Efficacy on resynchronization and longitudinal contractile function comparing His-bundle pacing with conventional biventricular pacing: a substudy to the His-alternative study

AIMS

His-bundle pacing has emerged as a novel method to deliver cardiac resynchronization therapy (CRT). However, there are no data comparing conventional biventricular (BiV)-CRT with His-CRT with regard to effects on mechanical dyssynchrony and longitudinal contractile function.

METHODS AND RESULTS

Patients with symptomatic heart failure, left ventricular ejection fraction ≤ 35%, and left bundle branch block (LBBB) by strict ECG criteria were randomized 1:1 to His-CRT or BiV-CRT. Two-dimensional strain echocardiography was performed prior to CRT implantation and at 6 months after implantation. Differences in changes in mechanical dyssynchrony (standard deviation of time-to-peak in 12 midventricular and basal segments) and regional longitudinal strain in the six left ventricular walls were compared between the BiV-CRT and His-CRT groups.In the on-treatment analysis, 31 received BiV-CRT and 19 His-CRT. In both groups, mechanical dyssynchrony was significantly reduced after 6 months [BiV group from 120 ms (±45) to 63 ms (±22), P < 0.001, and His group from 116 ms (±54) to 49 ms (±11), P < 0.001] but no significant differences in changes could be demonstrated between groups [-9.0 ms (-36; 18), P = 0.50]. Global longitudinal strain (GLS) improved in both groups [BiV group from -9.1% (±2.7) to -10.7% (±2.6), P = 0.02, and His group from -8.6% (±2.1) to -11.1% (±2.0), P < 0.001], but no significant differences in changes could be demonstrated from baseline to follow-up [-0.9% (-2.4; -0.6), P = 0.25] between groups. There were no regional differences between groups.

CONCLUSION

In heart failure, patients with LBBB, BiV-CRT, and His-CRT have comparable effects with regard to improvements in mechanical dyssynchrony and longitudinal contractile function.

Behavioural digital biomarkers enable real-time monitoring of patient-reported outcomes: a substudy of the multicenter, prospective observational SafeHeart study

INTRODUCTION

Patient-reported outcome measures (PROMs) serve multiple purposes, including shared decision-making and patient communication, treatment monitoring and health-technology assessment. Patient monitoring using PROMs is constrained by recall and non-response bias, respondent burden and missing data. We evaluated the potential of behavioural digital biomarkers obtained from a wearable accelerometer to achieve personalised predictions of PROMs.

METHODS

Data from the multicenter, prospective SafeHeart study conducted at Amsterdam University Medical Center in the Netherlands and Copenhagen University Hospital, Rigshospitalet in Copenhagen, Denmark, was used. The study enrolled patients with an implantable cardioverter defibrillator (ICD) between May 2021 and September 2022 who then wore wearable devices with raw acceleration output to capture digital biomarkers reflecting physical behaviour. To collect PROMs, patients received the KCCQ and EQ5D-5 L questionnaire at two instances; baseline and after 6 months. Multivariable Tobit regression models were used to explore associations between digital biomarkers and PROMs, specifically whether digital biomarkers could enable PROM prediction.

RESULTS

The study population consisted of 303 patients (mean age 62.9 ± 10.9 years, 81.2% male). Digital biomarkers showed significant correlations to patient-reported physical and social limitations, severity and frequency of symptoms and quality of life. Prospective validation of the Tobit models indicated moderate correlations between the observed and predicted scores for KCCQ (concordance correlation coefficient (CCC) = 0.49, mean difference: 1.07 points) and EQ5D-5 L (CCC = 0.38, mean difference 0.02 points).

CONCLUSION

Wearable digital biomarkers correlate with PROMs, and may be leveraged for real-time prediction. These findings hold promise for monitoring of PROMs through wearable accelerometers.

His-pacing and biventricular pacing show similar efficiency in resynchronization and improvements in longitudinal contractile function

Background

The clinical role for HIS-pacing in cardiac resynchronization therapy (HIS-CRT) is promising but is yet to be established. The randomised His-alternative study showed better remodelling with HIS-CRT compared to patients receiving conventional biventricular pacing (BIV-CRT) in the per-protocol-analysis.

Purpose

In this substudy we investigated whether HIS-pacing was more efficient compared to BIV-CRT in improving mechanical synchrony and longitudinal contractile function.

Methods

In the His-Alternative study 50 patients with symptomatic heart failure, left ventricular ejection fraction (LVEF) ≤35% and Left bundle branch block were randomized 1:1 to His-CRT or BiV-CRT and followed for 6 months. At implantation, 7 patients crossed over from His-pacing to LV-pacing in the His-CRT group and 1 patient crossed over from LV-pacing to His-pacing in the BiV-CRT group. All patients had echocardiography performed including 2D-strain echocardiography to asses global systolic longitudinal deformation (GLS) at baseline and 6 months. Mechanical dyssynchrony was measured as SD of time-to-peak in all 12 segments of the left ventricle (TPS-SD).

Results

There were no significant differences in baseline characteristics between patients receiving HIS-CRT and BIV-CRT with regard to dyssynchrony and longitudinal systolic strain. LVEF was significantly higher at 6 months (48±8% vs. 42±8%; p&lt;0.05) in the HIS-CRT group. However, GLS did not significantly improve more with HIS-CRT compared to BIV-CRT, (−8.7ms ± 2.0 to −11.1 ms ± 2.0 vs −9.1 ms ± 2.7 to −10.8±2.5 ms ± 2.8, P = ns for difference) and regarding resynchronization measured as TPS-SD there was no significant difference either (110 ms ± 51 to 47 ms ± 10 vs. 115 ms ± 42 to 60 ms ± 21, P = ns for difference).

Conclusion

In this substudy, HIS-pacing did not prove more efficient than BIV-CRT in resynchronizing the left ventricle, nor did the observed improvement in longitudinal function differ significantly between methods. However, the number of included patients was rather small and larger studies are needed to fully assess the possible benefits of HIS-CRT.

Funding Acknowledgement

Type of funding sources: None.

Risk of lead explantation after first-time implantation of cardiac implantable electronic device as a function of comorbidity: a nationwide study

Background

The benefit of cardiac implantable electronic devices (CIEDs) is challenged by the risk of procedure-related complications and lead explantation. Whether patient comorbidity burden is associated with risk of lead explantation &lt;6 months of implantation is unknown.

Purpose

We assessed the risk of lead explantation and its association with comorbidity burden within 6 months after first-time CIED implantation.

Methods

The study population comprised patients ≥18 years old with first-time CIED implantation (i.e., pacemaker [PM], implantable cardioverter defibrillator [ICD], and cardiac resynchronisation therapy with defibrillator [CRT-D] or without [CRT-P]) using Danish nationwide registries including the Danish Pacemaker and ICD registry (1 January 2000 to 30 June 2018). Patients were followed from their first-time CIED implantation and 6 months forward. Patient comorbidity burden was categorised in four groups according to the Charlson Comorbidity Index (CCI) score: 0 (none), 1–2 (mild), 3–4 (moderate), and ≥5 (severe). Multivariable cause-specific Cox regression was performed to assess risk of lead explantation according to comorbidity burden, with death as competing risk. Comorbidity burden was adjusted for sex, age, type of CIED, and body mass index categories.

Results

We identified 73,491 patients with first-time CIED implantation including 55,733 (75.8%) with PM, 11,351 (15.5%) with ICD, 2,989 (4.1%) with CRT-P, and 3,418 (4.7%) with CRT-D. In total, 1,049 (1.4%) patients underwent lead explantation. The median age of the study population was 75.1 years [25th-75th percentile 66.2–82.5 years], and 62.1% were male. Patients undergoing lead explantation had higher median CCI score, compared with those not undergoing lead explantation (2 [1–3] and 1 [0–3], respectively). The median age and distribution of sex were similar in both groups. In the multivariable Cox regression model (Figure 1), an increase in patient comorbidity burden was associated with higher hazard ratio [HR] of lead explantation, compared with CCI score 0 (CCI score 1–2: HR=1.38 [95% confidence interval [CI]: 1.12–1.69], CCI score 3–4: HR=1.61 [95% CI: 1.28–2.03], and CCI score ≥5: HR=1.60 [95% CI: 1.25–2.05]).

Conclusion

Risk of lead explantation within 6 months after first-time implantation of cardiac implantable electronic device was 1.4% and associated with higher comorbidity burden.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Independent Research Fund Denmark

Severity of chronic obstructive pulmonary disease and risk of one-year mortality after first-time implantation of implantable cardioverter defibrillator: a nationwide study

Background

Current guidelines, on implantable cardioverter defibrillator (ICD), recommend implantation in patients with an expected survival beyond one year. Information on risk of all-cause mortality among ICD recipients with chronic obstructive pulmonary disease (COPD) according to severity of COPD is lacking.

Purpose

We examined the association between the severity of COPD and risk of all-cause mortality within one year after first-time ICD implantation.

Methods

We identified patients ≥18 years old undergoing first-time ICD implantation with COPD using Danish nationwide registries (1 January 2000 to 31 December 2018). All patients were eligible for one-year follow-up. We used concomitant COPD-related pharmacotherapy six months prior to ICD implantation and COPD hospitalisations one year prior to ICD implantation to determine severity of COPD from mild to very severe according to Table 1. Multivariable Cox regression was used to assess risk of one-year all-cause mortality according to severity of COPD. Severity of COPD was adjusted for sex, age, year of implantation, primary prevention, type of ICD, history of atrial fibrillation, stroke, peripheral artery disease, diabetes, cancer, chronic renal disease, and dialysis.

Results

The study population included 1,536 patients with first-time ICD and COPD. The median age was 69.5 years [25th-75th percentile 63.5–74.3 years], and the majority of patients were males (79.4%). Of these, 896 (58.3%) received an ICD for primary prevention, and 485 (31.6%) had cardiac resynchronisation therapy device with defibrillator (CRT-D). In total, 1,348 (87.8%) patients were diagnosed with heart failure. Patients were grouped according to severity of COPD from mild to very severe: Group 1 (N=666), Group 2 (N=72), Group 3 (N=149), Group 4 (N=445), and Group 5 (N=204). Overall, 154/1,536 (10.0%) ICD recipients with COPD died within one year after first-time ICD implantation. No difference in sex and comorbidities was identified according to the five groups of COPD severity. However, ICD recipients with mild intermittent COPD (Group 1) were the youngest (68.3 years [61.8–73.0 years]). According to our multivariable cox regression in Figure 1, patients with very severe COPD (Group 5) were associated with increased risk of all-cause mortality within one year after first-time ICD implantation (adjusted hazard ratio [HR] 1.90 [95% confidence interval [CI]: 1.21–2.98]), compared with mild intermittent COPD (Group 1). The most common causes of death within one year after ICD implantation were attributed to cardiovascular diseases 95/154 (61.7%), respiratory diseases 15/154 (9.7%), and endocrine disorders 12/154 (7.8%).

Conclusion

In this nationwide study, very severe chronic obstructive pulmonary disease was associated with increased risk of all-cause mortality within one year after first-time implantation of implantable cardioverter defibrillator.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Independent Research Fund Denmark

Adherence to wearables in implantable cardioverter-defibrillator patients: Preliminary results from the prospective, multicenter SafeHeart-study

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon2020

Introduction

Wearable devices are gaining interest in the clinical assessment of physical behavior as a marker of disease severity. With the increased use, patient willingness and adherence will be increasingly important. As part of the SafeHeart study, examining the potential of physical behavior as an identifier of clinical deterioration in patients with an implantable cardioverter defibrillator (ICD), we present preliminary results on adherence to a wrist-worn wearable used for physical behavior assessment.

Purpose

Define the willingness to participate and long-term adherence to wearables in an ICD population.

Methods

This is a preliminary analysis of the ongoing multicenter, prospective, observational SafeHeart study. SafeHeart is aimed to construct a personalized prediction engine for ICD therapy using wearable-assessed physical behavior, remote ICD monitoring, electronic health records, and patient-reported data. The study will enroll 400 participants with an ICD with or without cardiac resynchronization therapy (CRT-D). In this preliminary analysis, wearable data was analyzed for the first 50 participants, where inclusion required a minimum of 1 month of follow up data. No data from the wearables were provided to the participants. The wrist-worn wearables were used continuously (day and night) for up to 12 months of follow-up. Adherence to the wearable was measured through patient-reported (subjective) adherence and wearable-measured (objective) adherence. Data were extracted from the wearables and non-wear time was detected via open source algorithms. A valid day was set to 22 hours of available wear time with 24-hour periods assessed from 3pm to 3pm for sleep metric capture. The willingness to participate and dropout rates were calculated for the same first 50 patients of the study.

Results

A total of 50 ICD participants were included in this study. The mean age was 65.1 years, 82 % male, with a mean follow up of 7 weeks, generating 326 patient weeks of data. Regarding patient-reported adherence, participants reported 81.4% full adherence and 18.6 % of participants reported very brief non-wear due to e.g. sauna or surgery. Of those reporting non-wear, 62.5% described one episode only of non-wear lasting 15-75 minutes. Regarding objectively measured adherence from wearable data, full adherence was shown in 91.7% of days. The mean number of valid days per participant was 41.3. Recruitment rates showed a willingness to participate of 50% (50/100) out of eligible subjects invited. No participants were lost to follow

Conclusion

Results show high adherence and reasonable willingness to participate without wearable adherence dropping over time. Comparison of objectively measured and patient-reported adherence showed similar values.

Reduced longitudinal strain in the left ventricular inferior wall predicts malignant arrhythmia in non-ischemic heart failure. A DANISH substudy

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Small studies have suggested that poor regional myocardial function may be associated with malignant arrhythmias, in particular around the inferior-posterior region. We tested this hypothesis in a subgroup of patients from the DANISH trial.

METHODS

From two centers, 317 patients with non-ischemic heart failure (LVEF &lt; 35%) from the DANISH trial were evaluated by 2D-strain echocardiography. Regional strain was calculated as the average longitudinal strain in basal-, midventricular- and apical segments in each of the six left ventricular walls. Reduced regional function was defined as below-median regional strain. The endpoint was a composite of sudden cardiac death (SCD), sustained VT, admission with ventricular arrhythmia, and appropriate therapy from a primary prophylactic ICD. Time-to-first-event analysis was performed using Cox models.

RESULTS

Mean age at inclusion was 62 years (72% male), median LVEF was 25% (IQR 20-30) median inferior strain was -8.7% (IQR -12.3; -4.9). After a five-year follow-up, 43 events were observed. Reduced inferior strain was associated with the composite endpoint in univariate analysis with a HR 2.08(95% CI 1.11-3.90), P = 0.021. After multivariate adjustment for clinical and echocardiographic parameters, inferior strain remained an independent predictor with a HR 2.78(95% CI 1.39–5.56), P = 0.004. Strain measurements in no other region were associated with the endpoint in the multivariate analysis. In subgroup analysis of patients in the two lower age tertiles (&lt;68 of age) we found that reduced inferior- and posterior strain were associated with development of the composite endpoint after multivariate adjustment with HRs of 3.25(95% CI 1.41-7.53), P = 0.006 and 2.51(95% CI 1.14-5.53), P = 0.022.

CONCLUSIONS

Low inferior-posterior strain was associated with a 2-3-fold increase in risk of malignant arrhythmia and SCD in patients with non-ischemic heart failure. Abstract Figure.

The CADI-study: Compression after device implantation - To examine the effect of a compressive dressing after device implantation or replacement focusing on the patient"s bleeding, hematomas and pain

Funding Acknowledgements

University Hospital Rigshospitalet, Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Denmark

Background

Bleeding and pocket hematomas are a known complication in pacemaker or implantable cardioverter defibrillator (ICD) implantations.  Hematomas are associated with increased risk of infection and pain.

Purpose

To investigate whether a compressive dressing applied for three hours can prevent bleeding, pocket hematomas and pain.

Method

The study was a pseudo-randomized intervention study including patients scheduled for implantation or box change of a pacemaker or an ICD. In alternating months patients either received a compressive dressing (intervention group) or not (control group). Patients were excluded by the implanting physician if there was a clinical indication for a compressive dressing due to seeping bleeding. Patients were followed at the catheterization lab, for three hours at the ward and until the first outpatient control visit (1-3 months). The outcomes were: Bleeding, pocket hematomas and pain. The bleedings were graded as active bleeding or seeping bleeding or hematomas. Hematomas were measured by degree 1 to 3 (3 largest) and size (in cm). Pain was rated by the patient by numerical rank scale (NRS) from 0 to 10 (10 worst). Descriptive statistics were used.

Results

A total of 191 patients were included, 95 patients in the intervention group. After inclusion 24 patients of the 96 patients in the control group were excluded by the implanting physician on clinical indication for a compressive dressing.

Before the intervention there were significantly more patients with bleeding (graded as: Seeping bleeding) in the intervention group (n = 25, (26.9%)) compared to the control group (n = 4, (5.6%), p &lt;0.001). No patients had developed pocket hematomas at the end of the procedure. Furthermore, the pain score was low in both groups (Total n = 19, NRS score ≤ 2.5).

Over the next three hours in the ward, there was no significant difference in the bleeding (graded as: Seeping bleeding) in the groups (intervention: n = 8 vs. control: n = 3, p = 0.55). Two patients in each group had developed a pocket hematoma after three hours (p = 0.36) and the intervention group experienced more pain (intervention: 1.7 (±2.4) vs. control: 1.1(±1.7), p= 0.02).

At the outpatient control 1-3 months after implantation, there was no significant difference between the groups related to bleeding, pocket hematomas and pain.

Conclusion

Compressive dressing did not significantly reduce bleeding or the number of pocket hematomas after pacemaker or ICD implantation. In addition patients reported a slight increase in pain scores related to the compressive dressing.

The results question routine compression after procedure, but should be validated in larger studies.

Regulation of Blood Flow by Prostaglandins

Prostaglandins (PGs) belong to the family of prostanoids together with thromboxanes and are produced mainly from arachadonic acid by the enzyme cyclooxygenase. PGs are known to stimulate platelet aggregation, mediate inflammation and edema, play a role in bone metabolism and in biological adaptation of connective tissues e.g. tendon. This review covers the role of PG for mediating tissue blood flow at rest and during increases in metabolic demand such as exercise and reactive hyperaemia. There is strong evidence that PGs contribute to elevate blood flow at rest and during reactive hyperaemia in a variety of tissues. Their role for regulating the large increases in muscle blood flow during exercise is less clear which may be explained by redundant mechanisms. Several interactions are known to exist between specific vasodilator substances, and therefore PGs can act in synergy with other substances and contribute to functional hyperaemia. Furthermore, there is evidence for differential, tissue-specific influences of PGs where their influence on blood flow during exercise may be profound.

Cyclo-oxygenase-2 mediated prostaglandin release regulates blood flow in connective tissue during mechanical loading in humans

Mechanical loading is known to increase connective tissue blood flow of human tendons and to cause local release of vasodilatory substances. The present study investigated the importance of prostaglandins (PG) formed by cyclo-oxygenase isoforms (COX-1 and 2) for the exercise-related increase in blood flow in connective tissue. Healthy individuals (n = 24, age: 23-31 years) underwent 30 min of intermittent, isometric, plantarflexion with both calf muscles either without (n = 6, Control, C) or with blockade of PG formation, either COX-2 specific (n = 10, Celecoxib 2 x 100 mg day-1 for 3 days prior to the experiment) or COX unspecific (n = 8, indomethacin 100 mg (12 and 1 h pre-experiment) and acetyl salicylic acid 500 mg day-1 for 3 days pre-experiment). Prostaglandin E2 (PGE2) concentration was determined by microdialysis and blood flow by 133Xe washout. In C, interstitial PGE2 rose from (0.8 +/- 0.2 (rest) to 1.4 +/- 0.5 ng ml-1 (exercise), P < 0.05), whereas during unspecific COX inhibition, tissue PGE2 was completely inhibited at rest and during exercise. COX-2 specific blockade did not inhibit tissue PGE2 at rest, but totally abolished the exercise induced increase. Blood flow was similar in the three groups at rest (P > 0.05), whereas the increase in flow with exercise was reduced by 35 and 43 % with COX-2 specific blockade (3.2 +/- 0.7 to 6.1 +/- 1.5 ml (100 g tissue)-1 min-1 or COX unspecific blockade (3.0 +/- 0.8 to 7.6 +/- 1.6), respectively, compared to C (2.7 +/- 0.8 to 10.2 +/- 2.0)(P < 0.05). The findings indicate that COX-2 specific mechanisms are responsible for the exercise-induced increase in prostaglandin synthesis, and that increase in tissue prostaglandin plays an important role for blood flow in peritendinous connective tissue during physical loading in vivo.