Cardiac Resynchronization Therapy Defibrillator Research Articles

A CASE REPORT OF HEART FAILURE WITH IMPAIRED EJECTION FRACTION DUE TO DILATED CARDIOMYOPATHY IN A YOUNG PATIENT

Abstract A 30–year–old female, with no prior history of heart disease sought medical treatment for increasing shortness of breath, oedema in the lower limbs, abdominal enlargement from seven days. She had was adopted, was a smoker, no use of illicit drugs. Her heart rate was 90 per minute, she had bilateral pitting oedema to mid–shin, her blood pressure was 100/70mm Hg, there were no signs of jugular venous hypertension, the pulmonary and cardiac auscultations were normal. She had ascites and her liver was palpable 3cm below the right costal margin. Her ECG had shown sinus rhythm, heart rate of 92bm, PR interval of 160ms, left bundle branch block (QRS duration of 130ms). Her echocardiogram showed severe global left ventricular dysfunction with left ventricular (LV) ejection fraction (EF) 18% using the apical biplane Simpson’s rule, GLS WAS –4.3%, her right ventricle was dilated and impaired (TAPSE 1,6cm). Her BNP was 2393,90pg/ml. To exclude coronary artery disease, especially congenital coronary artery disease a coronary CT angiography (CTA) was performed. The coronary CTA scan showed normal findings. Cardiac MRI showed severe impairment of both left and right ventricular systolic function with a pattern of gadolinium enhancement negative for necrosis or fibrosis. The patient, after being initially treated with large doses of diuretics and levosimendan, was promptly treated with sacubitril valsartan, empaglifozin, bisoprolol, spironolactone plus vericiguat with rapid titration to maximal tolerated dose. About 1 week later her symptoms began to subside and the patient was discharged in a stable condition. She was referred for consideration of cardiac transplantation and cardiac resynchronisation therapy defibrillator; blood samples for genetic pathology research were taken. A program of serial echocardiograms was introduced, every 30 days, and was observed after 2 months. At follow up our patient had an impressive improvement in terms of improved quality of life, NYHA functional class (from III to I), and performance capacity. A new echocardiographic assessment had shown an LVEF of42% with GLS of–12%. Conclusions: Four pillars of heart failure therapy and vericiguat addiction with rapid titration represents a safe and effective strategy for the treatment of cardiac decompensation with reduced FE. Basal / 60 day EF % 18 /42 GLS % –4.3/ –12.0 E/A 5 /2,1 BNP pg/ml 2393.90 / 889.90 TAPSE cm/s 1.6 / 2.1

Safety, efficacy, and reliability evaluation ofa novel small-diameter defibrillation lead: Global LEADR pivotal trial results

BackgroundImplantable cardioverter-defibrillators last longer, and interest in reliable leads with targeted lead placement is growing. The OmniaSecure defibrillation lead is a novel, small-diameter, catheter-delivered lead designed for targeted placement, based on the established SelectSecure SureScan MRI Model 3830 lumenless pacing lead platform. ObjectiveThis trial assessed safety and efficacy of the OmniaSecure defibrillation lead. MethodsThe worldwide LEADR pivotal clinical trial enrolled patients indicated for de novo implantation of a primary or secondary prevention implantable cardioverter-defibrillator or cardiac resynchronization therapy defibrillator, all of whom received the study lead. The primary efficacy end point was successful defibrillation at implantation per protocol. The primary safety end point was freedom from study lead–related major complications at 6 months. The primary efficacy and safety objectives were met if the lower bound of the 2-sided 95% credible interval was >88% and >90%, respectively. ResultsIn total, 643 patients successfully received the study lead, and 505 patients have completed 12-month follow-up. The lead was placed in the desired right ventricular location in 99.5% of patients. Defibrillation testing at implantation was completed in 119 patients, with success in 97.5%. The Kaplan-Meier estimated freedom from study lead–related major complications was 97.1% at 6 and 12 months. The trial exceeded the primary efficacy and safety objective thresholds. There were zero study lead fractures and electrical performance was stable throughout the mean follow-up of 12.7 ± 4.8 months (mean ± SD). ConclusionThe OmniaSecure lead exceeded prespecified primary end point performance goals for safety and efficacy, demonstrating high defibrillation success and a low occurrence of lead-related major complications with zero lead fractures.

Clinical impact of remote heart failure management using the multiparameter ICD HeartLogic alert

Introduction and objectivesThe multiparametric implantable cardioverter-defibrillator HeartLogic index has proven to be a sensitive and timely predictor of impending heart failure (HF) decompensation. We evaluated the impact of a standardized follow-up protocol implemented by nursing staff and based on remote management of alerts. MethodsThe algorithm was activated in HF patients at 19 Spanish centers. Transmitted data were analyzed remotely, and patients were contacted by telephone if alerts were issued. Clinical actions were implemented remotely or through outpatient visits. The primary endpoint consisted of HF hospitalizations or death. Secondary endpoints were HF outpatient visits. We compared the 12-month periods before and after the adoption of the protocol. ResultsWe analyzed 392 patients (aged 69±10 years, 76% male, 50% ischemic cardiomyopathy) with implantable cardioverter-defibrillators (20%) or cardiac resynchronization therapy defibrillators (80%). The primary endpoint occurred 151 times in 86 (22%) patients during the 12 months before the adoption of the protocol, and 69 times in 45 (11%) patients (P<.001) during the 12 months after its adoption. The mean number of hospitalizations per patient was 0.39±0.89 pre- and 0.18±0.57 postadoption (P<.001). There were 185 outpatient visits for HF in 96 (24%) patients before adoption and 64 in 48 (12%) patients after adoption (P<.001). The mean number of visits per patient was 0.47±1.11 pre- and 0.16±0.51 postadoption (P<.001). ConclusionsA standardized follow-up protocol based on remote management of HeartLogic alerts enabled effective remote management of HF patients. After its adoption, we observed a significant reduction in HF hospitalizations and outpatient visits.

Coronary venous lead reimplantation vs. left bundle branch area pacing crossover following cardiac resynchronization therapy defibrillator extraction: a single-centre experience.

Abstract

Impact of High-Voltage Device Implantation in Elderly Japanese Patients With Heart Failure as Primary Prevention - Post Hoc Analysis of HINODE.

Despite an increased incidence of chronic heart failure (HF) and sudden cardiac death (SCD), the use of implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) is much lower in Japan than in Western countries. The HF Indication and SCD Prevention Trial Japan (HINODE) prospectively assessed the mortality rate, appropriately treated ventricular arrhythmias (VA), and HF in Japanese patients with a higher risk of HF.Methods and Results: HINODE consisted of ICD, CRT-defibrillator (CRT-D), pacing, and non-device treatment cohorts. This subanalysis evaluated the impact of the implantation of high-voltage devices (HVD; ICD and CRT-D) in 171 Japanese patients. We compared all-cause mortality, VA, and HF events between elderly (age >70 years at study enrollment) and non-elderly HVD recipients. The estimated survival rate through 24 months in the HVD cohort was 85.8% (97.5% lower control limit 77.6%). The risk of all-cause mortality was increased for the elderly vs. non-elderly (hazard ratio [HR] 2.82; 95% confidence interval [CI] 1.01-7.91; P=0.039), but did not differ after excluding ICD patients with CRT-D indication (HR 2.32; 95% CI 0.79-6.78; P=0.11). There were no differences in VA and HF event-free rates between elderly and non-elderly HVD recipients (P=0.73 and P=0.55, respectively). Although elderly patients may have a higher risk of mortality in general, the benefit of HVD therapy in this group is comparable to that in non-elderly patients.

Heart Rhythm New Zealand consensus statement on the practical management of cardiac implanted electronic devices in the peri-operative environment.

Electrosurgery is commonly used during a range of operations in order to maintain effective haemostasis. This can cause electromagnetic interference (EMI) with cardiac implanted electronic devices (CIEDs), which prevents normal device function. CIEDs include pacemakers (PPM), implantable cardiac defibrillators (ICD), cardiac resynchronisation therapy devices-both pacemakers and defibrillators (CRT-P/CRT-D)-and implantable loop recorders (ILRs). Damage to the generator, inhibition of pacing, activation of asynchronous pacing and ventricular fibrillation can all be induced by electrocautery. An active management plan for CIEDs during electrosurgery is critical to minimise these adverse effects of EMI. Purpose: To facilitate the safe and effective peri-operative management of CIED patients during electrosurgery.

Long-Term Outcomes of Resynchronization–Defibrillation for Heart Failure

BackgroundThe Resynchronization–Defibrillation for Ambulatory Heart Failure Trial (RAFT) showed a greater benefit with respect to mortality at 5 years among patients who received cardiac-resynchronization therapy (CRT) than among those who received implantable cardioverter–defibrillators (ICDs). However, the effect of CRT on long-term survival is not known.MethodsWe randomly assigned patients with New York Heart Association (NYHA) class II or III heart failure, a left ventricular ejection fraction of 30% or less, and an intrinsic QRS duration of 120 msec or more (or a paced QRS duration of 200 msec or more) to receive either an ICD alone or a CRT defibrillator (CRT-D). We assessed long-term outcomes among patients at the eight highest-enrolling participating sites. The primary outcome was death from any cause; the secondary outcome was a composite of death from any cause, heart transplantation, or implantation of a ventricular assist device.ResultsThe trial enrolled 1798 patients, of whom 1050 were included in the long-term survival trial; the median duration of follow-up for the 1050 patients was 7.7 years (interquartile range, 3.9 to 12.8), and the median duration of follow-up for those who survived was 13.9 years (interquartile range, 12.8 to 15.7). Death occurred in 405 of 530 patients (76.4%) assigned to the ICD group and in 370 of 520 patients (71.2%) assigned to the CRT-D group. The time until death appeared to be longer for those assigned to receive a CRT-D than for those assigned to receive an ICD (acceleration factor, 0.80; 95% confidence interval, 0.69 to 0.92; P=0.002). A secondary-outcome event occurred in 412 patients (77.7%) in the ICD group and in 392 (75.4%) in the CRT-D group.ConclusionsAmong patients with a reduced ejection fraction, a widened QRS complex, and NYHA class II or III heart failure, the survival benefit associated with receipt of a CRT-D as compared with ICD appeared to be sustained during a median of nearly 14 years of follow-up. (RAFT ClinicalTrials.gov number, NCT00251251.)

Negative effects of COVID-19 on the implantation rate of cardiac resynchronization therapy with defibrillator device.

COVID-19 drastically impacted the landscape of the United States' medical system. Limited data is available on the nationwide implantation trends in Cardiac Resynchronization Therapy Defibrillator (CRT-D) devices before and during the pandemic. We aimed to explore the impact of the COVID-19 pandemic on CRT-D insertion rates and adverse outcomes related to delays in care. We conducted a retrospective cross-sectional analysis using the National Inpatient Sample database between 2017 and 2020. Variables were identified using their ICD-10 codes. Inclusion criteria: age ≥ 18 years, presenting for a nonelective admission, primary diagnosis of hypertensive heart disease, hypertensive heart, chronic kidney disease, or heart failure, and underwent insertion of a CRT-D. Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6198 devices were implanted yearly from 2017 to 2019, with only 5040 devices being implanted in 2020. Additionally, reduced implantation rates were noted for every cohort of hospital size, location, and teaching status during this year. The year 2020 also had the highest average death rate at 1.39%, but this difference was statistically insignificant (adjusted Wald test p = .767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p = .162). The COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. CRT-D procedures significantly decreased in 2020. This is the first retrospective study highlighting the trend of reduced rates of CRT-D implantation as a response to the COVID-19 pandemic.

Clinical Significance of Atrial Tachyarrhythmia Duration for Ventricular Arrhythmia in Patients With Cardiac Resynchronization Therapy.

Atrial tachyarrhythmias (ATAs) are reportedly associated with ventricular arrhythmias (VAs). However, little is known about the association between ATA duration and the risk of VA. We investigated the relationship between ATA duration and subsequent VA in patients with a cardiac resynchronization therapy defibrillator (CRT-D).Methods and Results: We investigated associations between the longest ATA duration during the first year after cardiac resynchronization therapy (CRT) implantation and VA and VA relevant to ATA (VAATA) in 160 CRT-D patients. ATAs occurred in 63 patients in the first year. During a median follow-up of 925 days from 1 year after CRT implantation, 40 patients experienced 483 VAs. Kaplan-Meier analysis showed a significantly higher risk of VA in patients with than without ATA in the first year (log rank P=0.0057). Hazard ratios (HR) of VA (HR 2.36, 2.10, and 3.04 for ATA >30s, >6 min and >24 h, respectively) and only VAATA (HR 4.50, 5.59, and 11.79 for ATA >30s, >6 min and >24 h, respectively) increased according to the duration of ATA. In multivariate analysis, ATA >24 h was an independent predictor of subsequent VA (HR 2.42; P=0.02). Patients with ATA >24 h in the first year after CRT had a higher risk of subsequent VA and VAATA. The risk of VA, including VAATA, increased with the longest ATA duration.

PP48 Cardiac Implantable Electronic Device (CIED) Infections In New South Wales, Australia: A Non-Interventional Study Utilizing Linked Secondary data

IntroductionCardiac Implantable Electronic Device (CIED) infection is a serious complication associated with morbidity, mortality and high healthcare costs. Internationally, the published rate of CIED infection ranges from 1.0 percent to 1.6 percent. There is a lack of data on CIED infection rates in Australia; the reported range is from less than 1 percent at 30 days to 7 percent over 5 years. Due to the variability within the limited number of studies there is a need for further analyses of CIED infection rates in Australia.MethodsThis was a retrospective cohort study using secondary linked hospital (the NSW Admitted Patient Data Collection) and mortality data for patients who underwent CIED procedures between July 2017 and June 2020 in NSW. Overall and procedure-and patient-specific incidence of infection was calculated.ResultsA total of 23,786 CIED procedures were performed among 22,404 patients and 422 CIED infections were identified, giving an overall infection rate of 1.77 percent. When infections were limited to those following a CIED procedure in the period July 2017-June 2020 (n=309), the procedure-specific CIED infection rate was 1.30 percent, ranging from 1.01 percent for permanent pacemaker (PPM) to 2.71 percent for cardiac resynchronization therapy-defibrillator (CRT-D). The proportion of patients undergoing CIED procedures in this period who had a subsequent CIED infection was 1.29 percent, ranging from 0.97 percent for permanent pacemaker (PPM) to 3.05 percent for cardiac resynchronization therapy defibrillator (CRT-D). Procedure-based infection rate in high-risk patients (generator replacement; system upgrade; revision; or CRT-D procedure) was 1.47 percent and patient-based infection rate was 1.68 percent. Infection rate was highest within the first month following the CIED procedure that dropped significantly over time.ConclusionsRates of infection were highest among patients with cardiac resynchronization therapy (CRT) devices, and those who underwent revision or upgrade procedures. Ongoing monitoring of CIED infection rates and preventative measures are necessary, especially for high-risk patients. This study highlights the important role linked secondary data has in reducing uncertainty and removing the reliance on international estimates by providing targeted, local data for health technology assessment.

Association of Device-Detected Atrial High-Rate Episodes With Long-term Cardiovascular and All-Cause Mortality: A Cohort Study

BackgroundDevice-detected atrial high-rate episodes (AHREs) were associated with an increased thromboembolic risk. Although limited data regarding the long-term prognosis of patients with AHRE were controversial, this study aimed to identify the association of device-detected AHRE with mortality. MethodsThis observational study included patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) placement and no history of atrial fibrillation (AF), atrial flutter (AFL), or atrial tachycardia (AT). During follow-up, patients with at least 1 day of AHRE duration ≥ 15 minutes were identified. The primary endpoint was cardiovascular mortality, and the secondary endpoint was all-cause mortality. ResultsDuring a mean follow-up period of 4.2 years, AHREs were detected in 124 of 343 (36.2%) patients. Of these, 44 deaths (35.5%) occurred in 124 patients with AHREs, which was significantly higher than those without AHREs (43 of 219; 19.6%; P = 0.001). The multivariate analysis revealed that patients with AHRE had a significantly higher risk of cardiovascular (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.23-4.67; P = 0.010), and all-cause mortality (HR, 2.31; 95% CI, 1.49-3.59; P < 0.001). Further analysis indicated that this association remained significant in patients with higher burden (≥ 6 hours) but not in patients with lower burden (≥ 15 minutes to 6 hours). Notably, even after excluding the patients diagnosed with clinical AF during follow-up, the remaining patients with AHREs still exhibited a higher risk of cardiovascular and all-cause mortality compared with patients without AHREs. ConclusionsAHREs were prevalent in ICD or CRT-D recipients with no history of clinical AF, AFL, or AT and were associated with more than twice the risk of cardiovascular and all-cause mortality. Clinical Trial RegistrationNo. ChiCTR-ONRC-13003695.

The Micra Transcatheter Pacing System: past, present and the future.

Leadless permanent pacemakers represent an important innovation in cardiac device developments. Althoughtransvenous permanent pacemakers have become indispensable in managing bradyarrhythmia and saving numerous lives, the use of transvenous systems comes with notable risks tied to intravascular leads and subcutaneous pockets. This drawback has spurred the creation of leadless cardiac pacemakers. Within this analysis, we compile existing clinical literature and proceed to evaluate the efficacy and safety of the Micra Transcatheter Pacing System. We also delve into the protocols for addressing a malfunctioning or end-of-life Micra as well as device extraction. Lastly, we explore prospects in this domain, such as the emergence of entirely leadless cardiac resynchronization therapy-defibrillator devices.

Inappropriate shock incidence in patients with subcutaneous implantable cardioverter-defibrillators with concomitant cardiac implantable electronic devices: A single-center cohort study.

Subcutaneous implantable cardioverter defibrillators (S-ICDs) are occasionally used in combination with other cardiac implantable electronic devices (CIEDs). However, whether the incidence of inappropriate shock increases in patients with S-ICDs and concomitant CIEDs remains unclear. This study aimed to investigate the association between the concomitant use of CIEDs and the incidence of inappropriate shock in patients with current-generation S-ICDs. A total of 127 consecutive patients received an S-ICD. Patients were assigned to two groups depending on concomitant use of CIEDs at the time of S-ICD implantation: patients without other CIEDs (non-combined group, 106 patients) and patients with other CIEDs (combined group, 21 patients). CIEDs included pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy pacemakers, and cardiac resynchronization therapy defibrillators. The primary outcome was inappropriate shock, defined as a shock other than ventricular arrhythmia. Hazard ratios and 95% confidence intervals were calculated using a time-varying Cox proportional hazards model which was adjusted for age because age differed between the groups and could be a confounder. During a median follow-up period of 2.2 years (interquartile range, 1.0-3.4 years), inappropriate shock events occurred in 17 (16%) and five (19%) patients of the non-combined and combined groups, respectively. While the age-adjusted hazard ratio for inappropriate shock was 24% higher in the combined than in the non-combined group (hazard ratio=1.24, 95% confidence interval, 0.39-3.97), this difference was insignificant (p=.71). The incidence of inappropriate shock did not differ between patients with and without concomitant use of CIEDs, suggesting that S-ICDs could potentially be combined with other CIEDs without increasing the number of inappropriate shocks. Further studies are warranted to confirm the safety and feasibility of concomitant use of S-ICDs and CIEDs.

Phenogrouping and risk stratification of patients undergoing cardiac resynchronization therapy upgrade using topological data analysis

Choosing the optimal device during cardiac resynchronization therapy (CRT) upgrade can be challenging. Therefore, we sought to provide a solution for identifying patients in whom upgrading to a CRT-defibrillator (CRT-D) is associated with better long-term survival than upgrading to a CRT-pacemaker (CRT-P). To this end, we first applied topological data analysis to create a patient similarity network using 16 clinical features of 326 patients without prior ventricular arrhythmias who underwent CRT upgrade. Then, in the generated circular network, we delineated three phenogroups exhibiting significant differences in clinical characteristics and risk of all-cause mortality. Importantly, only in the high-risk phenogroup was upgrading to a CRT-D associated with better survival than upgrading to a CRT-P (hazard ratio: 0.454 (0.228–0.907), p = 0.025). Finally, we assigned each patient to one of the three phenogroups based on their location in the network and used this labeled data to train multi-class classifiers to enable the risk stratification of new patients. During internal validation, an ensemble of 5 multi-layer perceptrons exhibited the best performance with a balanced accuracy of 0.898 (0.854–0.942) and a micro-averaged area under the receiver operating characteristic curve of 0.983 (0.980–0.986). To allow further validation, we made the proposed model publicly available (https://github.com/tokmarton/crt-upgrade-risk-stratification).

Therapeutic inertia in rhythm control strategies in hospitalized patients with fibrillation: Insights from Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study

BackgroundCurrent guidelines recommend a rhythm control strategy in patients with symptomatic atrial fibrillation (AF) while catheter ablation has been shown to be a safer and more efficacious approach than antiarrhythmic medications. MethodsHECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. In this sub-study, we included 276 cases who had a history of AF, particularly on the rhythm strategy, and catheter ablation procedures had been performed before the index admission. ResultsAmong 276 AF patients (mean age: 76.4 ± 11.5 years, 58 % male), 60.9 % (N = 168) had persistent AF and 39.1 % (N = 108) had paroxysmal AF. Heart failure was the main cause of admission in 54.3 % (N = 145) of the patients, while 14.1 % (N = 39) were admitted due to paroxysmal AF, 7.3 % (N = 20) due to bradyarrhythmic reasons, and 6.5 % (N = 18) suffered from acute coronary syndrome. Most importantly, heart failure with reduced ejection fraction was present in 76 (27 %) patients. Only 10 patients out of the total (3 %, mean age 59.7 years) had undergone AF ablation while electrical cardioversion had been attempted in 37 (13.4 %) patients. Interestingly, in this AF population with heart failure, 3.6 % (N = 10) had a defibrillator implanted (4 single-chamber), and only 1.5 % (N = 4) had a cardiac resynchronization therapy defibrillator (CRT-D). ConclusionHigh prevalence of persistent AF was detected in hospitalized patients, with heart failure being the leading cause of admission and main co-morbidity. Rhythm control strategies are notably underused, along with CRT-D implantation in patients with AF and heart failure.

Global Constructive Work is associated with ventricular arrythmias after cardiac resynchronization therapy

Abstract Aim Non-invasive left ventricular (LV) pressure-strain loops provide a novel method for quantifying myocardial work by incorporating LV pressure in measurements of myocardial deformation. Early studies suggest that myocardial work parameters such as Global Constructive Work (GCW) could be useful and reliable in arrhythmia prediction particularly in patients undergoing cardiac resynchronization therapy. The aim of this study was to evaluate whether the magnitude of GCW was associated with occurrence of ventricular arrhythmias in patients after cardiac resynchronization therapy. Method and results Patients on guideline-recommended treatment with a cardiac resynchronization therapy defibrillator (CRT-D) were evaluated by 2D speckle-tracking echocardiography including measurements of GCW at least six months after implantation. The primary outcome was a composite of appropriate defibrillator therapy and sustained ventricular arrhythmia under the monitor zone. A total of 162 patients (mean age 66 years (±10), 122 males (75%)), were included. 16 (10%) patients experienced the primary outcome during a median follow-up of 18 months (IQR: 12-25) after the index echocardiography. Patients with below-median GCW (&amp;lt;1,473 mmHg%) had a hazard ratio for the outcome of 8.14 [95% CI: 1.83-36.08], P=0.006 compared to patients above the median in a univariate model and remained an independent predictor after multivariate adjustment for eGFR and QRS duration (hazard ratio 4.75 [95% CI: 1.01 – 22.28], P&amp;lt;0.05. Conclusion In patients treated with CRT-D, GCW below median level was associated with a 5-fold increase in risk of ventricular arrhythmias.

Clinical characteristics of patients with cardiac sarcoidosis who were hospitalized for heart failure

Abstract Background Cardiac sarcoidosis (CS) often leads cardiac dysfunction and exacerbates heart failure. However, there are limited data regarding CS patients who were hospitalized for acute heart failure (AHF). Purpose We aimed to compare the patient characteristics and outcomes between patients with CS who were hospitalized for AHF (CS-AHF) and patients with AHF of other etiology. Methods A total of 4,556 hospitalized patients with CS were identified from the Japanese Diagnosis Procedure Combination database from 2012 to 2020. Among them, we analyzed 254 patients who were hospitalized due to AHF. Patient characteristics, prior medical history, medical therapy for heart failure, intensive care management during hospitalization, in-hospital outcomes and rehospitalization within one year after the index hospitalization were compared with general 4,056 hospitalized AHF patients who were enrolled in the Kyoto Congestive Heart Failure registry. Results Patients with CS-AHF were younger (71 [63-78] vs 80 [72-86]) and more women (69% vs 45%; p &amp;lt; 0.001) than general AHF patients. In addition, CS-AHF were associated with lower prevalence of hypertension, diabetes and dyslipidemia (46% vs 72%, p &amp;lt; 0.001; 28% vs 37%, p = 0.005; and 21% vs 38%, p &amp;lt; 0.001), and lower prescription of angiotensin converting enzyme inhibitors or angiotensin II receptor blocker (28 % vs 46%; p &amp;lt; 0.001) while prescription of beta-blockers were similar between the groups. The length of hospital stay was significantly longer in CS-AHF (23 [14-39] days vs 16 [11-25] days), more patients were treated by intensive respiratory care (32% vs 25%; p = 0.05) and cardiac resynchronization therapy defibrillator (CRTD) implantation (6% vs. 0.5%; p &amp;lt; 0.001) Although in-hospital mortality was similar between the groups, the rate of rehospitalization within one year was higher in CS-AHF (51% vs 39%; p = 0.001). Conclusions Patients with CS-AHF were younger, more women and had lower cardiovascular risk factors than those with AHF in general. CS-AHF were associated with longer hospital stay, higher rate of CRTD implantation and higher rehospitalization rates. More attention might be needed for this distinct group of patients.

Larger change in intra-thoracic impedance before and during heart failure hospitalization is associated with longer length of stay in patients with cardiovascular implanted electronic devices

Abstract Background Intra-thoracic impedance measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) is a measure of intravascular blood volume and have been shown to correlate with intracardiac pressures in previous studies. Purpose We investigated whether amount of change of intrathoracic impedance before admission is associated with length of stay (LOS) during heart failure (HF) hospitalizations in a large real-world cohort of patients with ICD/CRTD devices. Methods We linked a deidentified database of aggregated electronic health record during the period from 2007-2017 to a manufacturer’s device data warehouse with device based continuous diagnostic monitoring data. Patients with ICD/CRTD implants with intra-thoracic impedance measurements were included for this study. HF event was defined as an inpatient, emergency department, or observation unit stay in a hospital with primary diagnosis of HF and intravenous diuretics administration. Relative change of daily intra-thoracic impedance measurement from 60 days prior to admission and date of admission as well as from admission to discharge were compared in HF events with LOS &amp;lt; 5 days and LOS ≥ 5 days using a Wilcoxon rank sum test. Results A total of 17,886 patients with 1.8±1.2 years of follow-up met inclusion criteria. The average age of patients was 66.6 ±12.3 years, with 72% being males, and 51% with ICD devices. The relative change in intra-thoracic impedance from 60 days prior till date of admission and from admission to discharge for HF events with LOS &amp;lt; 5 days and LOS ≥ 5 days are shown in Table. A total of 1456 patients had 1720 HF events of which 874 events had LOS&amp;lt; 5 days and 846 had LOS≥ 5 days. HF events with a longer length of stay (LOS ≥ 5 days) had a higher relative decrease in intra-thoracic impedance prior to admission compared to HF events with a shorter length of stay. HF events with a longer length of stay (LOS≥ 5 days) had a higher relative increase in intra-thoracic impedance during hospital stay. Conclusions In a large real-world population of patients with ICD/CRTD devices, longer length of stay is more likely in patients with a larger relative decrease in intra-thoracic impedance prior to admission, indicating more accumulated fluid. Further, larger relative increase in intra-thoracic impedance during hospital stay was observed in patients with longer length of stay, indicating more fluid removal.

Redox imbalance in patients with heart failure and ICD/CRT-D intervention. Can it be an underappreciated and overlooked arrhythmogenic factor? A first preliminary clinical study.

Introduction: Redox imbalance and oxidative stress are involved in the pathogenesis of arrhythmias. They also play a significant role in pathogenesis of heart failure (HF). In patients with HFand implanted cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D), the direct current shocks may be responsible for additional redox disturbances and additionally increase arrhythmia risk. However, the precise role of oxidative stress in potentially fatal arrhythmias and shock induction remains unclear. Methods: 36 patients with diagnosed HF and implanted ICD/CRT-D were included in this study. Patients were qualified to the study group in case of registered ventricular arrhythmia and adequate ICD/CRT-D intervention. The control group consisted of patients without arrhythmia with elective replacement indicator (ERI) status. Activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), glutathione (GSH) in erythrocyte (RBC), SOD, GPx activity and reactive oxygen/nitrogen species (ROS/RNS) concentration in plasma were determined. The values were correlated with glucose, TSH, uric acid, Mg and ion concentrations. Results: In the perishock period, we found a significant decrease in RBC and extracellular (EC) SOD and RBC CAT activity (p = 0.0110, p = 0.0055 and p = 0.0002, respectively). EC GPx activity was also lower (p = 0.0313). In all patients, a decrease in the concentration of all forms of glutathione was observed compared to the ERI group. Important association between ROS/RNS and GSH, Mg, TSH and uric acid was shown. A relationship between the activity of GSH and antioxidant enzymes was found. Furthermore, an association between oxidative stress and ionic imbalance has also been demonstrated. The patients had an unchanged de Haan antioxidant ratio and glutathione redox potential. Conclusion: Here we show significant redox disturbances in patients with HF and ICD/CRT-D interventions. Oxidative stress may be an additional risk factor for the development of arrhythmia in patients with HF. The detailed role of oxidative stress in ventricular arrhythmias requires further research already undertaken by our team.

Abstract 15161: Prediction of Decompensated Heart Failure Using an Implanted Cardiac Device Risk Analysis

Introduction: TriageHF is a Heart Failure Risk Status (HFRS) diagnostic tool available on Medtronic implantable cardiac devices which reports dynamic statuses of risk of Heart Failure related Hospitalization (HFH) within the next 30 day, as high, medium or low. We investigated the accuracy of TriageHF in predicting 30-day HFH for patients attending a tertiary heart failure clinic. Methods: We retrospectively recorded HFRS between November 2021 and May 2023, from patients implanted with Medtronic Cardiac Resynchronization Therapy (CRT) or Internal Cardioverter Defibrillator (ICD) devices. We then correlated HFRS with HHF within 30 days of these alerts. Two thresholds were tested: T1 where High &amp; Medium HFRS were considered a positive alert and Low HFRS a negative alert and T2 where High HFRS was considered a positive alert and Medium &amp; Low HFRS a negative alert. The sensitivity and specificity of each threshold in predicting 30-day HFH was tested in a contingency table. Results: Over 18-months, we recorded 135 consecutive alerts from 32 patients. Median age was 72 years, 25% were female and 56% had an ischaemic substrate. 36, 88 and 11 alerts were high, medium, and low risk respectively. 0% of low HFRS and 19% of the high HFRS resulted in a 30-day HHF. 10 high HFRS alerts led to clinical interventions which was associated with a higher rate of HHF, compared to 26 high HFRS alerts where no contact was made (HHF 40% vs 11% p=0.05). The sensitivity and specificity of TriageHF in predicting 30-day HFH was 46.7% and 76.03% respectively for T1 and 100% and 9.1% respectively for T2. Conclusions: This real-world analysis suggests that TriageHF risk prediction using T2 correctly predicted HHF at 30 days with the caveat of a high false positive rate. The potential exists for viable clinical use, however research into the amalgamation of clinical data may improve it and consequently lead to better utilisation of limited clinical resources.