Arrhythmic Episodes Research Articles

Effects of CRT on atrial and ventricular arrhythmias in patients with HF

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac resynchronization therapy (CRT) is an accepted treatment for patients with heart failure (HF). Cardiac arrhythmias present a significant and complex issue in this patient group. Evidence exploring the influence of CRT on cardiac arrhythmias rate variations is limited. Purpose Our research investigates the effectiveness of CRT in the treatment of existing and newly diagnosed atrial and ventricular arrhythmias, and impact of epicardial lead position on these arrhythmias rate variations, as well as on the CRT response. Methods This single-center, prospective, observational study included 75 consecutive patients admitted for CRT implantation over a 12-month period. All included patients had episodes of atrial and/or ventricular arrhythmias, diagnosed by 12-lead ECG or 24-hour Holter monitoring. Pre-procedural demographic characteristics were collected for all patients, including ECG records, NYHA functional class, echocardiographic assessment of left ventricular ejection function and questionnaire for quality-of-life. During device follow up atrial and ventricular arrhythmias appearance was monitored. Additional assessment of echocardiographic parameters, NYHA - functional class, quality of life and rate of major cardiovascular complications and rehospitalizations was performed. Results The mean age of the patients was 62.4 ± 10.3 years, with 74.6% male and 25.3% females. 72% had a non-ischemic HF etiology. Pre-procedural paroxysmal AF was present in 34.7%, persistent AF in 36%, PVCs in 32%, NSVT 16%, and VT in 18,7% patients. 55% of the included patients were responders to CRT. Our results showed decrease in rate of all ventricular arrhythmias, with significant reduction in the percentage of VT (p=0.003), regardless of CRT response. Significant reduction of PVCs and NSVT rate (p=0.012 & p=0.024) was found in the responder group of patients. Regarding AF, our results showed a decrease in the number of AF events in both patient groups, however this was most visible in the responder patients with paroxysmal AF (p=0.057). In CRT responders, left ventricular pacing lead was most commonly located in a lateral branch vein of the CS with middle and mid/lateral position. In terms of quality of life and general condition of the patients, we noticed a significant improvement in the NYHA - functional class (p <0.001), as well as in both parts of the quality-of-life assessment questionnaire (p=0.0135, p<0.001). Conclusion CRT is an effective treatment for atrial and ventricular arrhythmias in HF patients, especially in responders to this therapy. LV epicardial lead position proved to be very important influence in the process of LV reverse remodeling, which is in direct correlation of the CRT responders and its effectiveness in reducing the rate of cardiac arrhythmias.

Appropriate and inappropriate therapies in remotely monitored patients with cardiac implantable devices long-term experiences of a tertiary centre

Abstract Funding Acknowledgements Type of funding sources: None. Background The evidence supporting the implantation of implantable cardioverter-defibrillator (ICD) in the primary prevention of sudden cardiac death (SCD) comes mostly from the times when optimal management of heart failure was not as effective as at present. Moreover, the detailed data on the long-term risk of arrhythmias in patients with ICD are scarce. Purpose To present the long-term results of the remote monitoring (RM) of patients with ICD from a large, tertiary cardiovascular centre registry. Methods The clinical data from the time of device implantation were derived from the COMMIT-HF registry, while the follow-up data were obtained from the investigator-initiated RM registry. In brief, the registry encompasses data regarding the types of the transmissions and their contents, with particular emphasis on the occurrence of arrhythmic episodes, device interventions, as well as the data on the causes of other alert transmissions. Results In total, 1,299 patients were included in the analysis. The median follow-up duration of RM was 4.4 years, and the primary indication for implantation was ischemic cardiomyopathy (60.3%). Appropriate antitachycardia pacing (ATP) and high-voltage therapy for ventricular arrhythmias occurred in respectively 25.3% and 26.1% of patients, while inappropriate ATP and HV in respectively 11.5% and 8.7%. The prevalence of AF was 40.8%. Conclusions In a large real-life cohort of continuously remotely monitored patients with ICDs, the percentage of patients with appropriate therapies for ventricular arrhythmias exceeded 25%. Further analyses are necessary to stratify the risk of ventricular arrhythmias in the contemporary practice.

P9 INCESSANT ARRHYTHMIC STORM, EFFECTIVELY TREATED BY VENTRICULOPLASTY

Abstract Arrhythmic storm is an emergency characterized by cardiac electrical instability leading to multiple episodes of sustained ventricular arrhythmias in a short period of time. Patients have multiple comorbidities that require multidisciplinary interventions to achieve clinical stability. The genesis of arrhythmic storm involves a complex interaction between a predisposing arrhythmogenic substrate, triggering factors, autonomic nervous system, and patient comorbidities. Antiarrhythmic drug therapy plays a key role and has been shown to be associated with a significant reduction in VT recurrence. Transcatheter ablation in patients refractory to drug therapy has been shown to reduce arrhythmic recurrences, ICD shocks, and improve patients‘ cumulative survival over time. Rare cases of arrhythmic storm refractoriness treated by plastic ventricle for the purpose of excluding scar are reported in the literature. We present the case of a 62–year–old man, Caucasian race, suffering from chronic ischemic heart disease with hypokinetic–dilated evolution carrying CRT–D, diabetic, obese, dyslipidemic, undergoing multiple percutaneous revascularizations. Sent to our hospital from a peripheral hospital for arrhythmic storm refractory to maximal antiarrhythmic therapy treated with multiple internal and external DC shocks. During hospitalization, the patient underwent SEF and attempted ATC which was ineffective in the following days due to recurrence of numerous episodes of TVS. In view of the clinical picture and refractoriness to therapy, it was decided to perform coronary examination which found subocclusion of the 1st diagonal branch treated by implantation of medicated stent. On ventriculography, the presence of severe pseudoaneurysmal formation supplied at the level of the anterior wall of the left ventricle was confirmed. It was decided to transfer the patient to cardiac surgery to perform ventriculoplasty surgery. In the following days, the patient underwent surgery through exclusion of the aneurysm by patching in pericardium in CEC. Procedure was free of complications. On follow–up echocardiogram dilated left ventricle with severe left ventricular dysfunction with findings of cardiac aneurysm exclusion. In the following days, the patient presented no further arrhythmic episodes.

P145 IVABRADINE IN TETRALOGY OF FALLOT AND POSTOPERATIVE JUNCTIONAL ECTOPIC TACHYCARDIA

Abstract Introduction Ivabradine is a selective inhibitor of sodium’s If current; it acts at the level of the sinus node causing a bradycardizing effect without effect on inotropism and atrioventricular conduction. In fact, the If channel, located in pacemaker cells, is activated in hyperpolarization and allows the membrane potential to become gradually more positive until the threshold potential is reached. Previous studies have actually shown the usefulness of ivabradine not only for slowing sinus rate but also in case of atrial tachycardia and ectopic junctional tachycardia. Case report: Our patient, suffering tetralogy of Fallot, undergoes transannular patch correction surgery at the age of 6 months. During the stay in postoperative intensive care presents numerous episodes of junctional tachycardia. Therapy with amiodarone ev is undertaken, with a discrete response; on the ECG, frequent isolated and repetitive supraventricular extrasystoles (pairs and triplets) are observed. After the infusion ev is undertaken, oral therapy with amiodarone and beta–blocker is associated, but not obtaining a good rhythm control. In addition, the presence of numerous and sustained episodes of high frequency arrhythmia affects the hemodynamic parameters of the child. For the persistence of arrhythmic episodes, ivabradine therapy is undertaken at a dose of 0.05 mg/kg orally twice a day. Stable sinus rhythm is observed, so amiodarone therapy is subsequently discontinued and ivabradine therapy continued. No arrhythmias are observed either during hospitalization or in the subsequent follow–up after discharge, carried out with seriated Holter ECGs. After about 3 months, therapy is discontinued, in the absence of supraventricular and ventricular arrhythmias. Conclusions Ivabradine is a selective inhibitor of the sodium channel at the level of pacemaker cells; born as a bradycardizing drug for its action on the sinus node, its usefulness has also been demonstrated in the treatment of supraventricular arrhythmias due to enhanced automatism and atrial reentry. It is, therefore, conceivable the presence of If channels also in ectopic foci, which would allow its use as a real antiarrhythmic drug, exploiting its peculiar action not interfering with inotropism and atrium and intraventricular conduction.

P184 TRANSESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY FOR FOLLOW UP OF NEONATAL PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Abstract Introduction Paroxysmal supraventricular tachycardia (TPS) is the most common form of arrhythmia in neonatal age. The transesophageal electrophysiological study allows us to demonstrate the possible persistence of arrhythmia after the first year of age. Aim of the study: To evaluate the reliability of transesophageal electrophysiological study in the follow–up of these patients. Materials and methods: We retrospectively observed 8 patients who came to our observation in neonatal age for TPS. All patients underwent echocardiogram and Holter and were discharged to effective drug therapy for rhythm control (with one or two drugs). Afterwards, they carried out follow–up with Holter in drug therapy every 3 months. Within one year of age, antiarrhythmic therapy was discontinued and a transesophageal electrophysiological study was performed, including atrial stimulation at increasing frequencies and programmed atrial stimulation with single, double and triple extrastimulus. In case of TPS inducibility, therapy was resumed and the study was repeated after one year in wash out. Results We observed 8 patients who came for TPS in neonatal age. 7 of these had a structurally normal heart; one patient had aortic coarctation corrected with aortoplasty. After one year of therapy, 4 patients (50%), half of whom were in dual therapy (flecainide associated with beta–blocker and/or amiodarone) were non– inducible; these patients, who were permanently discontinued, no longer presented arrhythmic episodes in the follow–up. The remaining 4 resumed therapy (double in half of the cases) for another year and then repeated the study in wash out: one patient continued to present arrhythmias (patient with correct aortic coarctation); the other 3 were non–inducible. In the subsequent follow–up, 3 of these patients only one showed a recurrence of arrhythmia. Conclusions The transesophageal electrophysiological study is a simple, minimally invasive and reliable method to identify subjects at risk of TPS recurrence. The persistence of arrhythmia in our study is independent of the pharmacological treatment carried out in mono or dual therapy. We also observed that in case of positivity after one year of therapy, the study can be repeated later allowing therapy to be interrupted at a later time.

C70 WEARABLE CARDIOVERTER DEFIBRILLATOR IN LONG QT SYNDROME DURING PREGNANCY: TIME TO USE THE SHIELD

Abstract Introduction Long QT Syndrome (LQTS) is a rare cardiac channelopathy characterized by a high risk of lethal arrhythmias. Pregnancy and post–partum period may induce an increased vulnerability, so an appropriate prevention is needed. Case presentation A 31–year–old primigravid woman at 36 weeks of pregnancy was referred to our Cardiomyopathy Unit located in a tertiary centre for LQTS screening. The patient had a family history of LQTS (mother and brother) and Brugada syndrome (cousin). The 12–lead ECG (Figure 1) showed a long QT interval (QT corrected: 508 msec), while the transthoracic echocardiogram was unremarkable. The genetic test performed is still ongoing. The patient reported sporadic episodes of palpitations at rest and the following 24–hour ambulatory ECG revealed a very high burden of polymorphic ventricular arrhythmias, with about sixteen thousand premature ventricular complexes and a non–sustained ventricular tachycardia. Therefore, due to the patient’s high–risk for life–threatening arrhythmic events, metoprolol 25 mg o.d. was initiated and a wearable cardioverter defibrillator (WCD) with remote monitoring was provided during pregnancy and labour. After 3 weeks a caesarean delivery in epidural analgesia was performed and managed by a pregnancy heart team including a cardiologist, gynaecologist, obstetrician, and anaesthetist in close cardiac monitoring. No maternal or infant complications occurred, without arrhythmic episodes detected by the device. The WCD will be maintained also in the post–partum period with a narrow follow–up of the patient. Discussion In pregnant high–risk LQTS patients, beta–blockers are the first line therapeutic option, but they do not able to interrupt lethal arrythmias in out–of–hospital setting. The implantable cardiac defibrillator is not the best choice, due to the concerns about radiation exposure and anaesthesia during pregnancy. Moreover, lead–associated thrombosis and infections during pregnancy were reported in literature. The WCD is the ideal option in these cases. It is an external device suited for transient higher arrhythmic risk periods. Moreover, it allows a remote monitoring of arrhythmic burden (figure 2) which may help clinicians in guiding the follow–up and the therapeutic management of the patient. One drawback is the need of continuous patient’s compliance. Finally, a pregnancy heart team is mandatory in presence of these rare cardiac syndromes.

P462 ATRIAL FIBRILLATION CIED DETECTED; WHEN TO SCOAGULATE? OUR EXPERIENCE ON A STILL VERY CONTROVERSIAL TOPIC

Abstract Introduction Atrial fibrillation (AF), which is constantly increasing in the population, is associated with an important care burden linked, in particular, to its consequences (stroke, heart failure, etc.). In patients with an implantable cardiac device (CIED) it is frequent the detection of high atrial frequency episodes (AHRE), often asymptomatic, for which an increased thromboembolic risk has been described (about 2.5 times) but lower than the clinical AF for which there is still no unanimous consensus regarding the initiation of oral anticoagulant therapy (OAT). We report below our experience in patients undergoing CIED implantation in whom AHRE was detected and OAT started, evaluating the characteristics of thromboembolic risk and the follow–up of complications. Methods From 01 January 2020 to 31 December 2021, 242 patients (mean age 74.8 years) underwent CIED implant. Among these, 41 patients (16.9% mean age 78.6 years – 30 males and 11 females) presented episodes of AHRE, detected by remote monitoring, lasting between a few seconds and more than 24 hours. The mean CHADsVasc score of these patients was 3.8. Seven patients were not anticoagulated due to arrhythmic episodes lasting a few minutes and CHADsVasc score equal to 1–2, while the other 34 started OAT with DOAC. Results No thromboembolic events or major bleeding events have been recorded to date; only minor bleedings (11 epistaxis, 4 haematuria and 5 SOF positivity) were easily treated. Conclusions The current guidelines indicate to prolong monitoring until the detection of clinical AF or an arrhythmic burden > 24 hours before considering OAT; however, there are studies that recommend carefully correlating the duration of arrhythmic events with the determination of the thromboembolic risk. In our experience, the high thromboembolic risk of patients, sometimes not adequately represented by the CHADsVasc score, led us to start OAT even when the duration of the episodes was not particularly long and at the moment no major complications have been observed. The two ongoing trials (ARTESia and NOAH) dedicated to the evaluation of these situations will provide valuable indications on the treatment of these patients in whom the thromboembolic risk is certainly lower than that of patients with clinical AF but still not negligible.

PO-05-083 ICD THERAPY CHARACTERISTICS IN PATIENTS WITH ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY, BRUGADA SYNDROME, AND LONG QT SYNDROME

Arrhythmogenic right ventricular cardiomyopathy (ARVC), Brugada syndrome (BrS) and Long QT syndrome (LQTS) are inherited arrhythmia disorders that frequently result in sudden death in young populations. ARVC often presents with monomorphic VT amenable to antitachycardia pacing (ATP) therapy, whereas BrS and LQTS are traditionally characterized by polymorphic VT or torsade de pointes requiring shock therapy. To assess the rates of ATP and shock therapies in a cohort of patients with ARVC, BrS and LQTS. Patients with ICD indications for ARVC, BrS and LQTS from the ALTITUDE database (Boston Scientific, Natick, MA) between 2011-2021 were identified. ATP and shock-free survival rates were calculated by Kaplan-Meier (KM) method and hazard ratios were analyzed by the Cox proportional hazards model. A total of 103 ARVC, 218 BrS, and 509 LQTS patients were identified. Mean age (46.6 ± 17.4) did not differ between groups while LQT had more female (69.2%) compared to ARVC (34%) and BrS (30.7%). Mean follow-up was 3.7 years. A total of 47 (45.6%) ARVC patients, 39 (17.9%) BrS, and 136 (26.7%) LQTS patients received any therapies during the follow-up period. Episodes in ARVC patients were significantly less likely to result in a shock (71/402, 18%) compared to BrS (73/157, 47%) and LQTS (333/581, 57%) (p<0.001). Per 100 patient-years (Figure 1a), ARVC patients had arrhythmia episodes requiring only ATP therapy 4.7 times the frequency of episodes requiring shock therapy (89.0 versus 19.1), whereas BrS and LQTS patients had comparable rates of ATP only vs shocks (10.2 versus 8.8 in BrS and 13.5 vs 18.2 in LQTS). From KM curve analysis, three-year rate of an ATP-only event was 43.0% in ARVC, 10.3% in BrS and 18.0% in LQTS. As compared with ARVC, risk of ATP only events in BrS (HR 0.20, 95% CI 0.12-0.33, p<0.001) and LQTS (HR 0.44, 95% CI 0.30-0.65, p<.0.001) were significantly lower. Three-year rate of events requiring shock therapy was 33.4% in ARVC, 14.5% in BrS and 20.0% in LQTS. As compared with ARVC, risk of a shock in BrS (HR 0.33, 95% CI 0.20-0.54, p<0.001) and LQTS (HR 0.62, 95% CI 0.41-0.93, p=0.020) were also significantly lower. ARVC patients had more ventricular arrhythmia episodes. When therapy was triggered, episodes in ARVC were less likely to be treated with a shock compared to BrS and LQTS. This may help guide programming parameters and device type selection in high-risk individuals with inherited arrhythmia syndromes.

CE-452777-2 CATHETER ABLATION VERSUS ADVANCED THERAPIES FOR PATIENTS WITH SEVERE HEART FAILURE AND ELECTRICAL STORM FROM VENTRICULAR ARRHYTHMIAS

Electrical storm (ES), defined by three or more episodes of sustained ventricular arrhythmia or appropriate defibrillations within 24 hours, is a marker for advanced heart disease and associated with high mortality. Limited studies have reported the outcome of an initial strategy of catheter ablation (CA) versus advanced therapy in patients with severe heart failure and drug-refractory ES. To evaluate the outcomes of CA versus heart transplant (HT) or left ventricular assist device (LVAD) implantation in patients with severe heart failure and ES. Patients with severe heart failure presenting with ES who underwent an initial strategy of CA or advanced therapy between 2012 and 2022 at UC San Diego were included. Severe heart failure was defined as ejection fraction ≤ 35% or having advanced stage genetic cardiomyopathy. We compared in-hospital mortality and long-term survival between the groups. Of 68 patients who met inclusion criteria, 40 patients underwent CA and 28 patients received advanced therapy (8 patients received an LVAD as bridge to transplant). There were no differences in age (62.5 vs 63.0 years, p = 0.69) and male gender (85% vs 89%, p = 0.61), but patients in the advanced therapy group had lower ejection fraction (30% vs 18%, p < 0.01). Inpatient death was comparable between the two groups (10% vs 11%, p = 0.92). There was no difference in survival between the two groups after a median follow up of 3 years (73% vs 75%, log-rank p = 0.471) (Figure). Eleven patients (28%) in the CA group received HT. Time to HT was significantly longer in the CA group (125.5 vs 26.0 days, p < 0.01). In a single-center, retrospective study of patients with severe heart failure and ES, CA was associated with longer transplant-free survival without worsened mortality. Larger studies are needed to evaluate the optimal management strategy in this patient population.

PO-04-232 PERCUTANEOUS STELLATE GANGLION BLOCKADE FOR ELECTRICAL STORM: LARGE SINGLE CENTRE EXPERIENCE

Electrical storm (ES) is defined as three or more episodes of ventricular arrhythmia requiring defibrilltaion or anti tachycardia pacing within a day.Some times electrical storm may not respond to anti-arrhythmic drugs alone.Increased sympathetic activity plays significant role in electrical storm.Stellate ganglion blockade reduces sympathetic activity and helpful in reduction of ventricular arrhythmias. We aimed to study the effectiveness and outcomes of percutaneous stellate ganglion blockade (SGB) in the patients with drug-refractory electrical storm. The study included patients with a drug-refractory electrical storm. Before giving SGB, at least two anti-arrhythmic drugs(AAD) were given before SGB. Bupivacaine was injected in the vicinity of the stellate ganglion under Ultrasound quidance. A total of 83 procedures were performed on 56 patients (71% males, 60+6 years).Fourty three patients (76%) had ischemic heart disease. Nearly 66%(37/56) of patients were free from ventricular arrhythmias(VA) at 24 hours after left SGB and 51%(29/56) were arrhythmia free at 72 hours. Bilateral SGB was done in 16 patients who had failed left-sided SGB with a success rate of 36%. Heart failure and shock were documented in 65% and 55% respectively. Twenty Five (44%) patients were on both Intra-aortic balloon counterpulsation and inotrope support. All-cause mortality was 32% (18/56). Cardiovascular mortality was 28% (16/56). Septic shock in one patient and Ischemic brain stroke was the cause of death in the other patient. VA recurrence, poor left ventricular ejection fraction, and failed stellate ganglion blockade were associated with increased mortality. Procedure-related complications like transient bradycardia(16%), hematoma(14%), hoarseness of voice (10%), persistent ptosis(5%), and monoparesis(3.5%) were noted, all of which were resolved within two weeks of post-procedure. SGB helps to stabilize the hemodynamic status of the patients with electrical storm. It also provides time for

PO-04-190 LONG TERM OUTCOMES OF VENTRICULAR TACHYCARDIA ABLATION IN DESMOPLAKIN ARRHYTHMOGENIC CARDIOMYOPATHY – A MULTICENTER STUDY

Desmoplakin (DSP) pathogenic/likely pathogenic (P/LP) variants have been associated with the development of highly arrhyhtmogenic phenotypes of the spectrum of the arrhythmogenic cardiomyopathy (DSP-ACM). Data addressing arrhythmic outcomes after ventricular tachycardia (VT) ablation in patients (pts) with DSP-ACM are scarce. To report on long-term outcomes of pts with DSP-ACM undergoing VT-ablation All pts with P/LP DSP variant at 8 tertiary academic institutions in North America and Europe undergoing VT ablation were included in the study. Demographic, clinical, and instrumental data, as well as all arrhythmic events including per patient rates of VA episodes/year were collected. Sustained ventricular arrhythmia (VA) episodes (defined as a combination of sustained VT, proper implantable cardioverter defibrillator (ICD) intervention, and ventricular fibrillation episodes) after index procedure were the primary outcome of the study and reported with Kaplan Meyer curves. A per-pt pre- and post- VT ablation paired comparison of VA episodes/year rates was performed as well. Nineteen DSP-ACM pts (29 [25–36] y.o.; 68.4% male; 94.7% probands) referred for VT ablation were included. At the time of index procedures, all patients had a highly arrhythmic profile with a high PVC burden and over 30 different VT morphologies (56.6% right bundle branch block (BBBB); 26.6% left BBB; 16.8% unknown)(Table1). VT ablation targets were located in the LV in 7/19 pts, the RV in 7/19 pts, and both ventricles in 5/19 pts. An epicardial ablation was needed in 14/19 pts. Over a median follow-up of 27 [20–72] months, 10/19 (52.6%) pts experienced recurrent VA episodes (Figure1-PanelA). A significant reduction in per-patient event/year pre- and post- VT ablation was observed (0.50 0.25–0.94] vs 0.14 [0–0.40]; Matched Pair Wilcoxon p=0.009) (Figure1-Panel B). VT ablation in DSP-ACM is effective in significantly reducing the VA burden of the disease. However, it is not uncommon for pts to experience VA recurrences during follow up.

PO-04-192 RISK FACTORS AND OUTCOMES OF ELECTRICAL STORM AFTER LEFT VENTRICULAR ASSIST DEVICE IMPLANTATION

Electrical storm after Left Ventricular Assist Device (LVAD) is a recognized complication. The risk factors associated with electrical storm, impact on survival is less studied. The aim of this study is to study the incidence, risk factors of electrical storm after LVAD implantation and the impact of electrical storm on survival in patients undergoing LVAD. We performed a retrospective cohort study of all patients who underwent the LVAD implantation from January 1, 2001, to December 31, 2020, at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). The incidence and outcomes of electrical storm (≥3 sustained [>30 seconds] ventricular arrhythmia episodes over a 24-hour period) were identified. Among 886 patients who underwent LVAD implantation, electrical storm occurred in 61 (7%) patients after median of 13 days (interquartile range [IQR] 4.5- 302) post LVAD implantation. Thirty-five patients (57.3%) developed electrical storm within 30 days, while 26 patients (42.6%) developed ES at a median of 689 days (IQR of 228-1171) after LVAD. Pre LVAD history of ventricular arrhythmias (43% vs 25%, p-value=0.002) and implantable cardioverter-defibrillator (ICD) shock (34% vs 22%, p-value=0.024) and history of were significantly associated with electrical storm after LVAD implantation. The 1-year mortality rate after first occurrence of electrical storm was 38%. Following LVAD implantation, the rate of electrical storm was 7% with majority of electrical storm occurring within 30-days of LVAD. Risk factors for electrical storm included pre-implant history of ventricular arrhythmias and ICD shock.

Radiofrequency catheter ablation of ventricular tachycardia using combined endocardial techniques in patients with structural heart disease improves procedural effectiveness and reduces arrhythmia episodes.

Evidence indicates that radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) in patients with structural heart disease (SHD) is safe and effective. However, arrhythmia recurrence is still relatively high, and the optimal procedural strategy is unclear. In clinical practice, several combinations of mapping and ablation techniques are used to improve VT ablation efficacy. The study aimed to evaluate and provide evidence on the efficiency and safety of a systematized combination of VT ablation (mapping) techniques in patients with SHD. From 2016 to 2019, 47 patients (54 procedures) with SHD (89% heart failure, 94% ischemic heart disease, 37% VT storm) who underwent RFCA of VT were retrospectively analyzed from a group of 58 consecutive patients. During RFCA of VT, different combinations of three techniques, activation mapping (AM), pace mapping (PM), and substrate-based mapping (SbM), were used. The procedures were performed using the CARTO® 3 (Biosense Webster Inc., Diamond Bar, CA, US) electro-anatomical mapping system. During a median (interquartile range [IQR]) follow-up of 25.5 months (11.75-52.25), VT-free survival after ablation was 68.5% (n = 37/54 procedures). Acute procedural success was achieved in 85% (n = 46/54 procedures). The number of induced VT morphologies, induction of non-clinical or non-sustained VT after ablation, and fewer VT mapping techniques used during the procedure were related to decreasing VT-free survival. VT ablation strategy based on systemic use of combined techniques is effective and safe in long-term follow-up of patients with SHD.

Electrical storm management in structural heart disease.

Electrical storm (ES) is a life-threatening condition characterized by at least three separate episodes of ventricular arrhythmias (VAs) over 24 h, each requiring therapeutic intervention, including implantable cardioverter defibrillator (ICD) therapies. Patients with ICDs in secondary prevention are at higher risk of ES and the most common presentation is that of scar-related monomorphic VAs. Electrical storm represents a major unfavourable prognostic marker in the history of patients with structural heart disease, with an associated two- to five-fold increase in mortality, heart transplant, and heart failure hospitalization. Early recognition and prompt treatment are crucial to improve the outcome. Yet, ES management is complex and requires a multidisciplinary approach and well-defined protocols and networks to guarantee a proper patient care. Acute phase stabilization should include a comprehensive clinical assessment, resuscitation and sedation management skills, ICD reprogramming, and acute sympathetic modulation, while the sub-acute/chronic phase requires a comprehensive heart team evaluation to define the better treatment option according to the haemodynamic and overall patient's condition and the type of VAs. Advanced anti-arrhythmic strategies, not mutually exclusive, include invasive ablation, cardiac sympathetic denervation, and, for very selected cases, stereotactic ablation. Each of these aspects, as well as the new European Society of Cardiology guidelines recommendations, will be discussed in the present review.

HeartInsight: from SELENE HF to implementation in clinical practice.

There is strong evidence that remote monitoring in cardiac implantable electronic devices can detect device malfunctions earlier than conventional monitoring and that it can be useful for detecting cardiac arrhythmias, while little data are available for an improved management of heart failure (HF). HeartInsight is a new remote monitoring algorithm developed and validated in the SELENE HF study that combines information from a diverse set of sensors integrated into one alert to detect worsening HF with promising accuracy. However, the shift from detecting technical issues or arrhythmia episodes to early predicting clinical events underscores the need to understand how to properly integrate these tools into the clinical workflow by defining an organizational model and shared guidelines for the management of HF alerts. Here, we critically discuss issues that will be raised by the implementation of this 'enhanced' remote monitoring approach to HF care in daily clinical practice.

The case of arrhythmic equivalent of myocardial ischemia in the practice of family doctor

In the practice of the family physician (general practitioner) there are patients with recurrent cardiac arrhythmia (most commonly ventricular extrasystoles) accompanying angina pectoris attacks associated with local myocardial ischemia and manifested by ST-segment depression or elevation on the electrocardiogram. At the same time, there are patients with ischemic heart disease who may have palpable or insensible episodes of cardiac arrhythmia without ST-segment displacement and typical retrosternal pain during exercise. This clinic requires a detailed approach to diagnosing the equivalent of myocardial ischemia, including, exercise tests and coronarography, especially if a diagnosis of ischemic heart disease has been confirmed before.&#x0D; The case of cardiac arrhythmia as an equivalent of angina pectoris in a 67-year-old male patient with a history of myocardial infarction with postinfarction angina pectoris is presented in the article. Stenting of the right coronary artery was performed twice during ischemic heart disease treatment.&#x0D; Knowledge of the signs of myocardial ischemia equivalents determined the tactics of patient management by a general practitioner already at the stage of interview of ischemic heart disease history. Examination and referral of the patient for coronarography contributed to timely angioplasty with stenting of the affected left circumflex coronary artery, which caused local myocardial ischemia and arrhythmia.

Outcomes of concomitant myectomy and left ventricular apical aneurysm repair in patients with hypertrophic cardiomyopathy

ObjectivesHypertrophic cardiomyopathy with left ventricular apical aneurysm is a phenotype associated with a 4-fold increase in the risk for sudden cardiac death. In this study, we describe the surgical outcome of concomitant apical aneurysm repair in patients undergoing transapical myectomy for hypertrophic cardiomyopathy. MethodsWe identified 67 patients with left ventricular apical aneurysms who underwent transapical myectomy and apical aneurysm repair between July 2000 and August 2020. Long-term survival was compared with that of 2746 consecutive patients undergoing transaortic septal myectomy for obstructive hypertrophic cardiomyopathy with subaortic obstruction. ResultsTransapical myectomy was indicated for midventricular obstruction (n = 44) or left ventricular remodeling for diastolic heart failure (n = 29). Preoperatively, 74.6% (n = 50) of patients were in New York Heart Association class III/IV heart failure, and 34.3% (n = 23) of patients had experienced syncope or presyncope. Atrial fibrillation was documented in 22 patients (32.8%), and episodes of ventricular arrhythmias were recorded in 30 patients (44.8%). Thrombus was present in the apical aneurysm in 6 patients. During a median (interquartile range) follow-up of 4.9 (1.8-7.6) years, the estimated 1- and 5-year survivals were 98.5% and 94.5%, respectively, which were not significantly different from that of patients undergoing transaortic septal myectomy for obstructive hypertrophic cardiomyopathy (P = .52) or an age- and sex-matched US general population (P = .40). ConclusionsApical aneurysm repair in conjunction with septal myectomy is a safe procedure, and the good long-term survival of patients suggests that the procedure may reduce cardiac-related death in this high-risk hypertrophic cardiomyopathy population.

Annals for Hospitalists - March 2023

Annals for Hospitalists - March 2023

MEDEA randomised intervention study protocol in Cyprus, Greece and Israel for mitigation of desert dust health effects in adults with atrial fibrillation

IntroductionMediterranean countries experience frequent desert dust storm (DDS) events originating from neighbouring Sahara and Arabian deserts, which are associated with significant increase in mortality and hospital admissions, mostly from cardiovascular...

Variants of development and management of patients with persistent atrial fibrillation

The article discusses controversial aspects of modern management of patients with persistent atrial fibrillation (AF). The appearance of a persistent form of AF is mainly a consequence of the processes of fibrosis and electrical restructuring (remodeling) of the atrial tissue. However, the question of the causes and mechanisms of the formation of fibrosis of the atrial tissue is quite debatable. The suggestions of experts regarding the division of persistent AF depending on the features of the arrhythmological anamnesis are presented: the appearance of persistent episodes of AF as a stage of disease progression in patients who previously had a paroxysmal form of arrhythmia, or «persistent AF from the beginning». From the standpoint of predicting the course of the disease and differentiating the management of patients, there are also grounds for distinguishing «early persistent AF» in cases where the duration of the episode is more than 7 days and less than 3 months, as well as «late persistent AF» lasting from 3 to 12 months. From the point of view of evidence-based medicine, the paradigm of managing patients with persistent AF is shifting towards the fastest and most aggressive fight for sinus rhythm. Changes in favor of the rhythm control strategy have largely occurred due to the rapid development of catheter treatment technologies. Its effectiveness is generally lower than in paroxysmal AF, which is due to more pronounced structural remodeling of the atria, as well as electrophysiological changes in the myocardium against the background of a prolonged episode of arrhythmia. At the same time, research into new techniques using modification of the arrhythmia substrate is ongoing.