow-up

In the unmatched patients, mean follow-up was 8.6±10.5 months. Annual incidence of all-cause death was high in both groups, and significantly higher in the LPM group than in CPM group (31%/year vs. 20%/year, p<0.0001) with a HR of 1.519 (95% CI: 1.296–1.780). Cardiovascular death was not significantly different between groups. Infective endocarditis was higher in the LPM group than in the CPM group with a HR of 2.108 (95% CI: 1.119–3.973).

In the matched patients, mean follow-up was 6.2±8.7 months. All-cause death, cardiovascular death and infective endocarditis were not significantly different between groups.

Conclusion

Mortality is high among unselected patients implanted with ventricular permanent pacemakers, whether leadless or conventional pacemaker are used.

Implantation of leadless pacemakers seems to be a safe procedure in this high-risk population, with better outcomes at 1 month.

Mid-term outcomes appear relatively similar in LPM and CPM patients.

Funding Acknowledgement

Type of funding sources: None. Central illustration

All-cause mortality and cardiovascular death in 52091 patients with hypertrophic cardiomyopathy. A nationwide cohort study

Background

Patients with hypertrophic cardiomyopathy (HCM) have high risk of death related to cardiovascular (CV) death. Improvements in risk stratification are needed to help identify those HCM patients at higher risk of all-cause death and cardiovascular death.

Methods

This French longitudinal cohort study from the database covering hospital care from 2010 to 2019 analyzed adultshospitalized with isolated HCM. The overall sample of 52,091 patients was randomly partitioned into derivation (n=26,067) and validation (n=26,024) populations. A logistic regression model was used to construct HCM death and CV-death scores in the derivation sample, which were compared to the Charlson index, Frailty index and CHA2DS2VASc scores using c-indexes and calibration analysis.

Results

In 52,091 patients with isolated HCM, 12,676 (24.0%) died during follow-up of 3.0±2.8 years (median 2.3, interquartile range 0.4–5.0). Rate of all-cause death was 8.10%/year (7.96–8.24) and was 2.76%/year (2.68–2.84) for CV death.Independent predictors of CV death in HCM were older age, diabetes mellitus, heart failure, history of pulmonary edema, atrial fibrillation, ventricular tachycardia or fibrillation, ischemic stroke, while smoking and poor nutrition were associated with better survival (all p<0.05). In addition to these, male sex, vascular disease, alcohol related diagnoses, kidney disease, lung disease, liver disease anemia and cancer were independent predictors of all-cause death. In the derivation cohort, c-indexes for the HCM death score were 0.720 (0.713–0.727) for all-cause death and 0.695 (0.685–0.705) for CV death. For the HCM CV-death score, c-indexes were 0.679 (0.671–0.686) for all-cause death and 0.723 (0.712–0.733) for CV death. Performances were very similar in the validation cohort. Both scores had good calibrations. Charlson and Frailty indexes however had a better clinical usefulness than the HCM death score and HCM CV-death scores for predicting all-cause death. Decision curve analysis for CV death demonstrated that the HCM CV-death score had the best clinical usefulness of all the tested risk scores.

Conclusion

HCM patients have a high risk of all-cause and CV mortality. Independent predictors of CV-mortality in HCM were used to derive and validate a simple risk prediction model (French HCM CV-mortality score) which performed better than clinical scores, Charlson Index and Frailty Index; showing the best clinical usefulness, with good calibration.

Funding Acknowledgement

Type of funding sources: None.

Single-chamber transvenous and subcutaneous defibrillators: clinical outcomes

Introduction/Background

By using an entirely extra-thoracic lead placement, subcutaneous implantable cardioverter–defibrillators (S-ICD) were designed to avoid lead-related complications of single-chamber transvenous implantable cardioverter-defibrillators (VVI ICD).

Purpose

Our objective was to assess and compare outcomes following first VVI ICD or S-ICD implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2010 to September 1, 2020, who underwent a VVI ICD or S-ICD implantation were included. Patients with a previous pacemaker or ICD or with a history of infective endocarditis were excluded.

Results

21,667 patients were included in the cohort, 19,493 patients had a transvenous VVI ICD and 2,174 had a subcutaneous ICD.

Mean follow-up was 28.8±31.8 months. S-ICD patients was associated with higher rate of all-cause death (HR: 1.684, 95% CI: 1.309–2.165, p<0.001). There were no significant differences in cardiovascular death (HR: 1.092, 95% CI: 0.697–1.711, p=0.70) and infective endocarditis (HR: 0.354, 95% CI: 0.067–1.433, p=0.15) between the two groups

Using propensity score, 1,582 patients with VVI ICD were matched 1:1 with S-ICD patients. Mean follow-up was 4.5±7.2 months. In the matched analysis, there were no significant differences in all-cause death (HR: 1.090, 95% CI: 0.728–1.633, p=0.68) and cardiovascular death (HR: 1.167, 95% CI: 0.603–2.260, p=0.65) between the two groups. A trend toward a lower risk of infective endocarditis in the S-ICD group was also observed without reaching significance (HR: 0.219, 95% CI: 0.047–1.017, p=0.053).

A sensitivty analysis in patients with coronary artery disease in the matched cohort was performed. 1,024 patients had a VVI ICD and 977 had a S-ICD. Same trends were observed without significant differences in all-cause death (HR: 0.966, 95% CI: 0.605–1.543, p=0.88) and cardiovascular death (HR: 1.307, 95% CI: 0.610–2.799, p=0.49).

Conclusion

Our nationwide study highlighted a higher risk of all-cause death in patients treated with subcutaneous which however was not statistically significant after propensity score matching. No differences regarding cardiovascular mortality was found. An interesting trend toward diminution of infective endocarditis was also observed without reaching significancy.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristicsCardiovascular death

Season of birth and cardiovascular mortality in atrial fibrillation: a population-based cohort study

Funding Acknowledgements

Type of funding sources: None.

Background. Month and season of birth may be indicators for a variety of prenatal and early postnatal exposures and they have been associated with life expectancy in adulthood. It is suggested that people born in the autumn on the northern hemisphere live longer than those born during the spring or summer, who may have an increase in cardiovascular disease specific mortality. Only few studies have followed populations longitudinally and no study has investigated the relation between season of birth and mortality in patients with established cardiac conditions.

Methods. All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. The relation between season of birth (autumn, winter, spring and summer) and mortality risk was assessed using Cox proportional hazard regression models using autumn as the reference. Analyses were also made separately for men and women. 

Results. In these 8962 patients (age 70 ± 10 years, CHA2DS2VASc score 3.1 ± 1.7), 1253 deaths were recorded during a follow-up of 2.5 ± 3.0 years (median 1.2, interquartile 4.3 years, yearly rate of death 5.5%) and 97% of causes of death were identified. Cardiovascular deaths accounted for 54% and 43% for non-cardiovascular. The three main causes of death were heart failure (29%), infection (18%) and cancer (12%). 

Season of birth was a significant predictor of cardiovascular mortality (overall p = 0.0006). The lowest mortality was seen for people born in autumn or winter and the highest mortality in those born in spring and summer. This was mainly related to a higher cardiovascular mortality in males (hazard ratio [HR] 1.46, 95%CI 1.10-1.93, p = 0.009 for males born in spring and HR 1.44, 95%CI 1.08-1.91, p = 0.01 for those born in summer when compared to males born in autumn as the reference) while this effect was not seen in women. In a model adjusted for age, CHA2DS2VASc score, HASBLED score, cardiovascular risk factors, other comorbidities, AF pattern, antithrombotic use and other cardiovascular drugs use, a higher cardiovascular mortality was still seen in males born in spring (adjusted HR 1.43, 95%CI 1.05-1.96, p = 0.03) or in summer (adjusted HR 1.46, 95%CI 1.07-1.99, p = 0.02) when compared to those born in autumn while this was not seen in women.

Conclusion. Birth in spring or summer is associated with a higher risk of cardiovascular mortality in male AF patients. Further studies should aim at clarifying the mechanisms behind this association, which would support the so-called fetal origins hypothesis.

Real-world experience with the insertion of a new implantable cardiac monitor

Funding Acknowledgements

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

OnBehalf

BIO|CONCEPT.BIOMONITOR III study group, BIO|MASTER.BIOMONITOR III study group, BIO|STREAM-ICM study group

Background

Implantable Cardiac Monitors (ICM) provide continuous long-term heart rhythm monitoring. The new ICM BIOMONITOR III / IIIm (BM III) is provided with a single-step insertion tool.

Purpose

To report on the insertion procedure of the BM III in a large real-world patient population.

Methods

The BM III combines a low cross-section (4.5 x 8.5 mm) with an extended ICM length (77 mm, including flexible antenna). It is inserted into subcutaneous tissue with an ‘injection’ tool that forms the pocket and delivers the device in a single step. We report results of the insertion procedure from a pooled data set from the BIO|CONCEPT BM III (completed) and the BIO|MASTER BM III and BIO|STREAM-ICM (ongoing) studies.

Results

From 54 investigational sites in 11 countries, 455 insertions were reported (including 39 BM IIIm). The patients were 63 ± 16 years old, had a BMI of 27.6 ± 5.4, and 43% were women. The indications were syncope or pre-syncope (57%), cryptogenic stroke (23%), management of AF (11%) or other (9%). Insertions took 1.7 ± 1.8 minutes until removal of the insertion tool, 4.7 ± 3.4 minutes until wound closure, and 7.1 ± 5.6 minutes including wound cleaning. The wound was sutured (79%) or closed with staples (10%) or adhesive strips (10%). General anaesthesia was used in 8% of the patients and antibiotic prophylaxis in 50% (44% systemic and 6% local). Insertions took place in the catheter laboratory (62%), operating theatre (22%) or in a consultation room (16%) without specific precautional equipment.

The insertion site was parallel to the heart"s long axis (56%), parasternal (39%), in the 2nd/3rd intercostal space (3.5%), axillary (0.9%) or at the clavicula (0.7%). The device was repositioned in one case (0.2%). 13 adverse events were reported in connection to the insertion procedure. 5 cases of device pocket bleeding or hematoma occurred. In 5 further cases, the device migrated, posing the risk of extrusion, or actually extruded. Three of these cases used only adhesive strips or no wound closure at all. In two cases, an incorrect usage of the incision tool and substantial subcutaneous fatty tissue may have contributed. One device was damaged by a 200 J defibrillation shock with a shock electrode placed over the device. One patient suffered from dyspnoea, possibly due to psychogenic hyperventilation. One patient had a vasovagal syncope due to pain after an insertion with insufficient local anaesthesia. No infections were reported until the day of analysis, which was more than 30 days after insertion in 92% of all cases.

Conclusion

The new BM III was inserted in typically less than 5 minutes until wound closure. A relevant number of insertions took place in a consultation room. Prophylactic antibiotics may be unnecessary, because no pocket infections were reported, although no antibiotic prophylaxis was used in one half of all cases (N = 229). In summary, the insertion with the new tool is fast and has a low risk of complications.

Subcutaneous and single-chamber transvenous defibrillators: a nationwide matched control study

Funding Acknowledgements

Type of funding sources: None.

Introduction / Background

Subcutaneous implantable cardioverter–defibrillators (S-ICD) was designed to avoid complications of single-chamber transvenous implantable cardioverter-defibrillators (VVI ICD) by using an entirely extra-thoracic placement.

Purpose

Our objective was to compare outcomes following first VVI ICD or S-ICD implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2010 to September 1, 2020, who underwent a VVI ICD or S-ICD implantation were included. Patients with a previous pacemaker or ICD or with a history of infective endocarditis were excluded. Multivariable analyses for clinical outcomes during the whole follow-up in the groups of interests were performed using a Cox model with all baseline characteristics and reporting hazard ratio. Owing to the non-randomized nature of the study, and considering for significant differences in baseline characteristics, propensity-score matching was also used to control for potential confounders of the treatment outcome relationship.

Results

21,667 patients were included in the cohort, 19,493 patients had a transvenous VVI ICD and 2,174 had a subcutaneous ICD. Mean age was 61.2 ± 13.2 years in the VVI ICD group and 52.3 ± 17.5 years in the S-ICD goup. Coronary artery disease was present in 71.6% of patients with a VVI ICD and 48.2% of patients with a S-ICD. Mean follow-up was 28.8 ± 31.8 months. S-ICD patients had a significant higher rate of all-cause death (HR: 1.684, 95%CI: 1.309-2.165, p < 0.001). There were no significant differences in cardiovascular death (HR: 1.092, 95%CI: 0.697-1.711, p = 0.70) and infective endocarditis (HR: 0.354, 95%CI: 0.067-1.433, p = 0.15) between the two groups

Using propensity score, 1,582 patients with VVI ICD were matched 1:1 with S-ICD patients. Mean follow-up was 4.5 ± 7.2 months. In the matched analysis, there were no significant differences in all-cause death (HR: 1.090, 95%CI: 0.728-1.633, p = 0.68) and cardiovascular death (HR: 1.167, 95%CI: 0.603-2.260, p = 0.65) between the two groups. A trend toward a lower risk of infective endocarditis in the S-ICD group was also observed without reaching significance (HR : 0.219, 95%CI: 0.047-1.017, p = 0.053). A sensitivity analysis in patients with coronary artery disease in the matched cohort was performed. Same trends were observed without significant differences in all-cause death and cardiovascular death.

Conclusion

Our nationwide study highlighted a higher risk of all-cause death in patients treated with subcutaneous which however was not statistically significant after propensity score matching. No differences regarding cardiovascular mortality was found. An interesting trend toward diminution of infective endocarditis was also observed without reaching significancy.

Prediction of mortality and mode of death by clinical risk score systems in 2.6 million patients with atrial fibrillation: a nationwide analysis

 

Atrial fibrillation (AF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict mortality and the different modes of death in AF.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all AF patients treated between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and CFI were calculated for each patient.

Results

Among 2,641,626 patients with AF, 670,541 patients died during a follow-up of 2.0±2.3 years (median 1.1) (yearly rate 12.6%, 30.3% cardiovascular and 69.7% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and CFI scores. CCI was a better predictor of total mortality than CFI and CHA2DS2VASc score (see C-statistics in table); however, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI. By contrast, CCI was a better predictor of non-cardiovascular mortality than CFI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity assessed with CCI demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CHA2DS2VASc score and Frailty assessed with CFI in AF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI in these patients.

Funding Acknowledgement

Type of funding source: None

Outcomes of permanent pacemaker implantation following transcatheter aortic valve replacement

Background

Conduction abnormalities leading to permanent pacemaker (PPM) implantation are common complications following transcatheter aortic valve replacement (TAVR). Whether PPM implantation placement is associated with adverse outcomes is unclear. The purpose of this study was to evaluate the incidence, predictors, and clinical outcomes of PPI following TAVR.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France.

Results

A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Among them, 10,019 (20.4%) had prior PPM implantation, including 476 (4.8%) treated with cardiac resynchronization therapy (CRT). New PPM implantation was required within 30 days of TAVR in 11,010 patients (22.4%), which varied among those receiving self-expanding valves (24.7%) versus balloon-expanding valves (20.9%). There were 349/10,010 patients (3.1%) treated with cardiac resynchronization therapy (CRT) within 30 days following TAVR. In a multivariable analysis comprising 38 variables (including among others underlying conduction disorders, Euroscore 2, Charlson comorbidity index, frailty score and type of implanted valve), prior PPM implantation was associated with an increased risk of all-cause death (adjusted hazard ratio [HR]: 1.10 95% CI 1.04–1.16). New PPM implantation was associated with even higher risk of mortality (adjusted HR: 1.21 95% CI 1.15–1.28). By contrast, previous CRT was associated with a lower risk of death during follow-up (adjusted HR: 0.78 95% CI 0.63–0.96), while PPM with CRT within 30 days of TAVR was not associated with a different risk of death (adjusted HR: 1.00 95% CI 0.80–1.24). Prior PPM and new PPM implantation were also associated with an increased risk of rehospitalization for heart failure (adjusted HR: 1.26 95% CI 1.19–1.32 and 1.18 95% CI 1.12–1.24, respectively). Previous CRT was associated with a non-significant lower risk of rehospitalization for heart failure (adjusted HR: 0.92 95% CI 0.77–1.09).

Conclusions

Both previous PPM and early PPM implantation following TAVR are commonly seen in patients treated with TAVR, and they are associated with a higher risk of death and rehospitalisation for heart failure when compared to patients with no PPM. The fact that CRT when implanted before TAVR was associated with a better survival may deserve consideration when elaborating future optimal approaches for management of conduction disturbances in patients treated with TAVR.

Funding Acknowledgement

Type of funding source: None

Bleeding risks with frailty and multimorbidity in patients with atrial fibrillation. A nationwide analysis of 1.4 million subjects

Background

Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (>75 yo).

Results

Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p<0.001). The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). In elderly patients (n=853,833), the c-statistics were all lower than in the whole population and were lower for the 4 scores than for the CCI and CFI scores (0.463, 0.473, 0.443, 0.445, 0.622 and 0.620 for HAS-BLED, ATRIA, ORBIT, HEMORR2HAGES, CCI and CFI, respectively).

Conclusion

Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF.

Funding Acknowledgement

Type of funding source: None

Risk of ischemic stroke in patients with acute myocardial infarction and new atrial fibrillation: a nationwide analysis

Background

In patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with a similar risk of stroke and should be similarly managed is a matter of debate.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. The adverse outcomes were investigated during follow-up.

Results

Among 797,212 patients with STEMI or NSTEMI, 146,922 (18.4%) had history of AF, and 11,824 (1.5%) had new AF diagnosed between day 1 and day 30 after AMI. Patients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. Both groups with history of AF or new AF had less frequent STEMI and anterior MI, less frequent use of percutaneous coronary intervention but more frequent HF at the acute phase than patients with no AF. During follow-up (mean [SD] 1.8 [2.4] years, median [interquartile range] 0.7 [0.1–3.1] years), 163,845 deaths and 20,168 ischemic strokes were recorded.

Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.06 95% CI 1.05–1.08) while this was not the case for patients with new AF (adjusted HR 0.98 95% CI 0.95–1.02). By contrast, both history of AF and new AF were associated with a higher risk of ischemic stroke during follow-up compared to patients with no AF: adjusted hazard ratio HR 1.29 95% CI 1.25–1.34 for history of AF, adjusted HR 1.72 95% CI 1.59–1.85 for new AF. New AF was associated with a higher risk of ischemic stroke than history of AF (adjusted HR 1.38 95% CI 1.27–1.49).

Conclusion

In a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was associated with an increased risk of ischemic stroke. Specific management should be considered in order to improve outcomes in these patients after AMI.

Funding Acknowledgement

Type of funding source: None

Does left atrial appendage morphology have any impact on the results of percutaneous closure?

Introduction

Transcatheter left atrial appendage (LAA) occlusion is an alternative treatment in patients with atrial fibrillation (AF), high CHADSVASC Score and a contra-indication to anticoagulants. This retrospective cohort study aims to evaluate the impact of LLA morphology on procedure outcomes.

Methods

Patients from eight French centers who underwent left atrial appendage occlusion from February 2012 to January 2017 were included in this retrospective cohort study. LLA morphology was described by preoperative cardiac computed tomography (CT). Clinical data and Transoesophageal echocardiography (TEE) or CT results were collected during follow-up.

Results

Among 469 included patients, LAA morphologies were described in 215 cases 45.8%), 150 patients (70%) were implanted with Watchman devices, 57 (26%) with Amplatzer devices and 8 procedures (4%) failed. LAA Morphology was Chicken Wing (34%), Windsock (45%), cauliflower (18%) and 3% had another morphology including Cactus.

There was no difference in patient characteristics between the different morphology groups. Mean follow-up was 9.6±11 months, during which 190 patients underwent LAA imaging (TEE in 171 and CT in 19 patients). There was no significant difference in the failure rate (p=0.72), duration of the procedure (p=0.065), peri-device leak (p=0.83) device-related thrombus (p=0.96) and the occurrence of stroke (p=1) during follow-up.

Conclusion

LLA morphology did not influence complication occurrence after occlusion in this cohort.

Funding Acknowledgement

Type of funding source: None

Pacemaker implantation after balloon- or self-expandable transcatheter aortic valve replacement in patients with aortic stenosis

Background

The incidence of conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with different devices available in recent years remains a matter of debate.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France. We compared the incidence of PPI after TAVR according to the type and generation of valve implanted.

Results

A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Patients treated with early BE or SE valves had higher Charlson comorbidity and frailty indexes than those treated with later BE or SE valves, and slightly higher EuroSCORE II. Patients treated with SE valves had higher rates of previous pacemaker or defibrillator than those treated with BE valves. Mean (SD) follow-up was 1.2 (1.5 years) (median [interquartile range] 0.6 [0.1–2.0] years). PPI after the procedure was reported in 13,289 patients, among whom 11,010 (22.4%) had implantation during the first 30 days (figure 1). In multivariable analysis, using early BE TAVR as reference, adjusted OR (95% CI) for PPI during the first 30 days was 0.88 (0.81–0.95) for latest BE TAVR, 1.40 (1.27–1.55) for early SE TAVR and 1.17 (1.07–1.27) for latest SE TAVR. Compared to early BE TAVR, adjusted HR for PPI during the whole follow-up was 1.01 (0.95–1.08) for latest BE TAVR, 1.30 (1.21–1.40) for early SE TAVR and 1.25 (1.18–1.34) for latest SE TAVR.

Conclusion

In patients with aortic stenosis treated with TAVR, our systematic analysis at a nationwide level found higher rates of PPI than previously reported. BE technology was independently associated with lower incidence rates of PPI both at the acute and chronic phases than SE technology. However, this was less apparent than previously reported in this large analysis of unselected patients seen in “real life” practice. Recent generations of TAVR were not independently associated with different rates of PPI than early generations during the overall follow-up.

Funding Acknowledgement

Type of funding source: None

Relationship of aging and incident comorbidities to stroke risk in 594,169 Patients with atrial fibrillation: a nationwide analysis

Background

When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. This study hypothesized that the “Delta CHA2DS2-VASc score”, which reflects the change in score between baseline and follow-up, may be predictive of ischemic stroke compared with the baseline or follow-up assessments of the CHA2DS2-VASc score.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all patients treated with AF between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. A total of 594,169 patients with AF who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc score was defined as the change/difference between the baseline and follow-up CHA2DS2-VASc scores. During 1,290,721 person-years, 19,492 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analysed and compared.

Results

The mean baseline CHA2DS2-VASc score was 1.69, which increased to 2.33 during the follow-up, with a mean Delta CHA2DS2-VASc score of 0.64. The CHA2DS2-VASc score increased in 39.8% of patients. Among 19,492 patients who experienced ischemic stroke, 66.0% had a Delta CHA2DS2-VASc score ≥1 compared with only 38.9% in patients without ischemic stroke, and 5,811 (29.8%) patients had ≥2 new-onset comorbidity, the most common being hypertension. The follow-up CHA2DS2-VASc score and Delta CHA2DS2-VASc score were significant predictors of ischemic stroke (C-index 0.670 95% CI 0.667–0.674 and 0.637 95% CI 634–641 respectively) that performed better than baseline CHA2DS2-VASc score (C-index 0.613 95% CI 0.609–0.616, p<0.0001 for DeLong test).

Conclusions

In this AF cohort, we found that stroke risk (CHA2DS2-VASc score) was non-static, and that many patients developed ≥1 new stroke risk factor(s) before presentation with ischemic stroke. The follow-up CHA2DS2-VASc score and its change (ie Delta CHA2DS2-VASc, reflecting the change in stroke risk profile between baseline and follow-up) were better predictors of ischemic stroke than relying on the baseline CHA2DS2-VASc score. This emphasises how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities, and regular re-assessment of risk is needed.

Funding Acknowledgement

Type of funding source: None

486Are the results of the CASTLE-AF trial reproducible in the real life? Clinical outcomes after catheter ablation for atrial fibrillation with heart failure in a nationwide cohort study

Background

Catheter ablation for atrial fibrillation (AF) is a validated therapy for patients with symptomatic AF to prevent recurrences. The CASTLE AF trial indicated that ablation for AF in patients with heart failure (HF) was associated with a lower rate of death from any cause or hospitalization for worsening HF than was medical therapy. The purpose of our study was to compare the incidence of these events in AF patients with HF after AF catheter ablation versus those not treated with AF ablation at a nationwide level in centers possibly less well experienced.

Methods

This French longitudinal cohort study was based on the national hospitalization PMSI (Programme de Médicalisation des Systèmes d'Information) database covering hospital care from the entire population. We included all patients, over 18 years old, with AF and HF from January 2010 to December 2015. Crude event rates were ascertained and hazard ratios (HR) were estimated using Cox proportional hazards risk model. Propensity-matched Cox regression was also used to compare event rates according to AF ablation usage status.

Results

Among the 261,449 patients identified with AF and HF, 1,270 patients were treated with AF ablation (24% female, mean age 63±10 yo) and 260,179 did not have AF ablation (45% female, mean age 79±11 yo). During follow-up (417±502 days), there were 56,981 hospitalizations with a primary diagnosis of HF and 81,393 deaths were recorded. Incidence of hospitalization for HF was significantly lower in patients with AF ablation than in those with no ablation (13.74% vs 51.11% person per year respectively, p<0.0001). Incidence of death was also significantly lower in patients with AF ablation than in those with no ablation (6.07% vs 27.42% person per year respectively, p<0.0001). These associations were confirmed in a multivariable analysis after adjustment on age and other comorbidities (HR 0.33, 95% CI 0.28–0.39, p<0.0001 for HF and HR 0.38, 95% CI 0.31–0.48, p<0.0001 for all-cause death). After 1:1 propensity score matching, AF ablation was also associated with a lower risk of hospitalization for HF (HR 0.38, 95% CI 0.31–0.47, p<0.0001) and a lower risk of death (HR 0.54, 95% CI 0.42–0.70, p<0.0001).

Conclusion

In the nationwide analysis of unselected AF patients with HF seen in hospitals, AF ablation was independently associated with a lower risk of hospitalization for HF and death. This provides “real world” data consistent with those observed in recent trials with lower numbers of highly selected patients

P999Major adverse events with percutaneous left atrial appendage closure in patients with atrial fibrillation in real life setting

Methods

We analysed data from all AF patients treated with Watchman or Amplatzer LAA closure according to European guidelines in 8 French cardiology departments. Antithrombotic management was decided for each patient on an individual basis. A Cox regression model was used for multivariable analysis of major adverse events. Yearly rate of ischemic stroke during follow-up was calculated and compared to that expected for a same risk score population. Yearly rate of bleeding was extrapolated from that reported with the HASBLED score.

Results

A total of 469 consecutive AF patients (299 males, 74.9±8.9 years old, mean CHA2DS2-VASc score 4.5±1.4, HASBLED score 3.7±1.0) received LAA closure from March 2012 to January 2017. There were 272 Watchman devices (58%) and 197 ACP devices (42%) implanted. At discharge, 36% received a single anti platelet therapy (APT), 23% received dual APT, 29% received OAC and no APT, 5% received OAC plus APT and 8% received no antithrombotic therapy. Mean follow up was 11.4 months (median 7, interquartile 3–22 months) during which 70 major adverse events (19 ischemic strokes, 18 major haemorrhages and 33 deaths) were recorded in 69 patients. The annual rate of ischemic stroke was 3.96%, which translates into a 13% relative risk reduction (95% CI −59 to 52%) as compared with the calculated stroke rate for similar CHA2DS2-VASc score after adjustment for exposure to APT and OAC. The annual rate of major bleeding in the study was 3.75%, which corresponds to a 48% relative risk reduction (95% CI 9 to 70%) as compared with the rate that would have been expected based on a comparable HAS-BLED score. Yearly rate of mortality was 7.4% (2.5 to 3 fold higher than in previous randomized trials) and the rate of non-cardiovascular death was 82%. None of the baseline characteristics was predictive of major adverse events, neither in univariate nor in multivariable analysis, which highlights the difficulty in identifying a risk of unfavourable outcome with simple tools.

Conclusions

AF patients treated with LAA closure may have a lower risk of stroke and bleeding events compared to their theoretical risk. However, our findings indicate that a high rate of major adverse events is observed in these patients during follow-up. This questions the suggested cost-effectiveness of the procedure (with models based on previous trials) for a real-life perspective. A better identification of patients with a relevant benefit of LAA closure is needed among those with long-term anticoagulation contraindication, both for an optimal management of each patient on an individual basis and for a global perspective with limited healthcare resources.

P6564Prediction of the progression from paroxysmal to persistent or permanent atrial fibrillation using different scores. Is AF progression mainly atrial aging?

Methods

All patients with AF seen over a period of 10 years were identified in a database and followed up for AF progression and mortality. Predictors of outcomes were identified using Cox regression model. The values of HATCH, CHA2DS2-VASc, ALARMEc, APPLE, MB-LATER scores and CHARLSON comorbidity index were evaluated with C statistics for prediction of AF progression.

Results

Among 8962 patients (71±14 years), 4991, 476 and 3495 had paroxysmal, persistent AF, and permanent AF, respectively. During a follow-up of 927±1084 days, 404 paroxysmal AF patients progressed to persistent or permanent AF (yearly rate of 3.0%). Progression was associated with a trend toward increased cardiovascular mortality. Independent predictors of AF progression were heart failure (hazard ratio (HR) 2.07; 95% CI 1.50–2.85, p<0.0001), valvular disease (HR=1.87, 95% CI=1.35–2.58, p=0.0002) and the use of digoxin (HR=2.39, 95% CI=1.75–3.29, p<0.001). Conversely, a history of stroke was associated with a lower rate of progression (HR=0.50, 95% CI=0.28–0.88, p=0.02). Overall, most of the score, particularly the HATCH score, were modest predictors of progression (table). The best score was actually the CHARLSON comorbidity index. The predictive values of all scores were better on patients not treated with antiarrhythmic agent.

C-statistics for AF progression All patients (n=4,991) p value* HATCH 0.576 (0.562–0.590) <0.0001 CHA2DS2-VASc 0.532 (0.503–0.560) <0.0001 ALARMEc 0.634 (0.607–0.660) 0.03 APPLE 0.631 (0.605–0.658) 0.03 MB-LATER 0.612 (0.587–0.638) 0.001 CHARLSON 0.667 (0.640–0.693) – *DeLong test vs CHARLSON comorbidity index.

Conclusion

Most of scores have a modest predictive value to identify the risk of evolution to permanent AF. Among them, the CHARLSON comorbidity index had the best predictive value and outperformed other tools. This suggests that AF progression may actually reflect global aging both at the individual and local atrial level.

P1870Predicting mortality and mode of death by clinical score systems for patients with atrial fibrillation

Methods

All patients with AF seen in an academic institution were identified and followed up for mortality. CHA2DS2VASc score, CCI and CFI were calculated for each patient. Predictive abilities of the scores were compared using the c-statistic.

Results

Among 8962 consecutive patients with AF, 1294 patients died during a follow-up of 929±1082 days (median 456), (yearly rate 5.5%) and 97% of causes of death were identified (54% cardiovascular and 43% non-cardiovascular). Death occurred more often in patients with higher CHA2DS2VASc scores, CCI and CFI. CFI was a better predictor of total mortality than CCI and CHA2DS2VASc score (table). CFI was also a better predictor of cardiovascular mortality than CCI and CHA2DS2VASc score. Finally, CFI was also a better predictor of non-cardiovascular mortality than CCI and CHA2DS2VASc score. The predictive performances of the 3 tools were better for cardiovascular death than for non-cardiovascular death.

Prediction of mode of death ROC area (95% C) p vs CHA2DS2VASc/Charlson Total mortality CHA2DS2VASc 0.651 (0.636–0.665) – / 0.0001 CHARLSON (CCI) 0.687 (0.672–0.702) 0.0001 / – Frailty index (CFI) 0.714 (0.700–0.729) <0.0001 / <0.0001 Cardiovascular death CHA2DS2VASc 0.673 (0.654–0.692) – / 0.004 CHARLSON (CCI) 0.707 (0.688–0.726) 0.004 / – Frailty index (CFI) 0.737 (0.719–0.756) <0.0001 / <0.0001 Non cardiovascular death CHA2DS2VASc 0.590 (0.567–0.612) – / 0.0008 CHARLSON (CCI) 0.637 (0.614–0.659) 0.0008 / – Frailty index (CFI) 0.650 (0.628–0.672) <0.0001 / 0.008

Conclusion

Frailty assessed with CFI demonstrated better performances in predicting total mortality, cardiovascular mortality and non-cardiovascular mortality than CHA2DS2VASc score and Charlson comorbidity index in AF patients. Identifying the risk of non-cardiovascular death with simple tools remains a more difficult challenge in these patients.

P5675Ischemic stroke in patient with sinus node disease in comparison to atrial fibrillation, bradycardia-tachycardia syndrome and other cardiac conditions: a nationwide cohort-study

Methods

This French longitudinal cohort study was based on the national database covering hospital care from for the entire population (PMSI) from 2010 to 2015. We compared incidences of IS in patients with a diagnosis of AF or SND to that in a control group of patients with a main diagnosis of cardiac condition (excluding those with AF or SND, history of stroke and mechanical valve or mitral stenosis).

Results

Of 1,732,412 patients included in the cohort, 1,601,435 (92.44%) had isolated AF, 102,849 (5.94%) had isolated SND and 28,128 (1.62%) had BTS. The control group with cardiac condition included 479,108 patients. Incidence of IS progressively increased when considering patients from the control population, patients with isolated SND, with BTS or with isolated AF (0.67%/yr, 1.95%/yr, 3.03%/yr and 5.48%/yr respectively). These differences were seen in all strata of CHA2DS2VASc score (table). SND patients with a CHA2DS2-VASc score ≥3 had a yearly incidence of IS >2%, comparable to AF population with a CHA2DS2-VASc score ≥1.

Incidence (%/year) of ischemic stroke CHA2DS2-VASc AF population SND population “Control” population Women Men Women Men Women Men All scores 6.72% 4.37% 1.93% 1.96% 0.67% 0.68% Score = 0 – 1.960% – 1.211% – 0.217% Score = 1 2.337% 3.046% 0.538% 1.486% 0.166% 0.345% Score = 2 3.917% 4.499% 0.879% 1.541% 0.298% 0.580% Score = 3 7.572% 4.733% 2.207% 2.084% 0.541% 0.907% Score = 4 7.016% 4.820% 2.363% 2.305% 0.930% 1.278% Score = 5 6.725% 5.345% 2.845% 2.849% 1.249% 1.553% Score = 6 7.637% 7.543% 3.319% 4.109% 1.737% 2.031% Score = 7 10.196% 13.927% 4.663% 7.708% 2.346% 4.089% Score = 8 17.654% 12.607% 8.519% 11.904% 2.446% 2.355%

Conclusion

Patients with isolated SND had a lower risk of IS than patients with AF or BTS. However, SND patients had a non-neglectable risk of IS during follow-up which was higher than in a “control” population. Whether oral anticoagulation may bring a significant clinical benefit might be studied in patients with SND at highest risk of IS.

66Clinical outcomes after catheter ablation for atrial fibrillation in elderly patients: a French nationwide cohort study

Methods

This French longitudinal cohort study was based on the national hospitalization PMSI (Programme de Médicalisation des Systèmes d'Information) database covering hospital care from the entire population. We included all patients, over 18 years old, with AF from January 2010 to December 2015.

Results

Among the 1,663,284 patients identified with AF, 28,018 patients were treated with AF ablation (28% female, mean age 60±10 yo) and 1,635,266 did not have AF ablation (48% female, mean age 78±11 yo). Among those treated with AF ablation, 1,605/28,018 patients (5.7%) were aged >75 yo.

During follow-up (456±546 days), hospitalization with a primary diagnosis of HF and death were recorded. Incidences of hospitalization for HF and death were significantly lower in AF ablation group (respectively 6.09% vs 13.29% person per year, p<0.0001, and 1.49% vs 17.11% person per year, p<0.0001). These associations were confirmed in a multivariable analysis after adjustment on age and other comorbidities (HR 0.66, 95% CI 0.63–0.69, p<0.0001 for HF and HR 0.21, 95% CI 0.19–0.23, p<0.0001 for all-cause death). Results were significant and relatively similar whether patients were aged below or above 75 yo: HR 0.63, 95% CI 0.60–0.66, p<0.0001 when age <75 yo and HR 0.60, 95% CI 0.51–0.70, p<0.0001 when age >75 yo for hospitalization for HF; HR 0.21, 95% CI 0.19–0.24, p<0.0001 when age <75 yo and HR 0.36, 95% CI 0.29–0.45, p<0.0001 when age >75 yo for all-cause death.

Conclusion

In the nationwide analysis of unselected AF patients seen in hospitals, AF ablation was independently associated with a lower risk of hospitalization for HF and death whether patients were aged below or above 75 yo.

P6576Use of atrioventricular nodal ablation after atrial fibrillation ablation failure: a nationwide cohort study

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from the entire population. The data for all patients admitted in France from January 2010 to December 2015 were collected from the national administrative database, the PMSI (Programme de Médicalisation des Systèmes d'Information). We included all patients, over 18 years old, with AF and at least one AF catheter ablation. Routinely collected medical information includes the principal or secondary diagnoses and procedures performed. Items from the baselines characteristics were pooled into a multivariate Cox model to identify predictors of AV node ablation.

Results

Of 1,663,284 patients identified with AF, 28,018 patients were treated with AF ablation (28% female, mean age 60±10 yo, 22,837 with 1 procedure, 4,576 with 2 procedures and 605 with 3 procedures). Of those 28,018 patients, there were only 369 patients (1.3%) treated with AVNA after a mean follow-up of 374±488 days (median 210, interquartile 15–798). AVNA was less commonly performed than redo AF ablation with 3 procedures, and among these latter patients, only 3.8% were treated with AVNA during follow-up. Most powerful independent predictors of AV node ablation (HR >1.7) were age≥75 yo, heart failure at baseline, abnormal renal function and valve disease. Other independent predictors for AV node ablation (HR 1.2–1.7) were age 65–74 yo, female gender, obesity, coronary artery disease, thyroid disorders, lung disease and hypertension.

Conclusion

Our findings indicate that AVNA is rarely used after AF ablation failure and is probably an underrated strategy in these patients for now. Considering evidence from the APAF-CRT trial indicating a beneficial effect on mortality of this treatment in symptomatic AF patients, a wider use of AVNA should be more widely proposed in these patients. Its optimal timing during rate and rhythm control management still remains to be established.

P4748HASBLED score, frailty index or comorbidity index for bleeding risk assessment in patients with atrial fibrillation?

Background

Charlson comorbidity index (CCI) is a tool to measure comorbid disease status and a strong estimator of mortality. The quantifiable frailty phenotype has also been validated as predictive of mortality and disability. Claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict the risk of bleeding in patients with atrial fibrillation (AF).

Methods

All patients with AF seen in an academic institution were identified and followed up for mortality, stroke and bleeding events. HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT scores, CCI and CFI were calculated for each patient. Hazard ratios were calculated and predictive abilities of the scores were compared using the c-statistic in the whole population and then separately in elderly patients (>75 yo).

Results

Among 8962 patients with AF, 274 major bleeding events were recorded during a follow-up of 874±1054 days. Bleeding occurred more commonly in patients with higher bleeding risk scores, CCI and CFI. The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). Results were similar whether patients were treated with OAC or no OAC. In elderly patients, the c-statistics were all lower and were not significantly different for the 4 scores, CCI and CFI scores (0.594, 0,572, 0.595, 0.594, 0.616 and 0.591 for HAS-BLED, HEMORR2HAGES, ATRIA, ORBIT, CCI and CFI, respectively).

Predictive values for major bleeding ROC Area 95% Conf. Interval P value vs CCI/CFI HASBLED 0.588 0.555–0.621 0.002/0.003 HEMORR2HAGES 0.564 0.531–0.598 <0.0001/<0.0001 ATRIA 0.559 0.522–0.595 <0.0001/<0.0001 ORBIT 0.577 0.542–0.612 0.0002/0.0003 Charlson, CCI 0.652 0.619–0.684 –/0.58 Frailty index, CFI 0.648 0.615–0.681 0.58/–

Conclusion

Comorbidities and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF, although all c-indexes were broadly similar. The 4 bleeding risk scores, CCI and CFI showed lower performance in predicting bleeding within elderly patients in whom they all performed equally to predict bleeding events. Given their simplicity and similar performances, the user-friendly bleeding risk scores remain attractive tools for the estimation of bleeding risk in elderly patients with AF.

Stabilization of Bacillus circulans xylanase by combinatorial insertional fusion to a thermophilic host protein

High thermostability of an enzyme is critical for its industrial application. While many engineering approaches such as mutagenesis have enhanced enzyme thermostability, they often suffer from reduced enzymatic activity. A thermally stabilized enzyme with unchanged amino acids is preferable for subsequent functional evolution necessary to address other important industrial needs. In the research presented here, we applied insertional fusion to a thermophilic maltodextrin-binding protein from Pyrococcus furiosus (PfMBP) in order to improve the thermal stability of Bacillus circulans xylanase (BCX). Specifically, we used an engineered transposon to construct a combinatorial library of randomly inserted BCX into PfMBP. The library was then subjected to functional screening to identify successful PfMBP-BCX insertion complexes, PfMBP-BCX161 and PfMBP-BCX165, displaying substantially improved kinetic stability at elevated temperatures compared to unfused BCX and other controls. Results from subsequent characterizations were consistent with the view that lowered aggregation of BCX and reduced conformational flexibility at the termini was responsible for increased thermal stability. Our stabilizing approach neither sacrificed xylanase activity nor required changes in the BCX amino acid sequence. Overall, the current study demonstrated the benefit of combinatorial insertional fusion to PfMBP as a systematic tool for the creation of enzymatically active and thermostable BCX variants.