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

Funding Acknowledgements

Type of funding sources: None.

Introduction

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

Purpose

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

Methods

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

Results

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

Conclusion

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

The role of CHA2DS2-VASc score in predicting atrial fibrillation recurrence in patients undergoing pulmonary vein isolation with cryoballoon ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of atrial fibrillation (AF) with high safety and efficacy profiles. The CHA2DS2 -VASc score is also a well-established predictor of AF stroke. Importantly, the role of CHA2DS2-VASc score is still unknown regarding the long-term clinical outcomes following PVI-C.

Purpose

The aim of this analysis is to evaluate the role of CHA2DS2-VASc score in predicting AF recurrence during long term follow up after PVI-C.

Methods

Patients with recurrent and symptomatic AF underwent an index PVI-C. Data were collected prospectively in the framework of 1STOP ClinicalService® project. Patients were categorized into two groups Low risk (LR) and high risk (HR) (CHA2DS2-VASc score = 0-1 and CHA2DS2 -VASc score ≥2, respectively).

Results

Out of 3313 patients, 1910 (57.6%) had CHA2DS2-VASc score = 0-1, while 1403 (42.3%) were in the HR score group (CHA2DS2 -VASc score ≥2). As expected, patient baseline characteristics were significantly different between the two cohorts including: age, sex, BMI, percentage of paroxysmal AF, history of stroke, diabetes, ischemic cardiomyopathy. On the contrary, procedural times and the incidence of acute complications were comparable between the two groups. The 36-month freedom from AF after a single procedure was 72.5% (95% CI 69.8% - 75.0%) in the LR group and 65.9% (62.3% - 69.2%) in the HR score group (HR: 1.26, 95% CI 1.08-1.47, p= 0003, Figure 1). At multivariate analysis, higher CHA2DS2 -VASc score was still a significant predictor of the risk of AF recurrence [HR: 1.33 (1.10 - 1.60, p=0.003]

Conclusions

PVI-C is highly effective in the treatment of AF over the long term. A CHA2DS2 -VASc score ≥2 is an independent predictor of AF recurrence during the follow-up and should be taken into account in the clinical management after the index procedure.

Third-generation laser balloon ablation for atrial fibrillation treatment: a multicenter experience

Background

Laser balloon ablation is a promising option for performing pulmonary vein isolation (PVI) which is the cornerstone of invasive atrial fibrillation (AF) treatment.

Purpose

We aimed to investigate the acute efficacy and safety of the novel third-generation of the laser balloon system in an initial multicenter experience.

Methods

First and consecutive patients who underwent PVI with LB3 for drug-resistant paroxysmal or persistent AF at 7 Italian sites were included in this analysis. Study endpoints were acute procedural efficacy, defined as successful isolation of all identified PVs without radiofrequency touch-up, total and fluoroscopy times, and periprocedural complications.

Results

Our population included 86 patients (81% males, mean age 60.6±9.5 years) who underwent a procedure of PVI using LB3 between June 2020 and March 2021.

Most patients had paroxysmal AF (74%) and were in sinus rhythm at the beginning of the procedure. The mean procedure time was 138±60 min; fluoroscopy time was 22±17 min and the mean ablation time was 44±40 min. Of the 313 targeted PVs, 311 (99.4%) could be isolated with first-pass LB3 application, while 2 (0.6%) required radiofrequency touchup. At the end of the procedure, all patients were in sinus rhythm and 26 (32%) received electrical cardioversion to achieve stable sinus rhythm.

The total rate of major compilations was 1.2% (1/82 patients): one pericardial tamponade requiring epicardial puncture. No surgical intervention was necessary, and the patient recovered without any sequalae. There were no vascular access complications or phrenic nervy palsy. Three pinhole balloon raptures (3.5%) were observed during energy applications that required replacement of the whole system but had no effect on patient safety.

Conclusions

In a first multicenter experience, the LB3 system for PVI was safe with excellent acute efficacy.

Funding Acknowledgement

Type of funding sources: None.

Cryoballoon ablation of atrial fibrillation is effectively feasible without previous imaging of pulmonary vein anatomy: insights from the 1STOP project

BACKGROUND

Pulmonary vein isolation by cryoablation (PVI-C) is a standard therapy for the treatment of atrial fibrillation (AF); however, PVI-C can become a challenging procedure due to the anatomy of the left atrium and pulmonary veins (PVs). Importantly, the utility of imaging before the procedure is still unknown regarding the long-term clinical outcomes following PVI-C. The aim of the analysis is to evaluate the impact of imaging before PVI-C on procedural data and AF recurrence.

METHODS

Patients with paroxysmal AF underwent an index PVI-C. Data were collected prospectively in the framework of 1STOP ClinicalService® project. Patients were divided into two groups according to the utilization of pre-procedural imaging of PV anatomy (via CT or MRI) or the non-usage of pre-procedural imaging.

RESULTS

Out of 912 patients, 461 (50.5%) were evaluated with CT or MRI before the PVI-C and denoted as the imaging group. Accordingly, 451 (49.5%) patients had no pre-procedural imaging and were categorized as the no imaging group. Patient baseline characteristics were comparable between the two cohorts, but the ablation centers that comprised the imaging group had fewer PVI-C cases per year than the no imaging group (p < 0.001). The procedure, fluoroscopy, and left atrial dwell times were significantly shorter in the no imaging cohort (p < 0.001). The rates of complications were significantly greater in the imaging group compared to the no imaging group (6.9% vs. 2.7%; p = 0.003); this difference was attributed to differences in transient diaphragmatic paralysis. The 12-month freedom from AF was 76.2% in the imaging group and 80.0% in the no imaging group (p = 0.390).

CONCLUSIONS

In our analysis, PVI-C was effective regardless of the availability of imaging data on PV anatomy.

Progression of functional and structural cardiac alterations in young normotensive uncomplicated patients with type 1 diabetes mellitus

OBJECTIVE

We have recently observed that in young, normotensive patients with a type I diabetes mellitus and no macro or microvascular complications, large artery structure and function are already altered. This study has been done to assess whether this condition is also characterized by early alterations in cardiac structure and function, and whether these alterations progress with time.

DESIGN AND METHODS

In 56 insulin-treated, normotensive uncomplicated type I diabetic patients (age 35.0 +/- 2 years, means +/- SE) in good metabolic control, left ventricular wall thickness and diameter were measured by echocardiography together with left ventricular ejection fraction and diastolic function E/A (ratio between early and late ventricular filling), before and after 23 +/- 1 months. The same measurements were made in 20 age and sex-matched subjects who served as controls (C).

RESULTS

Compared to C, diabetic patients had a significant increase in left ventricular wall (septal plus posterior wall) thickness (+ 8.4%), left ventricular mass index (+ 11%) and h/r ratio (left ventricular wall thickness/ventricular end diastolic diameter, + 16.0%) whereas they showed a reduction of E/A (-6%). In C, all echocardiographic values were unchanged after 2 years. This was the case also for diabetic patients, except for left ventricular ejection fraction and diastolic diameter which showed a significant reduction (-7.2%) and increase (+ 3.8%), respectively, with a reduction of ratio between LV wall thickness and diameter, h/r (-6.8%).

CONCLUSIONS

Uncomplicated type I diabetes mellitus is characterized by early structural and functional cardiac alterations. Some of these alterations show a measurable progression within a relatively short time span.

Lacidipine and blood pressure variability in diabetic hypertensive patients

The aim of our study was to assess the effects of lacidipine, a long-acting calcium antagonist, on 24-hour average blood pressure, blood pressure variability, and baroreflex sensitivity. In 10 mildly to moderately hypertensive patients with type II diabetes mellitus (aged 18 to 65 years), 24-hour ambulatory blood pressure was continuously monitored noninvasively (Portapres device) after a 3-week pretreatment with placebo and a subsequent 4-week once daily lacidipine (4 mg) or placebo treatment (double-blind crossover design). Systolic blood pressure, diastolic blood pressure, and heart rate means were computed each hour for 24 hours (day and night) at the end of each treatment period. Similar assessments were also made for blood pressure and heart rate variability (standard deviation and variation coefficient) and for 24-hour baroreflex sensitivity, which was quantified (1) in the time domain by the slope of the spontaneous sequences characterized by progressive increases or reductions of systolic blood pressure and RR interval and (2) in the frequency domain by the squared ratio of RR interval and systolic blood pressure spectral power approximately 0.1 and 0.3 Hz over the 24 hours. Compared with placebo, lacidipine reduced the 24-hour, daytime, and nighttime systolic and diastolic blood pressure (P<0.05) with no significant change in heart rate. It also reduced 24-hour, daytime, and nighttime standard deviation (-19.6%, -14.4%, and -24.0%, respectively; P<0.05) and their variation coefficient. The 24-hour average slope of all sequences (7.7+/-1.7 ms/mm Hg) seen during placebo was significantly increased by lacidipine (8.7+/-1.8 ms/mm Hg, P<0.01), with a significant increase being obtained also for the 24-hour average alpha coefficient at 0.1 Hz (from 5.7+/-1.5 to 6.4+/-1.3 ms/mm Hg, P<0.01). Thus, in diabetic hypertensive patients, lacidipine reduced not only 24-hour blood pressure means but also blood pressure variability. This reduction was accompanied by an improvement of baroreflex sensitivity. Computer analysis of beat-to-beat 24-hour noninvasive blood pressure monitoring may offer valuable information about the effects of antihypertensive drugs on hemodynamic and autonomic parameters in daily life.