Cardiac Resynchronization Therapy Defibrillator Research Articles

Prognostic value of galectin-3 and right ventricular function for long-term mortality in heart failure patients treated with cardiac resynchronization therapy

Recently, associations between the biomarker galectin-3 and numerous pathological processes involved in heart failure (HF) and right ventricular (RV) function have been observed. We aimed to assess the long-term prognostic ability of galectin-3 and RV function parameters for all-cause mortality in HF patients treated with cardiac resynchronization therapy (CRT). We prospectively studied 63 symptomatic HF patients with a left ventricular (LV) ejection fraction (EF) ≤ 35%. The median serum galectin-3 concentration was 13.4 ng/mL (IQR 11.05, 17.15). A detailed assessment of LV and RV geometry and function was performed with echocardiography. CRT defibrillator implantation was achieved in all patients without major complications. The follow-up lasted 5 years. In the multivariable Cox regression model, independent predictors for all-cause mortality were log baseline galectin-3 and baseline RV function expressed as tricuspid annular plane systolic excursion with HR 2.96 (p = 0.037) and HR 0.88 (p = 0.023), respectively. Analysis of subgroups defined by galectin-3 concentration and CRT response showed that patients with high baseline galectin-3 concentrations and a lack of response to CRT had a significantly lower probability of survival. In our patient cohort, the baseline galectin-3 concentration and RV function were independent predictors of long-term all-cause mortality in HFrEF patients following CRT implantation.

One-year mortality after implantable defibrillator implantation: do risk stratification models help improving clinical practice?

The purpose of this study was to assess the available mortality risk stratification models for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients. We conducted a review of mortality risk stratification models and tested their ability to improve prediction of 1-year survival after implant in a database of patients who received a remotely controlled ICD/CRT-D device during routine care and included in the independent Home Monitoring Expert Alliance registry. We identified ten predicting models published in peer-reviewed journals between 2000 and 2021 (Parkash, PACE, MADIT, aCCI, CHA2DS2-VASc quartiles, CIDS, FADES, Sjoblom, AAACC, and MADIT-ICD non-arrhythmic mortality score) that could be tested in our database as based on common demographic, clinical, echocardiographic, electrocardiographic, and laboratory variables. Our cohort included 1,911 patients with left ventricular dysfunction (median age 71, 18.3% female) from sites not using any risk stratification score for systematic patient screening. Patients received an ICD (53.8%) or CRT-D (46.2%) between 2011 and 2017, after standard physician evaluation. There were 56 deaths within 1-year post-implant, with an all-cause mortality rate of 2.9% (95% confidence interval [CI], 2.3-3.8%). Four predicting models (Parkash, MADIT, AAACC, and MADIT-ICD non-arrhythmic mortality score) were significantly associated with increased risk of 1-year mortality with hazard ratios ranging from 3.75 (CI, 1.31-10.7) to 6.53 (CI 1.52-28.0, p ≤ 0.014 for all four). Positive predictive values of 1-year mortality were below 25% for all models. In our analysis, the models we tested conferred modest incremental predicting power to ordinary screening methods.

Cardiac Implantable Electronic Devices: Reoperations and the Competing Risk of Death

The use of cardiac implantable electronic devices (CIED), which includes pacemakers, implantable cardioverter-defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and cardiac resynchronisation therapy defibrillators (CRT-D) has increased over the past 20 years, but there is a lack of real world evidence on the longevity of these devices in the older population which is essential to inform health care delivery and support clinical decisions. We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs database. The cohort consisted of people who had a CIED procedure between 2005 and 2015. The cumulative risk of generator replacement/reoperations was estimated accounting for the competing risk of death. A total of 16,662 patients were included. In pacemaker recipients with an average age of 85 years, the 5-year risk of reoperation ranged from 2.8% in single chamber, 3.6% in dual chamber to 7.6% in CRT-P recipients, while the 5-year risk of dying with the index pacemaker in situ was 63% in single chamber, 46% in dual chamber and 56% in CRT-P recipients. In defibrillator recipients with an average age of 80 years, the 5-year risk of reoperation ranged from 11% in single chamber, 13% in dual chamber to 24% in CRT-D recipients, while the 5-year risk of dying with the index defibrillator in situ was 46% in single chamber, 40% in dual chamber and 41% in CRT-D recipients. In this cohort of older patients the 5-year risk of generator reoperation was low in pacemaker recipients whereas up to one in four CRT-D recipients would have a reoperation within 5 years.

Prognostic significance of non-sustained ventricular tachycardia on stored electrograms of heart failure patients with cardiovascular implantable electronic devices

Abstract Background Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its true impact in real world is uncertain, and often does not lead to a change in clinical intervention. Purpose To determine the prognostic significance of NSVT detection on stored electrograms of CIEDs in HF patients with systolic left ventricle dysfunction. Methods We retrospectively enrolled 132 consecutive HF patients (mean age 67,5±11,1 years, males 72,0%) with systolic left ventricle dysfunction and CIEDs (biventricular pacemakers with or without cardiac defibrillators). Patients were evaluated through CIEDs interrogation and clinical evaluations and divided into NSVT positive (Group 1) and negative groups (Group 2). Mean follow-up period was 62,8±7,1 months. Results NSVT was detected in 51 (38,6%) patients. 70 (53,0%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 37 (28,0%) transvenous implantable cardioverter defibrillator (ICD), 13 (9,8%) CRT pacemaker (CRT-P) and 12 (9,1%) subcutaneous ICD (S-ICD). Medium left ventricular ejection fraction (LVEF) was 31,1±7,9%, 20,6% were in NYHA III-IV and 47,0% were ischemic (49% Group 1 and 45,7% Group 2, p=0,708). Dyslipidemia was more prevalent in Group 2 (p=0,042). In total 11 (8,3%) patients died, 2 (1,5%) from sudden cardiac death and 5 (3,8%) from cardiovascular death. NSVT was associated with CIEDs treatments (hazard ratio [HR]2,52; 95% confidence interval [CI]1,2–5,1; p=0,001), ventricular fibrillation (VF) (HR: 3,71, 95% CI: 1,19–11,58; p=0,018), sustained ventricular tachycardia (VT) (HR: 9,06, 95% CI: 2,82–29,12; p<0,05) and composite outcome of VT, VF, HF re-admissions and related admissions to emergency department (ED) and death by all causes (HR: 2,52; 95% CI: 1,20–5,10; p=0,011). NSVT at 1 year was associated with HF readmissions at 1 year (p=0,004). Conclusions On extended monitoring possible with CIEDs, NSVT in HF patients was associated with a worse prognosis and may serve as a predictor of significant arrhythmic events, HF hospitalizations and mortality. These findings enhances the importance of remote monitoring and optimization of therapeutic modalities in these patients along with a close supervision. Funding Acknowledgement Type of funding sources: None.

Non-sustained ventricular tachycardia on remote patient monitoring in heart failure patients

Abstract Background Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of remote patient monitoring (RPM) in Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its impact in real world is uncertain. Purpose To determine the clinical impact of NSVT detection in RPM in ischemic and non-ischemic chronic heart failure patients with reduced ejection fraction (HFrEF) and CIEDs. Methods We retrospectively enrolled 121 consecutive patients with HFrEF, CIEDs and RPM. Patients were evaluated through routine episodic CIEDs interrogation, routine clinical evaluations and continuous monitoring data obtained from CIEDs and transmitted remotely to the care team and divided into NSVT positive (Group 1) and negative groups (Group 2). Primary endpoint was admissions to the emergency department by HF decompensation and secondary endpoint was the occurrence of arrhythmic events. A sub-analysis of non-ischemic HF was also performed. Results NSVT was detected in 78 (72,2%) patients. The mean number of episodes of NSVT was 611,68±3271,25 during the follow-up period or 2,445±16,688 in 24 hours. Mean age was 62,40±13,218 years, 71,9% were males and mean follow-up period was 56,30±39,37 months. Fifty-eight patients (47,9%) had transvenous implantable cardioverter defibrillator (ICD), 48 (39,7%) implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 14 (11,6%) subcutaneous ICD (S-ICD) and 1 (0,8%) CRT pacemaker (CRT-P). Medium left ventricular ejection fraction (LVEF) was 34,70±12,53%, 25 (23,14%) were in NYHA III-IV and 46 (39,0%) were ischemic (29 (37,7%) in Group 1 and 11 (37,9%) in Group 2). NSVT was associated with the occurrence of sustained ventricular tachycardia (VT) (1,88±0,186episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,012), ventricular fibrillation (VF) (1,44±5,325 episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,011) and admissions to the emergency department by HF decompensation at 5 years (r=0,310, p=0,011). A sub-analysis in non-ischemic HF patients also showed correlation between NSVT and VT (r=0,602, p<0,05) and admissions to the emergency department by HF decompensation at 5 years (r=0,382, p=0,014). Conclusions On remote patient monitoring with CIEDs, NSVT in HF patients was associated with arrhythmic events and may serve as a predictor for HF decompensations. Funding Acknowledgement Type of funding sources: None.

Potential impact of a new generation of remote monitoring platform: evaluation of the yearly triage burden for 35 595 patients

Abstract Background Remote monitoring (RM) has become a new standard of care in the follow-up of patients with cardiac implantable electronic devices (CIEDs). It increases the probability of survival, reduces hospitalizations and health care costs, improves clinical outcome, prevents atrial fibrillation-related strokes and increases patient acceptance and satisfaction. However, human review of the all CIEDs generated data is tedious and time-consuming for healthcare professionals. Purpose This study intends to determine the RM alert burden in a European multicentric cohort of patients with a CIED and the impact that a multivendor platform could have on the remote management of patients. Method This retrospective study was conducted on all patients with a CIED remotely followed-up via a universal platform between 01/01/2020 and 12/31/2020 across 71 centers. We measured the quantity, frequency and criticality of patients' transmissions, and related episodes and alerts for all types of devices. Scheduled and triggered transmissions were included, but daily transmissions of data without alerts (such as Biotronik) were excluded as they are usually not reviewed by medical teams. Results A total of 35 595 patients were analyzed: 12 065 (34%) implantable cardioverter-defibrillator (ICD), 8 705 (24%) cardiac resynchronization therapy defibrillator (CRT-D), 8 341 (23%) implantable pulse generator (IPG), 1 248 (4%) cardiac resynchronization therapy pacemaker (CRT-P), 1 891 (5%) subcutaneous implantable cardioverter-defibrillator (S-ICD), and 3 345 (10%) implantable loop recorder (ILR). A total of 504 580 transmissions were received, with an average of 14.2 /patient (p)/year (y). 81% of the transmissions were scheduled, 16% patient-initiated and 3% device initiated. A total of 1 521 653 episodes were received (41.5/p/y) with CRT-D (63/p/y) and ILR (54.6 y/p/y) generating most of the episodes. Most common episodes for CRT-D is AT (atrial tachycardia)/AF atrial-fibrillation) (51%), whereas AT/AF (39.1%) and Pause (50.4%) are most common for ILR. A total number of 814 777 alerts were triggered (22.9 /p/y). ILR had 273% more alerts (85.5/p/y) while S-ICD (12/p/y), IPG (13.1/p/y) and ICD (13.6/p/y) had less. 3.5% were set as red alerts, 32.3% yellow alerts, 7.5% blue alerts. 56.7% were set to “off” by the medical teams on the proprietary platform by using the notification settings, allowing for a universal custom filtering of alerts. A total number of 28 284 red alerts were triggered (0.8 / p/y), mostly by CRT-D (1.4/p/y) and ILR (1.3/p/y). Conclusion A high number of transmissions, episodes and alerts are still generated by RM in 2020 with routine care settings, as measured with a new RM universal platform. Routine customizing settings across vendors allowed medical teams to reduce the total number of reviewed alerts by 57%. Algorithms identifying significant AF alerts, or readjudicating episodes from ICD and ILR could be important to further reduce the RM burden. Funding Acknowledgement Type of funding sources: None. Number of episodes per patient per yearAlerts by priority

Pacemaker upgrade to CRT-D or CRT-P without prior ventricular arrhythmias: a long-term single-centre retrospective analysis

Abstract Background Cardiac Resynchronization Therapy (CRT) can reverse the harmful effects of right ventricular pacing (RVP). Data are sparse on comparing all-cause mortality among patients undergone CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) upgrade from pacemakers without prior ventricular arrhythmias (VAs). Purpose We compared the differences in long-term all-cause mortality, postprocedural complications and the occurrence of VAs among patients receiving CRT-D or CRT-P upgrade. Methods Patients with a previously implanted conventional pacemaker (PM) developing heart failure (HF) despite optimal medical treatment and high rates of RVP, were included. Altogether 270 patients were investigated, 83 (30.7%) upgraded to CRT-D, 187 (69.3%) to CRT-P in our retrospective registry. The primary endpoint was all-cause mortality, secondary endpoints were malignant VAs and implantation-related complications. Results CRT-D upgrade patients were more likely to be males, have a favourable renal function and lower left ventricular ejection fraction (LVEF). During the median follow-up time of 3.7 years, 25 (30.1%) of CRT-D and 131 (70.1%) of CRT-P upgrade patients reached the primary endpoint. The CRT-D upgrade group showed a lower risk of all-cause mortality in the total cohort (HR: 0.55; 95% CI: 0.38–0.78; p=0.004) and in the ischaemic subgroups compared to CRT-P. After adjustment, CRT-D, ischaemic HF aetiology and LVEF have been confirmed as independent predictors of all-cause mortality. Malignant VA occurrence was higher among CRT-D patients (10.8% vs 1.1%; p=0.001), while no difference was observed in the rate of complications between the two patient groups. However, lead removal was performed more frequently (13.3% vs 1.1%; p<0.001) during CRT-D upgrade procedures compared to CRT-P. Conclusions Patients among the total and ischaemic HF aetiology subgroup benefited more from the CRT-D upgrade, although VAs and lead removal were more common than in the CRT-P group. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the ÚNKP-20-3-I-SE-43 New National Excellence Program if the Ministry for Innovation and Technology in Hungary. Project no. NVKP_16-1–2016-0017 (“National Heart Program”) has been implemented with the support provided by the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. All-cause mort of pts after UPG

Impact of programming in a large cohort of implantable cardioverter-defibrillator patients with long-term follow-up: findings from the UMBRELLA study

Abstract Background Data about the penetration of current ICD programming recommendations in a real-life setting are lacking. Purpose To assess how modern-era ICD patients are programmed and to study the relationship between programming and ICD therapies in large cohort of Spanish patients. Methods UMBRELLA (NTC01561144) is a prospective, multicentre, nationwide study of ICD patients followed by remote monitoring. ICD programming was performed according to regular clinical practice at each site and it was automatically stored through the remote monitoring system. Arrhythmic events were also automatically stored and reviewed in a blinded process performed by a committee of experts. The study outcomes were appropriate ICD therapies and inappropriate shocks (IS). Results The study population consisted of 4296 patients implanted with an ICD from 2005 to 2017 (61.9±12.9 years, ischaemic cardiomyopathy in 50% and dilated cardiomyopathy in 22.7% of population). Primary prevention (PP) was the main indication (64.2%). At implant, 66.4% of patients had LVEF ≤35% and 18.9% had LVEF >50%. Majority of patients (52.4%) presented with narrow QRS (<120 ms), while QRS width was >150 ms in 26.7% of population. Single-chamber, dual-chamber and cardiac resynchronization therapy-defibrillator (CRT-D) devices were implanted in 47.2%, 22.6% and 30.2% of population, respectively. At first remote transmission, single zone detection programming was only enabled in 43.2% of population (52.6% among PP patients), while the remaining patients (56.8%) had a ventricular tachycardia zone enabled, despite the ventricular fibrillation (VF) zone (73.8% among secondary prevention patients). Delayed high-rate detection programming (detection interval <320 ms and NID ≥30/40 within the VF zone) was only enabled in 39.7% of population. Adherence to programming recommendations significantly increased through the study period (Table). During a mean follow-up of 46.6±27.3 months, 16,067 episodes of sustained ventricular arrhythmia (SVA) occurred. An appropriate ICD therapy was delivered to 85.7% (n=13,767) episodes of SVA in 1173 patients (event rate: 27.3%). In multivariate analysis, delayed high-rate detection in PP patients (HR: 0.76, 95% CI: 0.61–0.94) (Figure) and single-zone programming (HR: 0.69, 95% CI: 0.59–0.81) were associated to lower risk of appropriate ICD therapies. At follow-up, 257 patients (6% of population) experienced an IS. The incidence of IS did not differ according to type of device (6.4% vs. 6.2% vs. 5.2% for single-, dual-chamber, and CRT-D, respectively, p=0.321). In multivariate analysis single-zone programming (HR: 0.71, 95% CI: 0.51–0.97) was the only ICD setting independently related to a lower risk of IS. Conclusions Implementation of current programming recommendations is required in modern-era ICD patients. Funding Acknowledgement Type of funding sources: None. Figure 1Table 1

Temporal changes in resting heart rate before and after heart failure decompensation in a large real-world population of patients with reduced ejection fraction

Abstract Background Diagnostic parameters measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) have been shown to change before and after heart failure (HF) events with fluid overload. Purpose We investigated the temporal characteristics of nighttime heart rate, as a surrogate of resting heart rate, before and after HF events in a large real-world cohort of patients with ICD/CRTD devices. Methods We linked a de-identified database of aggregated electronic health record (EHR) data (2007–2017) to a manufacturer's device database with continuous diagnostic monitoring data. Patients with ICD/CRTD implants with HF related diagnostics were included for this study. The device computes nighttime heart rate as the average heart rate between midnight and 4 am. 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. Temporal ensemble average of night heart rate in the 60 days pre and post HF events were compared between HF events with and without readmission within 60 days as well as with periods with no HF events. 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 average night heart rate pre and post HF events with and without readmission and in follow-ups with no events is shown in Figure. A total of 1174 patients had 1425 HF events with no readmission for HF within 60 days and 282 patients had 295 HF events which were followed by readmission for HF within 60 days. A total of 17,839 patients had no HF events over 86,858 follow-up months. A 3-day average night heart rate increased by >3 bpm in a large proportion of patients in the 30-day period before HF event compared to 30-day periods with no events (28% vs 16%; Odds Ratio: 2.08; p<0.001). Patients who were readmitted for HF have higher average NHR before and after admission compared to patients who are not readmitted. In patients who were not readmitted, the night heart rate recovers to baseline levels on an average within 10 days post discharge. Conclusions In a large real-world population of patients with ICD/CRTD devices, the average night heart rate increases before HF events. Patients who are readmitted are more likely to have higher night heart rate after discharge. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic Plc

Temporal characteristics of duration of daily activity before and after heart failure hospitalizations in a large real-world population of patients with cardiovascular implanted electronic devices

Abstract Background Diagnostic parameters measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) have been shown to change before and after heart failure (HF) events with fluid overload. Purpose We investigated the temporal characteristics of device measured daily activity duration before and after HF events in a large real-world cohort of patients with ICD/CRTD devices. Methods We linked a de-identified database of aggregated electronic health record (EHR) data (2007–2017) to a manufacturer's device database with continuous diagnostic monitoring data. Patients with ICD/CRTD implants with HF diagnostic feature were included for this study. Device accumulates the total number of active minutes during a 24-hour period with an active minute defined as total number of accelerometer fluctuations reaching a threshold during the minute. 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. Temporal ensemble average of daily duration of activity in the 60 days pre and post HF events were compared between HF events with and without readmission within 60 days and with periods with no HF events during follow-up. 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 average daily duration of activity in HF events with and without readmission and with no events is shown in Figure. A total of 1174 patients had 1425 HF events with no readmission for HF within 60 days and 282 patients had 295 HF events which were followed by readmission for HF within 60 days. A total of 17,839 patients had no HF events over 86,858 follow-up months. The 7-day average activity duration decreased by >10 minutes in a large proportion of patients in the 30-day period before HF event compared to 30-day periods with no events (43% vs 34%; Odds Ratio: 1.52; p<0.001). A 7-day average activity duration increase of >10 minutes from admission to 30 days after admission happens in a smaller proportion of HF events with versus without HF readmission within 60 days of index admission (24% vs 31%; Odds Ratio: 0.7; p<0.001). Conclusions In a large real-world population of patients with ICD/CRTD devices, the average daily activity duration reduces before HF events. Re-admissions are more likely in patients with smaller increase in activity duration post discharge. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic Plc

Looking for appropriate criterias for SCD prevention: prognostic role of MRI in patients with nonischemic ventricular arrhythmias

Abstract Background Currently left ventricular ejection fraction (LVEF) remains the only indicator for identifying candidates for implantable cardioverter-defibrillator (ICD)therapy for the primary prevention of sudden cardiac death (SCD). However the majority of patients suffering SCD have a preserved LVEF and some of them with poor LVEF do not benefit from ICD therapy. Late gadolinium enhancement (LGE) on cardiac-MRI (CMR) has been proposed as an independent predictor of ventricular arrhythmias. Limited data exist on the role and methods of LGE quantification in patients with a nonischemic ventricular arrhythmias. Purpose The goal of this study is to explore whether theextent of LGE would improve risk stratification in patients with a nonischemic ventricular arrhythmias with an indication for implantable cardioverter-defibrillator (ICD) therapy for the primary or secondary prevention of SCD. Methods Fifty six patients with a nonischemic ventricular arrhythmias underwent LGE-CMR prior to ICD implantation for primary and secondary prevention of SCD. LGE extent was quantified using both the full-width half-maximum (FWHM) andthe standard deviation–based (2-SD) method. The primary endpoint was appropriate ICD discharge for sustained ventricular tachyarrhythmia. Results During a median follow-up of 18 [11,5–26,0] months the primary endpoint occurred in 22 patients. The median percentage of LV myocardium fibrosis assessed by the 2-SD method was 9,8 [6,0–18,8]%, while for the FWHM method it was 5,1 [3,0–10,6]% (p<0,001). Intra-observer and inter-observer variability of the FWHM technique was excellent, intraclass correlation coefficients (ICC) 0,97 (95% CI: 0,92–0,99) for intraobserver variability and 0,95 (95% CI: 0,85–0,98) for interobserver variability. The ICC for the 2-SD method were lower: 0,92 (95% CI: 0,76–0,97) and 0,90 (95% CI: 0,69–0,96), for intra- and interobserver variability, respectively. By Cox univariate regression analysis, past syncope, HR: 3,14; (CI: 1,28–7,73), past sustained VT, HR: 8,24; (CI: 2,43–27,96), the presence of LBBB before implantation cardiac resynchronization therapy defibrillator (CRT-D), HR: 0,22; (CI: 0,05–0,96) as well as extent of LGE, HR: 1,067; per 1% increase in the extent of LGE, (CI: 1,029–1,107) demonstrated the strongest association with the appropriate ICD discharge. In multivariate regression analysis, the history of sustained VT, HR: 9,17; (CI: 2,60–32,38; p=0,001) and the value of the extent of LGE, HR: 1,081; per 1% increase in volume of LGE, (CI: 1,034–1,131; p=0,001) demonstrated an independent association with the appropriate ICD discharge. Conclusions FWHM is the optimal semi-automated quantification method in patients with nonischemic ventricular arrhythmias, demonstrating the highest technical consistency. LGE extent is an independent predictor of adverse outcomes in patients with nonischemic ventricular arrhythmia and may have an important role in risk stratification. Funding Acknowledgement Type of funding sources: None. LGE QuantificationEvent-Free Survival

The resuscitation status of implantable cardioverter-defibrillator patients according to electronic health records: are we ignoring the device?

Abstract Introduction/Background The Care Quality Commission (CQC) has recently raised concerns around resuscitation decisions in the UK. In our hospital an early resuscitation decision is made on admission, often by junior doctors, and documented in electronic notes. Concerns have been raised about the veracity of these discussions in patients with implantable cardioverter-defibrillators (ICD's). We investigated resuscitation status as documented on the electronic record for our ICD population. Methods The ICD database was interrogated in 2020 for patients under current follow-up. Baseline demographics, hospital admissions over the past 5 years and ICD indications were documented from the electronic hospital records. All patients with an electronic do-not-resuscitate (DNR) flag on the electronic system were recorded, as were any documented resuscitation discussions and ICD deactivations between 2015 and 2020. Any patient deaths were recorded and correlated with resuscitation status and ICD status at the time of death. Results Six-hundred and thirty-six patients with ICD's (transvenous, subcutaneous and CRT defibrillators) were identified under follow-up for the study period. The mean age of the population was 68 years old. 251 had an ischaemic cardiomyopathy, 209 had dilated cardiomyopathy, 50 prior ventricular fibrillation or tachycardia, 40 hypertrophic cardiomyopathy, 26 ARVC and the rest a channelopathy, congenital heart disease, sarcoidosis or valvular heart disease. Thirty-seven of the 636 patients were flagged on the electronic record as being not for resuscitation (5.9%). They had a mean age of 79 and 54% had an ischaemic cardiomyopathy. Of these, only 15 (39%) had their ICD deactivated and only 12 of those at the time of the resuscitation decision (32%). 15 of the 37 (39%) patients made DNR have subsequently died. Six of these (40%) had an active ICD at the time of death. In the 257 patients who had had a hospital admission in the study period, 34 were made not for resuscitation during the admission (13%) of whom 11 had their ICD deactivated at the time of discussion (32%). Patients with a DNR flag and an “active” ICD were contacted about deactivation of their ICD and offered discussion with a cardiologist or specialist nurse about ICD deactivation. Of these 9/27 (33%) stated that they wanted resuscitation and the alert was removed and the ICD kept on, although 3 subsequently had the device deactivated. Conclusions In this study the majority of patients with ICD's who were made not for resuscitation on admission to hospital did not have their ICD therapies switched off, therefore putting them at risk of unnecessary ICD shocks. In addition, one third these patients subsequently chose to be for resuscitation after discussion. These complex decisions would be improved with the early involvement of cardiologists and specialist nurses. Funding Acknowledgement Type of funding sources: None.

Response to cardiac resynchronisation therapy in men and women: a secondary analysis of the SMART-AV randomised controlled trial

ObjectivesThere is a controversy about whether both sexes’ response to cardiac resynchronisation therapy (CRT) is similar. We aimed to assess a causal effect of sex on CRT response.DesignSecondary analysis of...

Advances in telemedicine for the management of the elderly cardiac patient.

Telemedicine is the use of information and communication technology to deliver healthcare at a distance. It has been resorted to during the COVID-19 pandemic to lessen the need for in-person patient care decreasing the risk of transmission, and it can be of benefit afterward in the management of cardiac disease. The elderly population has unique challenges concerning the use of telehealth technologies. We thus review the advances in telemedicine technologies in treating elderly cardiac patients including in our discussion only studies with a mean age of participants above 60. Remote monitoring of blood pressure, weight, and symptoms, along with home ECG recording has been found to be superior to usual in-clinic follow up. Combining remote monitoring with video conferencing with physicians, patient education websites, and applications is also of benefit. Remote monitoring of Implantable Cardioverter Defibrillators (ICD) and Cardiac Resynchronization Therapy Defibrillators (CRT-D) is also beneficial but can be at the cost of an increase in both appropriate and inappropriate interventions. Implantable sensing devices compatible with remote monitoring have been developed and have been shown to improve care and cost-effectiveness. New smartphone software can detect arrhythmias using home ECG recordings and can detect atrial fibrillation using smartphone cameras. Remote monitoring of implanted pacemakers has shown non-inferiority to in clinic follow up. On the other hand, small-scale questionnaire-based studies demonstrated the willingness of the elderly cardiac patients to use such technologies, and their satisfaction with their use and ease of use. Large-scale studies should further investigate useability in samples more representative of the general elderly population with more diverse socioeconomic and educational backgrounds. Accordingly, it seems that studying integrating multiple technologies into telehealth programs is of great value. Further efforts should also be put in validating the technologies for specific diseases along with the legal and reimbursement aspects of the use of telehealth.

Burden of Ventricular Arrhythmias in Cardiac Resynchronization Therapy Defibrillation and Implantable Cardioverter-Defibrillator Recipients with Recovered Left Ventricular Ejection Fraction: The Additive Role of Speckle-Tracking Echocardiography

Patients with heart failure undergoing cardiac resynchronization therapy with or without defibrillator function may exhibit recovery of left ventricular ejection fraction (LVEF) during follow-up. Mechanical dispersion (MD; the SD of time to peak longitudinal strain by two-dimensional speckle-tracking echocardiography) is a known predictor of life-threatening ventricular arrhythmias (VAs). Relationships among LVEF recovery, changes in MD, and incidence of VA are still not extensively investigated. In this retrospective study, recipients of cardiac resynchronization therapy defibrillation (n=183) or implantable cardioverter-defibrillators only (n=87) underwent conventional and speckle-tracking echocardiography, both at baseline and after 10 to 12months, and were followed clinically. Both a ≥10% increase in LVEF and a final LVEF > 35% defined echocardiographic response (EchoResp). Reduction in MD ≥10 msec defined MD response (MDResp). Risk for appropriate implantable cardioverter-defibrillator therapy for VAs was assessed using a multivariable Cox hazard model. The prevalence of EchoResp+ and MDResp+ was 39% and 46%, respectively. During follow-up (49.8±33.5months), 74 VA events occurred. The incidence rate (per 100 patient-years) of VAs was lowest in the EchoResp+/MDResp+group (1.66%; 95% CI, 0.69%-3.99%), highest in the EchoResp-/MDResp- group (12.8%; 95% CI, 9.53%-17.2%; P<.0001), and intermediate in the EchoResp-/MDResp+ (5.5%; 95% CI, 3.3%-9.4%) or EchoResp+/MDResp- (5.3%; 95% CI, 3.0%-9.4%) group. Multivariable analysis showed that higher MD at follow-up (>71.4 msec) was associated with VAs independent of whether final LVEF was below or above the guideline-reported cutoff of 35% (P<.05). Among ICD recipients, improvements in both left ventricular function and MD are associated with reduced risk for VAs. In patients whose follow-up LVEFs improved to >35%, risk for VAs, although substantially decreased, remained elevated in the presence of still elevated MD.

Association between cardiac autonomic function and physical activity in patients at high risk of sudden cardiac death: a cohort study

BackgroundHigh levels of physical activity (PA) and heart rate variability (HRV) are associated with cardiovascular benefits in patients with cardiovascular diseases. HRV, representing cardiac autonomic function, is positively associated with PA. However, the impacts of PA and cardiac autonomic function on cardiovascular outcomes were not analysed in the same study population. This lack of evidence supported our hypothesis that PA might contribute to cardiovascular benefits via enhanced cardiac autonomic function.MethodsPatients with implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy defibrillator (CRT-D) implantation were included from the SUMMIT registry. HRV and PA values were assessed during the first 30–60 days post device implantation using a continuous home monitoring system. Causal mediation analysis was conducted to explore the possible mediation function of HRV in the association of PA with long-term cardiac death and all-cause mortality in patients at a high risk of sudden cardiac death.ResultsOver a mean follow-up period of 47.7 months, 63 cardiac deaths (18.9%) and 85 all-cause death events (25.5%) were observed among 342 patients with ICD/CRT-D implantation. A positive linear association between HRV and PA was demonstrated and the β value of HRV was 0.842 (95% confidence interval [CI]: 0.261–1.425, P = 0.005) in the multiple linear regression analysis. Multivariable Cox proportional hazards analysis revealed that high levels of PA (≥11.0%) and HRV (≥75.9 ms) were independent protective factors against cardiac death (PA: hazard ratio [HR] = 0.273; 95% CI, 0.142–0.526, P < 0.001; HRV: HR = 0.224; 95% CI, 0.103–0.489, P < 0.001) and all-cause mortality (PA: HR = 0.299; 95% CI, 0.177–0.505, P < 0.001; HRV: HR = 0.394; 95% CI, 0.231–0.674, P = 0.001). Causal mediation analysis demonstrated partial mediation effects of PA that were mediated through HRV on cardiac death (mediation proportion = 12.9, 95%CI: 2.2–32.0%, P = 0.006) and all-cause mortality (mediation proportion = 8.2, 95%CI: 1.6–20.0%, P = 0.006).ConclusionsHRV might be a modest mediator in the association between high levels of PA and the reduced risks of cardiac death and all-cause mortality in ICD/CRT-D recipients. This finding supports that enhanced cardiac autonomic function might be one of the underlying mechanisms by which regular PA contributes to cardiovascular benefits.

Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation.

AimsThere are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation.Methods and resultsWe retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse‐probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P < 0.001), more frequently male (82.5% vs. 75.5%, P = 0.02), and had higher heart rate (75.7 vs. 71.0 b.p.m., P < 0.001). Of the 229 AF patients, 162 (70.7%) received suboptimal CRT (<98%) and 67 (29.3%) had adequate CRT (≥98%). During a median follow‐up of 24 months, total mortality did not differ between AF and SR groups (propensity‐score‐weighted hazard ratio, HR 1.32 [95% confidence interval, 0.82–2.15], P = 0.25). The risk of appropriate shocks was significantly higher in the AF group with <98% CRT than in the SR group (weighted‐HR, 1.99 [1.21–3.26], P = 0.006) and was similar in the AF group with ≥98% CRT versus the SR group (1.29 [0.66–2.53], P = 0.45). During follow‐up, sinus rhythm was recovered in 23 patients in the AF group (10%) after a median time of 106 (42–256) days. The rate of sinus rhythm recovery in the AF group was 4.5 (95% CI, 2.8–6.7) per 100 patient‐years; the rate of permanent AF occurrence in the SR group was 2.5 (95% CI, 1.9–3.3) per 100 patient‐years.ConclusionsAlthough mortality was similar across patient groups, patients with permanent AF and suboptimal CRT had twofold higher risk of appropriate shocks than SR patients or AF patients with CRT ≥ 98%.

Check the Need-Prevalence and Outcome after Transvenous Cardiac Implantable Electric Device Extraction without Reimplantation.

Background: after transvenous lead extraction (TLE) of cardiac implantable electric devices (CIEDs), some patients may not benefit from device reimplantation. This study sought to analyse predictors and long-term outcome of patients after TLE with vs. without reimplantation in a high-volume centre. Methods: all patients undergoing TLE at our centre between January 2010 and November 2015 were included into this analysis. Results: a total of 223 patients (median age 70 years, 22.0% female) were included into the study. Cardiac resynchronization therapy-defibrillator (CRT-D) was the most common device (40.4%) followed by pacemaker (PM) (31.4%), implantable cardioverter-defibrillator (ICD) (26.9%), and cardiac resynchronization therapy-PM (CRT-P) (1.4%). TLE was performed due to infection (55.6%), malfunction (35.9%), system upgrade (6.7%) or other causes (1.8%). In 14.8%, no reimplantation was performed after TLE. At a median follow-up of 41 months, no preventable arrhythmia-related events were documented in the no-reimplantation group, but 11.8% received a new CIED after 17–84 months. While there was no difference in short-term survival, five-year survival was significantly lower in the no-reimplantation group (78.3% vs. 94.7%, p = 0.014). Conclusions: in patients undergoing TLE, a re-evaluation of the indication for reimplantation is safe and effective. Reimplantation was not related to preventable arrhythmia events, but all-cause survival was lower.

An up-to-date review of cardiac pacemakers and implantable cardioverter defibrillators.

Cardiac pacemakers are one of the most frequently encountered cardiac devices seen on chest imaging. They may include single or dual chamber pacemakers, automated implantable cardioverter defibrillators (AICD), biventricular pacemakers used for cardiac resynchronisation therapy (CRT), wireless CRT, leadless pacemakers, and subcutaneous implantable cardioverter defibrillators (SICD). This review aims to provide an up-to-date review on current implantable pacemaker and defibrillator devices.

Potential of remote monitoring to prevent sensing and detection failures in implantable cardioverter defibrillators

Sensing malfunction and misinterpretation of intracardiac electrograms (IEGMs) in patients with implantable cardioverter defibrillators (ICDs) may lead to inadequate device activity such as inappropriate shock delivery or unnecessary mode-switching. Remote monitoring has the potential for early detection of sensing malfunction or misclassification and may thus prevent adverse device activity. Therefore, the authors analyzed the amount, nature, and distribution of misclassification in current ICD and cardiac resynchronization therapy defibrillator technology using the device transmissions of the IN-TIME study population. All transmitted tachyarrhythmic episodes in the 664 IN-TIME patients, comprising 2214 device-classified atrial fibrillation (DC-AF) episodes lasting ≥ 30 s and 1330 device-classified ventricular tachycardia or fibrillation (DC-VT/VF) episodes, were manually analyzed by two experienced cardiologists. After evaluation of all DC-VT/VF episodes, atotal of 300 VT/VF events (23.1%) were false-positive, with supraventricular tachycardia being the most frequent cause (51.7%), followed by atrial fibrillation (21.3%) and T‑wave oversensing (21.0%). Atotal of 15patients with false-positive DC-VT/VF received inappropriate shocks. According to the inclusion criteria, 616 IEGMs with DC-AF were assessed. Atotal of 19.7% were false-positive AF episodes and R‑wave oversensing was the most common reason (55.9%). Remote monitoring offers the opportunity of early detection of signal misclassification and thus early prevention of adverse device reaction, such as inappropriate shock delivery or mode-switching with intermittent loss of atrioventricular synchrony, by correcting the underlying causes.