Cardioverter Defibrillator Research Articles

The impact of QRS complex fragmentation status before and after cardiac resynchronization therapy with defibrillator implantation: Is it a predictor of arrhythmic events?

Abstract Introduction Cardiac resynchronization therapy with an implantable cardioverter defibrillator (CRT-D) has demonstrated efficacy in reducing mortality, hospitalization for heart failure (HF), and sudden cardiac death among subgroups of patients with HF with reduced ejection fraction (HFrEF). However, this population is highly heterogeneous, necessitating risk stratification. Several clinical findings, including QRS complex fragmentation (QRSf), have been identified as potential prognostic factors for arrhythmic risk. Nonetheless, evidence supporting the prognostic significance of QRSf in patients undergoing CRT-D remains limited. Purpose The aim of this study is to assess whether alterations in QRSf status, before and after CRT-D implantation, can predict arrhythmic events (AE) in patients with HFrEF. Methods This study included consecutive patients underwent CRT-D implantation at our center from October 2009 to December 2022. Demographic, clinical, electrocardiographic and echocardiographic data were obtained from electronic medical records and telephone interviews. QRSf was defined by the presence of various RSR′ patterns, including additional R waves (R′) or notching of the R and S wave in two contiguous leads corresponding to a primary coronary artery territory on a 12-lead electrocardiogram conducted before and after CRT-D implantation. An AE was characterized by appropriate ICD therapy (antitachycardia pacing or shock) for a ventricular arrhythmia or sustained ventricular arrhythmia without the need for ICD therapy. Results A total of 176 patients were included (mean age 69.9 ± 9.6 years with 80.6% male). Ischemic etiology accounted for 54.6% of cases of LV systolic dysfunction, with a mean baseline LVEF of 23.6%. CRT-D was indicated as secondary prevention in 18 patients. At baseline, 114 patients (64.8%) presented QRSf. Following CRT implantation, 17 patients (9.8%) without previous QRSf developed QRSf, while 26 patients (14.9%) resolved QRSf. The median follow-up was 43.6 months (interquartile range 19.5-81.1). During follow-up, 90 patients died and 29 AE occurred (16.5%). Among these, 23 patients had QRSf before and after CRT, whereas 6 AE occurred in patients without QRSf. Multivariate survival analysis using Cox regression demonstrated that the presence of QRSf before and after CRT-D was an independent predictor of AE (HR 3.56; 95% CI 1.00-12.70). Univariate and multivariate Cox regression analyses are presented in Table 1. Kaplan-Meier curves for AE in relation to QRSf status before and after CRT-D are illustrated in Figure 1. Conclusions Our findings suggest that the presence of QRSf and its persistence following CRT-D implantation appears to be an independent predictor of AE after CRT-D implantation in patients with HFrEF. Therefore, these patients would benefit from closer monitoring as they exhibit a heightened risk of arrhythmic events. Nevertheless, further research is warranted to validate these results.Table 1.Cox Regression Analysis.

Impact of sacubitril/valsartan on atrial fibrillation burden in heart failure: a retrospective observational study

AbstractBackgroundSacubitril/valsartan (an angiotensin receptor‐neprilysin inhibitors [ARNI]) might improve atrial fibrillation (AF) condition, but its added value remains controversial.AimWe aimed to analyse the effect of ARNI on AF burden.MethodWe conducted a single‐centre, retrospective self‐controlled study in a tertiary centre. Data were retrieved from January 2019–January 2023. All cardiac resynchronisation therapy‐implantable cardioverter defibrillator (CRT‐D) carriers on ARNI were included if implantation had been at least 3 months before drug initiation. Proarrhythmic events, equal time length control (before ARNI initiation), and exposure (after ARNI initiation) periods were defined. Echocardiographic data were retrieved if they were up to 1 year old before ARNI initiation and if they were available 3 months to 1 year after initiation. AF burden was defined by frequency and median value of paroxysmal events and the overall variation in AF status was determined. Ethical approval was granted by the Ethics Committee of the Centro Hospitalar e Universitário de Coimbra (Reference no: PI OBS.SF.174‐2022) and the study conforms with the Declaration of Helsinki.ResultsSeventy‐two patients were included in the study (73.3% men). After ARNI, there was a reduction in New York Heart Association functional class ± standard deviation (2.00 ± 0.75 to 1.85 ± 0.61, p = 0.043) and an increase in left ventricular ejection fraction ± standard deviation (from 31.67% ± 9.28% vs 37.33% ± 14.49%, p = 0.027). Before ARNI initiation, 34 patients did not have AF, 19 had paroxysmal AF, 15 had permanent AF, and 2 had persistent AF. The total amount of AF episodes (91 vs 44, p = 0.808) and median paroxysmal episodes (among those with paroxysmal AF or no AF) (5 vs 3, p = 0.121) were numerically reduced after ARNI initiation, though variation was not statistically significant. No differences were found as well regarding ventricular arrhythmias or device therapies.ConclusionARNI did not significantly decrease the number of AF paroxysmal episodes or median number of paroxysmal events per patient. Even though ARNI may have a positive impact on AF burden of heart failure patients, larger studies are needed to provide unequivocal evidence.

Cardiac Resynchronization Therapy with Defibrillator in Ischemic Versus Nonischemic Cardiomyopathy.

Cardiac resynchronization therapy with implantable cardioverter defibrillators (CRT-Ds) are established therapy options for patients suffering from heart failure (HF). Several aspects of HF modification have yet to be described regarding etiology-dependent outcome differences in the long-term.The Mannheim CArdiac Resynchronization TherApy RetrospeCtive ObservAtioNAl (MARACANA) Registry retrospectively included all patients provided with CRTs in our center from 2013 to 2021. CRT-D recipients (n = 380) were grouped to either ischemic cardiomyopathy (ICM, n = 206) or nonischemic cardiomyopathy (NICM, n = 174). Both groups were compared regarding survival, left ventricular ejection fraction (LVEF), hospitalizations due to HF, intrinsic and paced QRS width, NYHA classification, and several further aspects of HF modification in the long-term (59.1 ± 4.81 months).Patients with ICM were older (73.3 ± 8.4 versus 67.7 ± 10.8 years) and predominantly male (86.4 versus 74.7%) and presented with higher creatinine values (1.57 ± 0.92 versus 1.31 ± 0.66 mg/dL, each P < 0.05) at baseline. The mean survival for patients with NICM was better (51.9 ± 1.2 versus 54.4 ± 1.1 months, P = 0.03). Improvements in NYHA (2.93 ± 0.4 versus 2.79 ± 0.5-2.19 ± 0.7 versus 1.79 ± 0.7) and LVEF (26.4 ± 6.8 versus 27% ± 6.9% to 35.7 ± 9.6 versus 44 ± 11%, each P < 0.05) were similar for both groups after 5 years. Patients with ICM experienced more hospitalizations due to HF within the first year (odds ratio 1.9, P < 0.05), whereas electrical remodeling was more impressive for NICM (QRS width 157.1 ± 19.4 milliseconds versus intrinsic 116.6 ± 12.7 milliseconds and paced 131.9 ± 21 milliseconds after 5 years, both P < 0.05).Patients with HF might experience long-term improvements in functional status and left ventricular reverse remodeling following CRT-D, regardless of underlying etiology. Alterations in some aspects of HF modification could be influenced by time- and etiology-associated comorbidities.

Navigating Complications in Cardiac Pacemakers: A Comprehensive Review and Management Strategies.

The landscape of cardiac pacemaker technology has undergone significant evolution over the last two decades, transitioning from simple single-chamber devices to sophisticated multi-chamber rate-responsive systems and cardioverter defibrillators. This progression has introduced a complex array of complications inherent to device implantation and operation, encompassing both mechanical and clinical challenges. These complications notably include lead dislodgment, device migration, venous thrombosis, and hemothorax, which not only affect patient outcomes but also impose substantial economic burdens. This review meticulously analyzes these complications, elucidating their mechanisms, clinical implications, and the economic consequences associated with their management. It also outlines current and emerging strategies aimed at mitigating these complications, emphasizing the need for continual updates in clinical practices and protocols. Through this discourse, the review seeks to equip clinicians with a comprehensive understanding of these complications, thereby enhancing the safety and efficacy of cardiac pacing interventions.

Factors that Determined a Positive Response to Resynchronization Therapy in Patients With Chronic Heart Failure and Cardiac Dyssynchrony. One Center Experience.

To evaluate the efficacy of cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) associated with cardiac dyssynchrony and to identify the factors that influence the CRT efficacy. This retrospective study included 155 patients after implantation of CRT devices. The CRT devices with a built-in cardioverter-defibrillator (CRT-D) and without it (CRT-P) were implanted in 139 (89.7%) and 16 (10.3%) patients, respectively. The follow-up period was 52.37±35.94 months. Based on the study results, two groups of patients were formed depending on the presence of a clinical response to CRT, responders and non-responders. The factors that influenced the clinical response to CRT were studied. The effect of the baseline state of patients on the effect of therapy was assessed. The need for CRT optimization and a possibility of using electrocardiographic criteria for that purpose were studied. Modern devices and leads for CRT, their functional capabilities and their influence on the CRT efficacy were characterized. Statistical analysis was performed with an IBM SPSS Statistics 21.0 (Chicago, USA) package. CRT implantation with the left ventricular lead placement according to the traditional technique, through the coronary sinus, was successful in 130 (87.9%) patients. Difficulties with the left ventricular lead placement were noted in 13 (8.3%) patients when other techniques were used. After 6 months, a hemodynamic and clinical response was observed in 112 (72.2%) patients, and no positive response in 43 (27.8%). The increase in left ventricular ejection fraction in the responder group was more than 21.8±3.7%, which was associated with an improvement of the 6-minute walk test results. Th clinical response was significantly influenced by the possibility of stimulation from the basal parts of the heart; the use of more modern devices for CRT and quadripolar left ventricular leads; timely CRT optimization; and persistent dyssynchrony in non-responders. During the follow-up period, 34 (21.9%) patients died. The death rate in the non-responder group was significantly higher than in the responder group, 18 (41.3%) vs. 16 (14.3%), p=0.001. The main cause of death in the group of non-responders was CHF. Heart transplantation was performed in 3 (1.9%) patients. CRT increases the life span and improves the quality of life in patients with CHF and cardiac dyssynchrony. There was a group of patients with no benefit from CRT in this study. Modern devices allow increasing the number of patients who benefit from CRT. Periodic optimization of CRT is necessary. When optimizing CRT, it is possible to use electrocardiographic criteria of effectiveness: duration of the QRS complex and changes in the position of the electrical axis of the heart.

Outcomes of Cardiac Resynchronization Therapy by New York Heart Association Class: A Patient-Level Meta-Analysis.

Data on the benefits of cardiac resynchronization therapy (CRT) in patients with severe heart failure symptoms are limited. We investigated the relative effects of CRT in patients with ambulatory New York Heart Association (NYHA) IV versus III functional class at the time of device implantation. In this meta-analysis, we pooled patient-level data from the MIRACLE (Multicenter InSync Randomized Clinical Evaluation), MIRACLE-ICD (Multicenter InSync Implantable Cardioversion Defibrillation Randomized Clinical Evaluation), and COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure) trials. Outcomes evaluated were time to the composite end point of the first heart failure hospitalization or all-cause mortality, and time to all-cause mortality alone. The association between CRT and outcomes was evaluated using a Bayesian hierarchical Weibull survival regression model. We assessed if this association differed between NYHA III and IV groups by adding an interaction term between CRT and NYHA class as a random effect. A sensitivity analysis was performed by including data from RAFT (Resynchronization-Defibrillation for Ambulatory Heart Failure). Our pooled analysis included 2309 patients. Overall, CRT was associated with a longer time to heart failure hospitalization or all-cause mortality (adjusted hazard ratio [aHR], 0.79 [95% credible interval [CI], 0.64-0.99]; posterior probability or P=0.044), with a similar association with time to all-cause mortality (aHR, 0.78 [95% CI, 0.59-1.03]; P=0.083). Associations of CRT with outcomes were not significantly different for those in NYHA III and IV classes (ratio of aHR, 0.72 [95% CI, 0.30-1.27]; P=0.23 for heart failure hospitalization/mortality; ratio of aHR, 0.70 [95% CI, 0.35-1.34]; P=0.27 for all-cause mortality alone). The sensitivity analysis, including RAFT data, did not show a significant relative CRT benefit between NYHA III and IV classes. Overall, there was no significant difference in the association of CRT with either outcome for patients in NYHA functional class III compared with functional class IV.

Open Access Data and Deep Learning for Cardiac Device Identification on Standard DICOM and Smartphone-based Chest Radiographs.

Purpose To develop and evaluate a publicly available deep learning model for segmenting and classifying cardiac implantable electronic devices (CIEDs) on Digital Imaging and Communications in Medicine (DICOM) and smartphone-based chest radiographs. Materials and Methods This institutional review board-approved retrospective study included patients with implantable pacemakers, cardioverter defibrillators, cardiac resynchronization therapy devices, and cardiac monitors who underwent chest radiography between January 2012 and January 2022. A U-Net model with a ResNet-50 backbone was created to classify CIEDs on DICOM and smartphone images. Using 2321 chest radiographs in 897 patients (median age, 76 years [range, 18-96 years]; 625 male, 272 female), CIEDs were categorized into four manufacturers, 27 models, and one "other" category. Five smartphones were used to acquire 11 072 images. Performance was reported using the Dice coefficient on the validation set for segmentation or balanced accuracy on the test set for manufacturer and model classification, respectively. Results The segmentation tool achieved a mean Dice coefficient of 0.936 (IQR: 0.890-0.958). The model had an accuracy of 94.36% (95% CI: 90.93%, 96.84%; 251 of 266) for CIED manufacturer classification and 84.21% (95% CI: 79.31%, 88.30%; 224 of 266) for CIED model classification. Conclusion The proposed deep learning model, trained on both traditional DICOM and smartphone images, showed high accuracy for segmentation and classification of CIEDs on chest radiographs. Keywords: Conventional Radiography, Segmentation Supplemental material is available for this article. © RSNA, 2024 See also the commentary by Júdice de Mattos Farina and Celi in this issue.

Systematic review and meta-analysis comparing cardiac resynchronization therapy with versus without defibrillation in patients with non-ischemic cardiomyopathy

Abstract Background Cardiac resynchronization therapy (CRT) stands as a notable medical breakthrough for individuals with heart failure and electrical desynchrony. This intervention aims to alleviate symptoms, diminish hospitalization rates, and enhance overall survival, both in conjunction with and without implantable cardioverter-defibrillator (ICD) therapy. Despite these advancements, the role of defibrillator therapy in addition with CRT for patients with non-ischemic cardiomyopathy (NICM) remains a topic of debate. Objective To assess and compare the outcomes of individuals diagnosed with NICM who have underwent CRT with implantable cardioverter-defibrillator (CRT-D) against those who received CRT with a pacemaker only (CRT-P). Methods We conducted a systematic search of PubMed, Embase and Cochrane database during August 2023 for studies comparing CRT-P and CRT-D in patients with nonischemic cardiomyopathy. Results Thirteen studies, including two randomized clinical trials, were incorporated, with a total of 61,326 patients providing 16,446 pooled death events (9,108 in CRT-D and 7,338 in CRT-P). The meta-analysis revealed that CRT-D was associated with a significantly lower risk of all-cause mortality compared to CRT-P (pooled HR 0.74; 95% CI: 0.62-0.88; I2=84%). Subgroup analysis focusing on propensity score-matched studies yielded consistent findings (pooled HR 0.82; 95% CI: 0.77-0.87; I² = 0%, P&amp;lt;0.001). However, subgroup analysis for patients older than 75 years suggested no statistically significant difference in mortality risk within this specific age group (pooled HR 0.96; 95% CI: 0.811-1.15; I² = 39%, P&amp;lt;0.001). Regarding the secondary endpoint of cardiovascular mortality, no significant risk reduction with CRT-D was observed (pooled HR 0.70; 95% CI: 0.49-1.01; I² = 92%), albeit with high heterogeneity. Conclusion Our study suggests that the addition of defibrillator therapy significantly reduces all-cause mortality in CRT-eligible patients with NICM, although results were not observed for patients older than 75 years.All-cause MortalityPatients older 75 years old

Percutaneous coronary intervention before transcatheter aortic valve implantation: A propensity score matched analysis

BackgroundThe role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) who subsequently undergo transcatheter aortic valve replacement (TAVR) remains uncertain. Therefore, we conducted this study to assess the association of PCI before TAVR with mortality and cardiovascular outcomes. MethodsWe used the TriNetX database (Jan 2012 - Aug 2022) and grouped patients into PCI (3 months or less) before TAVR and no PCI. We performed propensity score matched (PSM) analyses for outcomes at 30 days and 1 year. ResultsOf 17,120 patients undergoing TAVR, 2322 (14 %) had PCI, and 14,798 (86 %) did not have PCI before TAVR. In the PSM cohort (2026 patients in each group), PCI was not associated with lower all-cause mortality at 30 days (HR: 1.25, 95 % CI: 0.82–1.90) or 1 year (HR: 1.02, 95 % CI: 0.83–1.24). Frequency of repeat PCI after TAVR was low in both no PCI vs. PCI (2.4 % vs. 1.2 %) at 1 year; PCI was associated with a lower rate of repeat PCI (HR: 0.49, 95 % CI: 0.30–0.80). Sensitivity analysis revealed an E-value of 3.5 for repeat PCI (E-value for lower CI for HR: 1.81). PCI was not linked to reductions in MI, heart failure exacerbation, all-cause hospitalization, major bleeding, or permanent pacemaker/implantable cardioverter defibrillator. ConclusionThis analysis showed that PCI prior to TAVR was not associated with improvement in all-cause mortality. However, PCI was associated with a reduced rate of repeat PCI at 1 year.

Membranous Septum Length Predicts New Conduction Abnormalities in Surgical Aortic Valve Replacement: A Novel Predictor for Permanent Pacemaker Implantation After Surgical Aortic Valve Replacement

IntroductionThe membranous septum (MS) length measured by cardiac computed tomography (CT) is useful for the prediction of permanent pacemaker implantation (PPMI) and new left bundle branch block (LBBB) after transcatheter aortic valve replacement. However, its predictive value for patients undergoing surgical aortic valve replacement (SAVR) is unknown. MethodsA total of 2531 consecutive patients were registered in the institutional Society of Thoracic Surgeons database between July 2017 and June 2020. Patients who underwent non-SAVR procedures, had prior pacemaker/implantable cardioverter defibrillator, prior SAVR, no preprocedural CT assessment, or suboptimal CT imaging were excluded. ResultsA total of 126 SAVR with preprocedural CT assessment were analyzed. Bicuspid aortic valve morphology was confirmed on CT in 59.5% of patients. There were three new PPMIs and five new LBBBs observed after SAVR at the time of discharge. In-hospital mortality was 0.8%. Low left ventricular (LV) ejection fraction (<50%), LV mass index >120 g/m2, large right coronary artery height, and MS length <1.5 mm predicted new PPMI/LBBB. Multivariate analysis showed LV mass index >120 g/m2 (odds ratio: 9.165; 95% confidence interval: 1.644-51.080; P = 0.011) and MS length <1.5 mm (odds ratio: 14.449; 95% confidence interval: 1.632-127.954; P = 0.016) were independent predictors for new PPMI/LBBB. ConclusionsShort MS length on preoperative cardiac CT is a powerful and novel predictor for the risk of new PPMI/LBBB after SAVR. Special care should be taken in patients with short MS length to avoid suture-mediated trauma.

Cardiac resynchronization therapy with or without defibrillation in patients with non-ischemic cardiomyopathy: a systematic review and meta-analysis

Abstract Introduction Cardiac resynchronization treatment (CRT) is a significant medical achievement for patients with heart failure and electrical desynchrony to relieve symptoms, reduce hospitalization, and increase survival, both with and without implantable cardioverter-defibrillator therapy. However, the value of defibrillator therapy in addition to CRT in patients with non-ischemic cardiomyopathy (NICM) who are eligible for CRT remains unclear. Objective Compare the outcomes of patients with NICM and heart failure who received CRT with implantable cardioverter-defibrillator (CRT-D) against CRT-pacemaker only (CRT-P). Methods A literature search from inception through January 2023 was conducted in PubMed and Cochrane Central Register of Controlled Trials for all studies reporting outcomes of CRT-D versus CRT-P in CRT-eligible patients with NICM. Studies reporting non-stratified outcomes, including patients with ischemic cardiomyopathy, were excluded. The primary endpoint of interest was all-cause mortality. Secondary outcomes included device complications. A random-effects model was used. Results Of a total of 1976 potential citations, the search yielded 9 citations that met our inclusion criteria. Ten studies were included, one randomized clinical trial and nine observational studies, providing 11064 CRT-eligible patients with NICM (7459 CRT-D implantation and 1275 with CRT-P). Our meta-analysis revealed a significantly lower all-cause mortality (pooled OR, 0.85; 95% CI [0.75, 0.97], P = 0.02; I ²= 31%), albeit with moderate heterogeneity. Additionally, regarding device complications, only one study reported these outcomes with no significant difference (HR 0.82 [95% CI, 0.29–2.20]). Conclusions Our meta-analysis suggests that the addition of defibrillator therapy significantly reduced all-cause mortality in CRT-eligible patients with NICM.

Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC.

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).

Imaging in patients with cardiovascular implantable electronic devices: part 1-imaging before and during device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC.

More than 500 000 cardiovascular implantable electronic devices (CIEDs) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, and the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients for standard indications and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators, and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2).

Survival after a heart attack with subsequent cardiac arrest: a 1-year patient case report

BackgroundCardiac events have become a common occurrence worldwide and especially in India, more so after the coronavirus disease (COVID) pandemic. Apparently healthy and young individuals suffering from cardiac disorders are on the rise. In most cases, there is no clearly established cause/risk factor for the cardiac disorder. Once someone has suffered a cardiac event, the rehabilitation team is expected to keep a constant watch on the prognosis and any complications that might arise, especially during the first year after the cardiac event.Case presentationThis case report describes the sequence of events that occurred in a 44-year-old male patient who had a heart attack, survived a cardiac arrest, was implanted with a cardioverter defibrillator (ICD), and was on rehabilitation. The report throws some insights into what happened with this patient since his heart attack, and it also discusses the possible signs that could have helped identify the cardiac event before the actual occurrence.ConclusionThe rehabilitation post heart attack, angioplasty, and cardiac implants have to be individualized and tailor-made. Appropriate alterations to the rehabilitation would give the necessary direction to achieve maximum recovery and well-being of the patient. Constantly watching for any complications that might arise and addressing them immediately are vital to the prognosis. Physiotherapy rehabilitation plays a major role in giving a positive reinforcement and better prognosis.

Recent Experience in the use of Del Nido Cardioplegic Solution in Pediatric Patients

Background: The interest in Del Nido cardioplegia for myocardial protection in pediatric cardiac surgery is growing. Research hitherto supports the use of Del Nido cardioplegia in providing myocardial preservation as well as reducing surgery time. Objectives: To contribute to the literature, we sought to share our own experiences and outcomes of 86 pediatric patients who underwent cardiac surgery at our centre in whom this cardioplegic solution was used. Methods: In a retrospective study, we evaluated 86 pediatric patients with congenital cardiac defects who underwent corrective cardiac surgery in whom Del Nido cardioplegic solution was used. Results: The mean age of the patients was 55.1±48.6 months and the mean weight was 16.2±11.4 kilograms. Repair of tetralogy of Fallot and closure of atrial septal defect or ventricular septal defect represented 44% of the operations. Mean cross clamp time was 75.5±38.6 minutes. In five patients (5.8%), cardioversion defibrillation was used to regain sinus rhythm after cross clamp release. Only one patient needed inotropic support grade 3 (epinephrine dose equal or more than 0.1mcg/kg/min), while the remainder were in grade 2 or less. Conclusion: We think that the use of Del Nido cardioplegia in our patients was associated with clinical benefits and decreased morbidity. It can provide appropriate myocardial protection for longer cross clamp times with decreased repeat dosing. However, the preferred cardioplegic solution in congenital cardiac surgery remain highly variable among centers.

198 ROLE OF CARDIAC MAGNETIC RESONANCE IMAGING IN ARRHYTMICH RISK STRATIFICATION

Abstract Introduction Danon disease (DD) is a rare multi-systemic disorder firstly described by Danon et al. in 1981 and characterized by a triad consisting with hypertrophic cardiomyopathy, skeletal myopathy, and intellectual disability. It is an inherited dominant X-linked condition, due to mutations in the lysosome-associated membrane protein 2 (LAMP2) gene. Typically, males present a more severe phenotype with earlier onset and rapid heart failure progression with extracardiac manifestations; female patients manifest a milder phenotype with later onset and isolated cardiac involvement. Female carriers may develop dilated cardiomyopathy (DCM). In recent years, it has been described a severe arrhythmogenic phenotype, particularly in women, with a high risk of sudden cardiac death (SCD). Case presentation Case 1 is a 16 y.o. woman referred to our outpatient cardiomyopathies clinic, diagnosed with left ventricle (LV) hypertrophy on the basis of ECG and echocardiography, performed in 2016, in view of cutaneous nevus surgical exeresis. At echocardiographic evaluation we found an asymmetric LV hypertrophy with preserved LV ejection fraction (LVEF 65%). A cMRI was performed, showing mild LV thickening and left ventricular hypertrabeculation morphology, mainly in the LV lateral wall, but not all criteria for LV noncompaction (NC) were satisfied. There was no late gadolinium enhancement (LGE) accumulation. She underwent a genetic screening with inconclusive results, so we started a clinical outpatient follow-up showing no significant arrhythmias at ECG Holter and no limitation of physical activities. In 2021, when she was 21 yo, her father died suddenly and no autoptic examination was performed. A genetic exam was repeated, highlighting a LAMP2 gene mutation. In 2016 her 3 years older sister, Case 2, underwent a familiar screening. She had a long history of mild dyspnea occurring during exertion. Echocardiography showed asymmetric hypertrophy with marked thickening of infero-lateral wall (25 mm,) with normal systolic function (EF 70%). She underwent a cMRI, highlighting diffuse asymmetric hypertrophy (max 24 mm) with LGE in lateral wall and lower septum. First genetic test was nonconclusive but after her father's death another test was performed, demonstrating LAMP2 gene mutation. In 2021 a follow-up cMRI showed markedly reduced myocardial thickness of the apex, with a pattern of noncompaction myocardial. We found a LVEF at lower limits, depressed longitudinal function (MAPSE 8 mm) and manly severe progression of fibrotic degeneration. ECG Holter revealed premature ventricular complex, in absence of nonsustained ventricular tachycardia. Following the evolution of fibrosis, cardioverter defibrillator (ICD) implantation was performed. Case 1 was clinically stable during strict follow-up. Conclusion Cardiac magnetic resonance imaging (cMRI) may be useful in arrhythmic risk stratification, accurate systolic dysfunction evaluation, and proper timing and indication for ICD implantation.

Echocardiographic Predictors of Ventricular Tachyarrhythmias in Patients With Cardioverter-Defibrillator Implanted for Primary Prevention of Sudden Cardiac Death. Results From a two-Year Prospective Follow-up Study

Aim To compare variables of transthoracic EchoCG for determining echocardiographic predictors and their prognostic role in the development of persistent paroxysmal ventricular tachyarrhythmias (VT) in patients with ischemic CHF who had been implanted with a cardioverter defibrillator (CD) for primary prevention of sudden cardiac death.Material and methods This single-site prospective study included 176 patients with CHF of ischemic origin aged 58.7±7.4 years with a left ventricular ejection fraction (LV EF) of 30 % [25; 34] % who had been implanted with CD. The follow-up duration was 24 months. The primary endpoint was a newly developed persistent paroxysm of VT (duration ≥30 sec) detected in the "monitored" VT area or a VT paroxysm that required electric treatment. The echocardiographic picture was evaluated by 28 variables. Statistical analysis was performed with the c2, Fisher's, and Mann-Whitney tests, and the one-factor logistic regression (LR). Prognostic models were developed with a multifactorial LR. The model accuracy was evaluated by 4 metrics: area under the ROC (AUC), sensitivity, specificity, and diagnostic efficacy.Results The primary endpoint was observed in 60 (34 %) patients. Mean time to a persistent VT episode was 19.2±0.8 months (95 % confident interval (CI): 17.5-20.8). Superior-inferior dimensions of the right and left atria (RA and LA, respectively) and the left atrial volume (LAv) were independent predictors for VT. The odds of VT development in patients of the study cohort increased with RAl ≥4.5 cm (odds ratio (OR), 1.6; 95 % CI: 1.4-1.9; р=0.03), LAl ≥5.5 cm (OR, 2.5; 95 % CI: 1.01-6.1; р=0.04), LAv ≥95 ml (OR, 3.2; 95 % CI: 1.3-17.5; р=0.01). A comprehensive analysis of echocardiographic variables proved the prognostic potential of LAv that was linearly associated with the development of VT. The metrics of the best prognostic model were AUC 0.7±0.07 with 95 % CI: 0.54-0.83; specificity, 20.9 %; sensitivity, 95.7 %; and diagnostic efficacy, 47 %.Conclusion This study allowed evaluation of capabilities of transthoracic EchoCG for predicting the probability of VT in patients with CHF of ischemic origin and reduced LV EF. It was shown that linear and volumetric atrial dimensions could be used for stratification of risk of VT and for determining the tactics for primary prevention of sudden cardiac death in this patient category.

Heart Rhythm Society Policy Statement Update: Recommendations on the role of industry-employed allied professionals

In 2001, the North American Society of Pacing and Electrophysiology (now the Heart Rhythm Society) published a policy statement to provide guidance for industry-employed allied professionals (IEAPs) who provide technical assistance during pacemaker/implantable cardioverter defibrillator (ICD) implantations, programming, analysis of malfunctions, and follow-up1; the policy was updated in 2008 (Table 1).2 Since those publications, their principles have been incorporated in the other Heart Rhythm Society expert consensus statements that look at the role of the cardiac implantable electronic device (CIED) team and IEAPs in patient care delivery in our profession.

Surgical extraction of cardiac implantable electronic device leads based on a heart team approach

BackgroundAs cardiac implantable electronic devices, such as pacemakers, cardioverter defibrillators, and cardiac resynchronization therapies, have become more popular, device extraction has become more frequent. At our institution, individual treatment strategies are discussed at a heart team meeting. Transvenous lead extraction (TVLE) is a first-line treatment; however, surgical lead extraction (SLE) is sometimes selected as a primary choice to provide optimal treatment and maintain the medical safety policy. This study aimed to investigate the validity of this heart team decision-making. MethodsFrom 2013 to 2021, 384 consecutive patients underwent lead extraction at our institution. ResultsSLE was proposed as the primary intervention for 21 patients who had high risk of bleeding, difficult TVLE conditions, large vegetations, and other concomitant cardiac diseases. Of the 363 TVLE patients, 10 patients required surgical intervention; 5 had TVLE difficulty followed by SLE and 5 had excessive bleeding. SLE was performed in 26 patients, 19 of whom required valve surgery, and 8 required plication of the great veins. In 4 of the 17 hybrid procedures with SLE and TVLE, excessive bleeding occurred due to laceration of the superior vena cava and innominate vein. Operative mortality was not observed in SLE patients but was observed in 1 of the 4 TVLE patients who required emergent open-chest hemostasis. ConclusionsThe heart team discussion was essential to provide optimal treatment and maintain medical safety policies for each patient. SLE should be selected for patients with high risk of TVLE or other cardiac complications such as tricuspid valve incompetence.

Misconception in patients with cardiovascular implantable electronic device as a factor of anxiety and depression – how to design optimal educational approach?

Abstract Purpose The aim of this study is to assess the level of knowledge of safety and awareness about daily living in patients with cardiac implantable electronic devices (CIED) and potential impact upon anxiety and depression. Methods Data were collected in consecutive patients visiting pacemaker clinic for regular CIED follow-up. Demographic, clinical and psychological data were collected: Hospital Anxiety and Depression Scale-Modified (HADS-M) and a custom self-reported questionnaire was used (CIED-SRQ, 18 questions regarding daily activities, medical procedures and the safe use of electronic devices) to assess the knowledge regarding CIED. Dedicated questions referred to the preferences for CIED education channels in various age groups. Results We studied 186 patients (36,6% women, mean age 66,7±10,8) with CIED (63,5% pacemaker, 17,7% cardioverter defibrillator, 18,8% cardiac resynchronization therapy) in their first year following the implantation. In the CIED-SRQ the mean score of correct answers related to knowledge of CIED 13,25±2,86 (with 18 as the maximum possible score). The knowledge of CIED was correlated with the patients' level of education (p&amp;lt;0,001) and inversely correlated with age (rho=−0443; p&amp;lt;001). In the anxiety subscale of HADS-M, normal scores were noted in 75,8% patients, 13,5% cases were borderline, and abnormalities were observed in 10,7% patients. In the depression subscale, 70,4% were recognized as normal, 21,5% as borderline, and 8,1% as abnormal. As the knowledge of patients about CIED increased, there was a significant decrease in their depression level (rho=−0,149; p=0,042) and in the anxiety level (rho=−0,193; p=0,008). Anxiety level was higher in patients with CIED experiencing complications from the implantation (15,6% of patients in total experienced complications), both the mild (hematoma, bruising) and the severe (tamponade, lead dislocation, pneumothorax), when compared to the group without complications (p&amp;lt;0,001). Conversely, no statistically significant difference between these groups was found as to their level of depression (p=0,051). The younger patients (≤64 years) were more often in favour of remote education on CIED (p=0,025), while the elder (≥65 years) most often preferred to be personally informed by the attending physician. Conclusions Lack of information and misinformation in patients with CIED may result in self-imposed restrictions, which could in turn result in higher levels of anxiety and depression. Patients experiencing CIED complications should be offered increased psychological care as well as more intense education about CIED, due to higher anxiety levels. Age influences the preferences for CIED education channels, thus educational approach must be individualized and age-appropriate. These findings may help health care professionals to provide holistic care to help patients manage to live with CIED and optimize postprocedural quality of life. Funding Acknowledgement Type of funding sources: None.