Implantable Cardiac Defibrillator Implantation Research Articles

Intermuscular placement and defibrillation with the extravascular ICD: a single-centre experience

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICD), owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. The proposed implantation technique for EV-ICDs is a subcutaneous pocket along the mid axillary line, although an intermuscular ICD placement can potentially reduce the risk of pocket complications, device migration and improve patient comfort and aesthetic outcomes. Purpose exploring the safety and feasibility of extravascular ICDs implantation with a substernal coil and an intermuscular generator placement. Methods Seventeen patients with a class I or IIa ICD indication either for primary (14/17) or secondary (3/17) prevention underwent EV-ICD implantation in our centre as part of the EV ICD Pivotal Study from May 2021 to November 2022. Access and tunnelling along the retrosternal space were performed based on current standard recommendations for EV-ICDs implantation. An intermuscular pocket for generator placement was obtained between the latissimus dorsi and the serratus anterior muscles beyond the left mid-axillary line. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients, with one implant failure due to inadequate sensing (0,5 mV); the median sensing amplitude was 2,3 mV (min = 1,3 mV; max = 5,8 mV), with R1R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16. Defibrillation Testing (DFT) was performed in all patients: a 15 J shock terminated induced ventricular fibrillation (VF) in 12/16 patients, 20 J terminated VF in 3, a single patient had VF terminated at 30 J. No patient had infection or skin erosion or complained pain/discomfort at the pocket site along an 18±4 months follow-up. Only 1/16 patients had ventricular tachycardia at follow-up, successfully treated by the device. Conclusions Intermuscular placement of the EV ICD may be a feasible and reliable alternative to a subcutaneous one in terms of defibrillation efficacy, enabling patient comfort and aesthetic acceptance in thin-habit or young patients. Additional long-term data and larger patient cohorts are required to confirm its advantage compared to the subcutaneous placement.

CE-454029-1 THE IMPACT OF GENDER ON DECISIONAL CONFLICT SURROUNDING IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IMPLANTATION AMONG BLACK PATIENTS AT RISK FOR SUDDEN CARDIAC DEATH

Implantable cardiac defibrillators (ICD) reduce the risk of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). Previous studies have shown that women are less likely to undergo ICD implantation than men. "Videos to Address Racial Disparities in Implantable Cardioverter-Defibrillators Via Innovative Designs (VIVID): A Randomized Clinical Trial" (VIVID) investigated the impact of a video-based decision support tool on the decision for ICD implantation and associated decisional conflict. The overall aim of this study is to analyze the impact of gender on decisional conflict and ICD receipt among Black men and women with HFrEF at risk for SCD. The VIVID trial was conducted from September 2016 to April 2020. Gender and race were self-reported. Black patients were randomized to a video-based decision support tool or usual care. A decisional conflict scale (DCS) adapted from the Ottawa Decision Support Framework was used to assess decisional conflict associated with ICD implantation before and after the intervention. Logistic regression was used to measure differences in ICD implantation within 90 days of study enrollment and the association between decisional conflict and ICD implantation between men and women at 90 days. ANCOVA regression was used to measure differences in DCS between Black men and women and the interaction by intervention group. Among 330 Black patients included in the final analysis, 309 patients (197 men and 112 women) had gender and DCS data available. At 90-day follow-up, 73.9% of women compared with 61.9% of men underwent ICD implantation (adjusted OR (95% CI): 2.07 (1.14, 3.78); p=0.02). There was no significant interaction between gender and intervention for ICD implantation. Among all participants, decisional conflict scores decreased and did not differ by intervention (adjusted mean difference (95% CI): -2.00 (-4.05, 0.05)). Women had a greater mean decrease in DCS scores than men (adjusted mean difference (95% CI): -2.16 (-4.23, -0.09); p=0.04); and there was no significant interaction between gender and intervention in DCS scores (p=0.32). Among Black patients eligible for an ICD, women had less decisional conflict associated with ICD implantation and were more likely to receive an ICD than men. Future research should seek to understand the role of gender on decision-making for an ICD.Tabled 1Table 1. Differences in ICD Implantation within 90 Days.Number of ICD Implants/Total (%)Odds Ratio (95% CI)P-valueIntervention GroupUsual Care71/99 (71.7%)Video-Based Decision Support Tool128/203 (63.1%)1.48 (0.83, 2.63)0.18GenderMen118/192 (61.5%)Women81/110 (73.6%)2.07 (1.14, 3.78)0.02All values are adjusted for patient characteristics including age, educational attainment, income, marital status, work status and pertinent comorbidities including hypertension, hyperlipidemia, diabetes, coronary artery disease and atrial fibrillation. Open table in a new tab

Brugada Syndrome within Asian Populations: State-of-the-Art Review

Brugada syndrome (BrS) is an inherited cardiac channelopathy with variable expressivity that can lead to sudden cardiac arrest (SCA). Studies worldwide suggest that BrS and Brugada pattern (BrP) have low prevalences in general. However, studies also note that BrS is most prevalent among certain Asian populations. Among the different global regions, the highest prevalence is believed to be in Southeast Asia, followed by the Middle East, South Asia, East Asia, Europe, and North America. It is not only important to recognize such varying degrees of BrS prevalence within Asia but also to understand that there may be significant differences in terms of presenting symptoms, occult risk factors, and the impact on clinical outcomes. The importance of identifying such differences lies in the necessity to develop improved risk assessment strategies to guide secondary prevention and treatment for these patients. Specifically, the decision to pursue placement of an implantable cardiac defibrillator (ICD) can be lifesaving for high-risk BrS patients. However, there remains a significant lack of consensus on how to best risk stratify BrS patients. While the current guidelines recommend ICD implantation in patients with spontaneous Type 1 ECG pattern BrS who present with syncope, there may still exist additional clinical factors that may serve as better predictors or facilitate more refined risk stratification before malignant arrhythmias occur. This carries huge relevance given that BrS patients often do not have any preceding symptoms prior to SCA. This review seeks to delineate the differences in BrS presentation and prevalence within the Asian continent in the hope of identifying potential risk factors to guide better prognostication and management of BrS patients in the future.

Radial and Circumferential CMR-Based RV Strain Predicts Low R Wave Amplitude after ICD Implantation in Patients with Arrhythmogenic Cardiomyopathy.

Inadequate R wave amplitude (RWA) after implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) was suspected to relate to right ventricle impairment. However, little data-based evidence was provided to quantify the association. We retrospectively enrolled ACM patients receiving CMR examinations before transvenous ICD implantation from Fuwai Hospital. The RWA was obtained within 24 h and at 2-6-month follow-up after the operation. Structural, functional, as well as tissue characterization of the left ventricle (LV) and right ventricle (RV), were analyzed in relation to RWA. Among the 87 ACM patients (median RWA: 8.0 mV), 19 (21.8%) patients were found with low initial RWA (<5 mV) despite attempts in multiple positions. RV end diastolic diameter (RVEDD), (r = -0.44), RV ejection fraction (RVEF, r = 0.43), RV end diastolic volume index (RVEDVi, r = -0.49), RV end systolic volume index (RVESVi, r = -0.53), RV global circumferential (RVGCS, r = -0.64), and radial strain (RVGRS, r = 0.61, all p < 0.001) rather than LV metrics correlated strongly with initial RWA. RVGCS, RVESVi, and RVGRS were decent predictors of low RWA (areas under the curve AUC: 0.814, 0.769, 0.757, respectively) early after implantation and during 2-6-month follow-up. To summarize, low RWA of ICD lead in ACM patients was associated with RV abnormalities. The RVGCS, RVGRS, and RVESVi can be valuable predictors for identifying low RWA prior to ICD implantation.

Implantable cardiac defibrillators in octogenarians.

Implantable cardiac defibrillators (ICD) implantation in the very elderly remains controversial. We aimed to describe the experience and outcome of patients over 80 years old implanted with an ICD in Belgium. Data were extracted from the national QERMID-ICD registry. All implantations performed in octogenarians between February 2010 and March 2019 were analysed. Data on baseline patient characteristics, type of prevention, device configuration and all-cause mortality were available. To determine predictors of mortality, multivariable Cox proportional hazard regression modelling was performed. Nationwide, 704 primo ICD implantations were performed in octogenarians (median age 82, IQR 81-83 years; 83% male and 45% secondary prevention). During a mean follow-up of 3.1 ± 2.3 years, 249 (35%) patients died, of which 76 (11%) within the first year after implantation. In multivariable Cox regression analysis age (HR = 1.15, P = 0.004), oncological history (HR = 2.43, P = 0.027) and secondary prevention (HR = 2.23, P = 0.001) were independently associated with 1-year mortality. A better preserved left ventricular ejection fraction (LVEF) was associated with a better outcome (HR = 0.97, P = 0.002). Regarding overall mortality multivariable analysis withheld age, history of atrial fibrillation, centre volume and oncological history as significant predictors. Higher LVEF was again protective (HR = 0.99, P = 0.008). Primary ICD implantation in octogenarians is not often performed in Belgium. Among this population, 11% died within the first year after ICD implantation. Advanced age, oncological history, secondary prevention and a lower LVEF were associated with an increased one-year mortality. Age, low LVEF, atrial fibrillation, centre volume and oncological history were indicative of higher overall mortality.

Abstract 15106: Impaired Regional Strain by Cardiovascular Magnetic Resonance Feature-Tracking Predicts Low Sensing Value After Cardiac Defibrillator Implantation in Patients With Arrhythmogenic Cardiomyopathy

Introduction: Inadequate ventricular sensing at implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) is troubling and might cause inappropriate ICD interventions and complications. We aimed to evaluate the value of ventricular mechanics features in predicting low sensing value by emerging cardiovascular magnetic resonance-feature tracking (CMR-FT) in ACM patients. Hypothesis: CMR-FT characteristics prior to ICD implantation might assist in predicting low R wave amplitude. Methods: We retrospectively enrolled ACM patients receiving CMR examinations prior to ICD implantation at our center from January 2011 to July 2021. The strain parameters of LV and RV were analyzed by CMR-FT. The R wave amplitude (RWA) was obtained within 24 hours of completion of the ICD implantation and its association with CMR strain parameters was analyzed. Results: We enrolled 83 ACM patients with a median RWA of 8.0 mV (Interquartile range IQR:5.4-12.1 mV) and impedance within the normal range. 18 (21.7%) patients were found with low RWA (&lt;5mV) despite attempts in over 5 positions. RV strain parameters including RV global longitudinal, circumferential and radial strain rather than LV strain parameters correlated significantly with RWA (Spearman’s correlation coefficients: GLS: -0.35, GCS: -0.58, GRS: 0.59, all P&lt;0.01). RVGRS and RVGCS were found not only associated with RWA after adjusting for clinical cofounders (coefficients: RVGCS: -0.53, RVGRS:0.32, p&lt;0.01) but also valuable in predicting low RWA (areas under the curve: 0.76 and 0.73 respectively; sensitivity: both 0.72, specificity: both 0.71). Conclusions: Low sensing of ICD lead in ACM patients was associated with impaired RV mechanics. RVGCS and RVGRS by CMR-FT were valuable parameters for predicting low RWA and might assist operation planning.

Management of the patient with a wearable cardiac defibrillator in a virtual remote monitoring clinic

Abstract Funding Acknowledgements Type of funding sources: None. Background the risk of sudden cardiac death (SCD) currently represents a severe problem that significantly involves the population. The implantable cardiac defibrillator (ICD) has been used to prevent SCD among patients with a high risk for life-threatening sustained ventricular arrhythmias. However, there are a number of patients at risk for SCD either awaiting a work-up for reversible causes of SCD or with acute contraindications to ICD implantation. Nevertheless, ICD implantation is dependent on defining ventricular substrate, evaluating the future risk of SCD and estimation of the patient’s overall survival. The wearable cardiac defibrillator (WCD) provides an option for protection during this vulnerable period when the risk of SCD is unclear. Methods our virtual device control clinic is managed by 3 cardiovascular technicians and 3 electrophysiologists. From August 2017 to January 2022, we included 29 patients who received WCD, 6 women (21%), with an average age of 66 years. The indications for the use of WCD were: ischemic cardiomyopathy (62,1%) and non-ischemic cardiomyopathy (17,24%),during cardiovascular rehabilitation pending eventual recovery of the ejection fraction (EF), waiting for genetic test result (10,34%) or ICD explant for infection awaiting reimplantation (10,34%).The patient is trained by technician staff to ensure the correct wearing of the WCD, the management of any alarms, the management of the device in case of arrhythmia and shock, as well as the daily replacement of the battery and the management of the remote monitoring system. Results in virtual control device clinic Cardiovascular Technician checks the transmissions from the WCD site: only clinical parameters such as recorded ECGs (manual, asystolic, events detected but not treated and events treated with shock) and patient compliance (wearing hours per day) can be verified.The average wearing duration has been 37 days, with a daily average of 23.1 hours. We received and controlled a total of 1097 transmissions, of which 22 with events, of which 7 were generated for VT, 4 for TSV, 10 for T wave oversensing and 1 for inappropriate Shock; in all these cases, the patient has been contacted by the clinic staff for clinical management. At the end of wearing period, technical staff schedules a check-up with echocardiogram monitoring the EF to evaluate the patient's clinical path. Following the clinical evaluation, a recovery of cardiac function has been possible for 13 patients, without any implantation of ICD, whereas 16 patients underwent a defined implantation of ICD. Conclusions the WCD has been shown to be an effective device in protecting SCD from VT/VF. Despite the small number of patients, it was necessary to take them in charge at the virtual remote monitoring clinic for proper clinical management, which generated a workload increase. Therefore, it will be important to propose a recognition of the service and its reimbursement.

PO-674-05 THE SHOCKING PRACTICES OF PEDIATRIC ELECTROPHYSIOLOGISTS: CONTEMPORARY DFT DATA FROM CIED REGISTRY

Defibrillator threshold (DFT) testing is no longer recommended except in certain circumstances. Data on current national practice pertaining to DFT testing in pediatrics is scarce. To report current implant characteristics, DFT testing practice, and intraprocedural events in pediatric patients undergoing implantable cardiac defibrillator (ICD) placement. We leveraged the pediatric cardiac implantable electronic devices (CIED) registry, a retrospective multicenter study endorsed by PACES, to identify patients (age≤21) who underwent ICD placement between 2017 and 2020. Among 705 patients, 51 underwent new ICD implantation. Median age and median weight at implant were 16 years (IQR 14-18) and 62 kg (53-78) respectively. Cardiomyopathy was diagnosed in 28, congenital heart disease (CHD) in 8, idiopathic VT/VF in 8, channelopathy in 5, and other in 2. An ICD was implanted for secondary prevention in 18 patients. Type of implants were as follows: transvenous in 39, subcutaneous in 8, and epicardial in 4. DFT status was known in 49 patients, of whom 30 (61%) underwent testing. DFT testing was performed in all patients who had a subcutaneous device but there was no difference in those with transvenous vs. epicardial leads (53% vs. 66%, p=0.63). DFT testing was less likely in patients seen at a freestanding Children’s Hospital (48% vs. 87%, p=0.012) but did not vary between diagnoses (CHD 59%, cardiomyopathy 62%, channelopathy 60%, and idiopathic ventricular fibrillation 75%, p=0.68) or type of cardiomyopathy (hypertrophic cardiomyopathy vs. all other types, 62% vs. 55%, p=0.67). Age, weight, mild ventricular dysfunction or greater, history of cardiac arrest, or implant provider were not associated with DFT testing. DFTs failed in 2 patients: inability to induce VT/VF in 1 and inability to defibrillate with an acceptable safety margin in 1. There were no reported complications with DFTs. DFT testing is still performed at implant in the majority of transvenous devices in pediatric patients. Presence of CHD or hypertrophic cardiomyopathy was not associated with higher DFT testing rates. Freestanding children’s hospitals were less likely to perform DFTs.

Predictors of appropriate implantable cardiac defibrillator therapy in cardiac sarcoidosis.

Cardiac sarcoidosis (CS) is associated with an increased risk for sudden cardiac death. An implantable cardiac defibrillator (ICD) is recommended in a subgroup of CS patients. However, the recommendations for primary prevention differ between guidelines. The purpose of the study was to evaluate the efficacy and safety of ICDs in CS and to identify predictors of appropriate therapy. A retrospective cohort study was performed in CS patients with an ICD implantation between 2010 and 2019. Primary outcome was appropriate ICD therapy. Independent predictors were calculated using Cox proportional hazard analysis. 105 patients were included. An ICD was implanted for primary prevention in 79%. During a median follow-up of 2.8 years, 34 patients (32.4%) received appropriate ICD therapy of whom 24 (22.9%) received an appropriate shock. Three patients (2.9%) received an inappropriate shock due to atrial fibrillation. Independent predictors of appropriate therapy included prior ventricular arrhythmias (hazard ratio [HR]: 10.5 [95% confidence interval (CI): 5.0-21.9]) and right ventricular late gadolinium enhancement (LGE) (HR: 3.6 [95% CI: 1.7-7.6]). Within the primary prevention group, right ventricular LGE (HR: 5.7 [95% CI: 1.6-20.7]) was the only independent predictor of appropriate therapy. Left ventricular ejection fraction did not differ between patients with and without appropriate therapy (44.4% vs. 45.6%, p = .70). In CS patients with an ICD, a high rate of appropriate therapy was observed and a low rate of inappropriate shocks. Prior ventricular arrhythmias and right ventricular LGE were independent predictors of appropriate therapy.

Optimal Timing of Cardioverter-Defibrillator Implantation in Patients with Left Ventricular Dysfunction after Acute Myocardial Infarction

Background: Prevention of sudden cardiac death (SCD) early after acute myocardial infarction (AMI) is still a challenge, without clear recommendations in spite of the high incidence of life-threatening ventricular arrhythmias, as implantable cardiac defibrillator (ICD) placement is not indicated in the first 40 days after an AMI; this timing is aleatory and it is owed to fact that the two pivotal studies for evaluation of ICDs in primary prevention, MADIT and MADIT II, excluded the patients within three, respectively four weeks after AMI. Methods: We conducted a retrospective, single-center study that included 77 patients with AMI. All patients were monitored by continuous ECG in the first week after the event. Transthoracic echocardiography was performed at discharge and 40 days after the event. Patients with ejection fraction of 35% or less as assessed by 2D echocardiography 40 days after the MI, which received an ICD for the primary prevention of SCD, were included in the study. The subjects were followed for a median of 38 months, by means of device interrogation and echocardiography. Results: We divided our patients into two groups: in the first group, with left ventricular ejection fraction (LVEF) under 30% after MI, all patients remained in the reduced ejection fraction heart failure category, with an increase from an initial mean of 18.93 ± 4.99% to a mean of 22.18 ± 4.53% after a period of 40 days; we obtained a positive and statistically significant correlation (p &lt; 0.001 and r – 0.547), and all patients presented indication of ICD implant 40 day after MI. In the second group with LVEF between 30% and 35% after MI, the mean LVEF increased from an initial mean of 31.73 ± 1.33% to a mean of 32.33 ± 1.49% after a period of 40 days. A statistically significant correlation (p – 0.02 and r – 0.78) was obtained, although 3 patients presented a LVEF over 35% at 40 days post-MI. Most of the ICD therapies (14.54%) appeared in patients with LVEF &lt;30% and these patients also presented a higher percentage of NSVT at initial ECG monitoring (54% vs. 50%) and NSVT at ICD interrogation (80% vs. 66.7%); statistical significance was not reached – p &gt; 0.05. The majority of the ICD therapies (11.9% from 13.4%) appeared in patients with NSVT at initial ECG monitoring; also, these presented an increased number of NSVT at ICD interrogation (77.6% vs. 6%) when compared to patients without VT detection at the initial ECG monitoring. Still, statistical significance was not reached – p &gt; 0.15. Conclusions: The patients could benefit from ICD implant earlier than stated in the actual guidelines, since there are insufficient data in the literature for the waiting time of 40 days. Correlated with the increased risk of SCD in the first months post myocardial infarction, the present study proves the benefit of early ICD implantation considering that all our patients with a low ejection fraction immediately after infarction remained in the same category and the great majority (96.1%) required the implantation of an ICD after 40 days. Thus, we could avoid exposing our patients at risk of SCD for an unnecessary prolonged period, and choose early ICD implantation.

Fragmented QRS is associated with ventricular arrhythmias in heart failure patients: A systematic review and meta-analysis.

IntroductionMany primary prevention heart failure (HF) patients with an implantable cardiac defibrillator (ICD) rarely experience life‐threatening ventricular arrhythmias (VA). New strategies are required to identify patients most at risk of VA and sudden cardiac death who would benefit from an ICD. One potential method is the detection of fragmented QRS (fQRS) on the electrocardiogram. The aim was to assess the predictive capacity of fQRS for VA and mortality in ischemic (ICM) and non‐ischemic cardiomyopathy (NICM) primary prevention HF patients.Methods and ResultsA systematic review and meta‐analysis of studies examining fQRS in HF patients with or without an ICD who met primary prevention indications with reduced ejection fraction ≤40%. Outcome measures were VA (or appropriate ICD therapy) and all‐cause mortality. Ten studies involving 3885 patients were included for analysis. Most patients were male with non‐fQRS patients being significantly younger (−1.5[−2.66, −0.42], p = .03). Diabetes was more likely in fQRS patients (1.12[1.01, 1.25], p = .03) while non‐fQRS patients were 28% more likely to have a history of atrial fibrillation (0.82[0.67,1.00], p = .05). Ventricular arrhythmias were significantly 1.5 times more likely in patients with fQRS (1.51[1.02, 2.25], p = .04). HF patients were 1.7 times more likely to die of any cause if fQRS was present (1.68[1.13, 2.52], p = .01). NICM patients with fQRS have a significant 2.6‐fold increased incidence of death compared with ICM patients (2.55[1.63, 3.98], p < .0001).ConclusionfQRS is associated with VA and all‐cause mortality and may be a novel marker in the risk stratification of primary prevention HF patients indicated for ICD implantation.

Sex differences in implantable cardiac defibrillator decision: myth or fact?

Abstract Introduction Previous studies have found sex differences in implantable cardiac defibrillator (ICD) implantation counseling, especially in primary prevention. Possible explanations to this phenomenon have been described: under-representation of women in clinical trials, patient's preferences, lower overall sudden cardiac death risk in women compared to men, higher prevalence of non-ischemic dilated cardiomyopathy (DCM) in women and better response to cardiac resynchronization therapy in this population. Nevertheless, this gap appears to narrow in most recent registries. Purpose Our aim is to asses if there is still sex discrimination in ICD counseling by comparing ICD implantation between men and women. Methods A single-centre retrospective registry of 160 patients with a reduced left ventricle ejection fraction (LVEF ≤35%) found in a routine transthoracic echocardiogram (TTE) from January 2019 to June 2020. Inclusion and exclusion flow chart is described in Picture 1. Data collected included demographic, clinical and echocardiographic characteristics. Date of heart disease diagnosis, earliest date of LVEF ≤35% diagnosis (with TTE or cardiac magnetic resonance) and date of death when applicable were recorded. Cardiac resynchronization devices with ICD function were also considered for the analysis. In ICD carriers, implantation date and type of prevention for indication were collected. ICD implants and deaths up to December 31, 2020 were included for the analysis. Results Basal characteristics are described in Picture 2. The mean age was 67.5 years and 24.4% of the population were women. Ischemic etiology was the most frequent etiology in the overall population and in the male group. In women, DCM was the most common etiology. Sixty-eight patients carried an ICD. No significant differences between both sexes, neither globally nor according to the implant indication (primary vs. secondary prevention) were observed. In the subgroup analysis of patients with ICD, there were no significant differences in the number of devices between men and women, neither in ischemic or non-ischemic etiology. In primary prevention, there was a non-significant trend towards earlier implantation of the device in women (1.4 years vs 3.4 years, p=0.008) since the diagnosis of LVEF ≤35%. In patients without ICD (n=92), the mean age was significantly higher (72.5 years vs. 60.8 years, p&amp;lt;0.0001) and similar in both sexes (women 74.6 years, men 71.8 years, p=0.414). Conclusions Despite under representation of women in pur population, we could not find differences in ICD implantation decision based on gender, even considering differences in underlying cardiomyopathy. There was no delay in implantation depending on sex, and even the trend was towards earlier implantation in women. Funding Acknowledgement Type of funding sources: None. Inclusion and exclusion flow chartBasal characteristics

The value of c-reactive protein to albumin ratio in predicting long term mortality among hfref patients with implantable cardiac defibrillators

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and comorbid conditions. C-reactive protein to albumin ratio (CAR) may be of value for identifying those with high risk for mortality despite ICD implantation. Methods Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance to CAR at the time of implantation. After follow up of 48 ± 35 months, survival times of tertiles were compared by using Kaplan-Meier survival method. Results Thousand and eleven patients constituted study population. Ischemic cardiomyopathy was primary diagnosis in 92.3%. Of those 14.5% had died after discharge. Patients in tertile 3 (T3) had higher risk of appropriate shock (19.3% vs 23.7% vs 38.0%) and mortality (4.2% vs 11.0% vs 28.5%) compared to those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as reference, both those in T2 and T3 had independently higher risk of appropriate shocks and mortality. These effects were consistent in the unadjusted and adjusted multivariable models. Conclusion Among patients with HFrEF and ICD, elevated CAR increased the risk of appropriate device shock and mortality at long term. Table 1Admission C-reactive protein/Albumin ratio (n = 1011)T1 (n = 337)T2 (n = 337)T3 (n = 337)Mortality, %4.211.028.5Mortality, HR (95% CI)Model 1: unadjusted1[Reference]3.85 (2.12 - 11.20)8.14 (2.46 - 28.56)Model 2: adjusted for age, sex1[Reference]3.20 (1.90 - 9.48)6.32 (2.12 - 20.12)Model 3: adjusted for comorbiditesa1[Reference]4.85 (2.06 - 14.12)10.86 (4.12 - 44.82)Model 4: adjusted for covariatesb1[Reference]2.72 (1.66 - 7.12)5.72 (2.04 - 18.05)Frequency, %19.323.738.0Appropriate shock, HR (95% CI)Model 1: unadjusted1[Reference]1.38 (0.44 - 6.88)2.48 (1.34 - 5.82)Model 2: adjusted for age, sex1[Reference]1.42 (0.48 - 7.24)3.02 (1.52 - 6.24)Model 3: adjusted for comorbiditesa1[Reference]1.34 (0.38 - 6.66)2.74 (1.40 - 7.28)Model 4: adjusted for covariatesb1[Reference]1.30 (0.34 - 5.68)2.28 (1.16 - 8.28)Cox proportional analysis and logistic regression models for the appropriate shock and the long-term mortality by CAR.Abstract Figure 1

Sudden cardiac death risk stratification in patients with a preserved or mildly reduced ejection fraction: role of cardiac magnetic resonance and electrophysiological study

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Patients presenting with syncope of suspected arrhythmogenic origin or symptomatic documented non sustained ventricular tachycardia (NSVT) may represent a population with higher risk for sudden cardiac death (SCD). However today there are still no defined criteria to stratify the risk of SCD in this population. PURPOSE To assess the prognostic value of magnetic resonance (MRI) and electrophysiological study (EPS) in the risk stratification for SCD of patients with a preserved or mildly-reduced ejection fraction (EF) that may benefit from implantable cardiac defibrillator (ICD) therapy. METHODS We selected ischemic and non-ischemic patients with a preserved or mildly-reduced ejection fraction who came to our attention either after a probably arrhythmogenic syncopal event or a documented NSVT between 12/2018 and 09/2020. Patients with other ICD indications following current guideline-criteria were excluded (id est Brugada syndrome, Long QT and hypertrophic cardiomyopathy). All patients underwent an echocardiography, a coronary angiography, and an MRI with gadolinium, those among them with a positive LGE also underwent an induction EPS. Non inducible patients were followed-up clinically or with an implantable event-recorder, while inducible patients received an ICD. RESULTS In our observational study seventeen patients with preserved or only mildly-reduced EF were enrolled (13 males and 5 females; mean age 68 years). Among these patients, nine were identified with an underlying myocardial scar with positive Late-Gadolinium-Enhancement (LGE) in MRI. Based on the clinical orientation and the MRI LGE pattern patients were divided in ischemic group (5 patients) and non-ischemic group (4 patients). All 9 patients underwent an induction EPS. Three of them, 2 with non-ischemic and 1 with an ischemic pattern, demonstrated a reproducible inducibility of a sustained ventricular tachycardia or ventricular fibrillation and were implanted with an ICD. During our follow-up two of the three patients had an adequate shock within a year from the ICD implantation. Among the 6 patients with negative induction EPS there were no clinical events in the follow up, except one death for unknown causes. CONCLUSION Our preliminary results demonstrated that in patients with ischemic or non ischemic cardiopathy with preserved or mildly reduced EF, a positive MRI LGE pattern and the inducibility of ventricular arrhythmias during induction EPS identify a population at higher risk for clinical recurrence of ventricular arryhthmic events. Further investigation is needed to validate this combined diagnostic strategy as new SCD prevention tool.

Pregnancy in patients with implantable cardiac defibrillators.

The number of patients of reproductive age with inherited and congenital heart disease receiving implantable cardiac defibrillators (ICD) is steadily increasing. Safely and effectively coordinating pregnancy in this high-risk cohort is important to optimise maternal-foetal outcomes. As members of the multidisciplinary team caring for pregnant patients with indications for ICD, cardiologists and electrophysiologists should be aware of the considerations and nuances involved in managing these patients. This article reviews the pathophysiology of arrhythmias, ICD implantation considerations, novel minimal fluoroscopy techniques and subcutaneous ICD. In addition, antenatal and device management during pregnancy and delivery are discussed.

The value of C-reactive protein-to-albumin ratio in predicting long-term mortality among HFrEF patients with implantable cardiac defibrillators.

Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and prevalent comorbid conditions. The primary aim of this research was to evaluate the predictive value of C-reactive protein-to-albumin ratio (CAR) for all-cause mortality among patients with HFrEF despite ICD implantation. Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. Data were extracted from hospital's database. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance with CAR at the time of the implantation. During follow-up duration of 38 [17-77] months, survival times of tertiles were compared by using Kaplan-Meier survival method. Forward Cox proportional regression model was used for multivariable analysis. Thousand and eleven patients constituted the study population. Ischaemic cardiomyopathy was the primary diagnosis in 92.3%, and ICD was implanted for the primary prevention among 33.9% of patients. Of those, 14.5% died after the discharge. Patients in tertile 3 (T3) had higher risk of mortality (4.2% vs 11.0% vs 28.5%) compared with those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as the reference, both those in T2 and those in T3 had independently higher risk of all-cause mortality. This finding was consistent in the unadjusted and adjusted multivariable models. Among patients with HFrEF and ICD, elevated CAR increased the risk of all-cause mortality at long term.

Future bradyarrhythmia in patients with hypertrophic cardiomyopathy.

BackgroundA few studies to evaluate an incidence of bradyarrhythmia in patients with hypertrophic cardiomyopathy (HCM) have been reported.MethodsWe enrolled 161 patients with HCM to evaluate their bradyarrhythmia risk, especially the risk of patients who were at risk for sudden cardiac death (SCD) and eligible for implantation of an implantable cardiac defibrillator (ICD). We defined symptomatic bradyarrhythmia requiring a pacing therapy as a bradyarrhythmia event and collected the data on an occurrence of the event after the time of diagnosis of HCM. The incidence of bradyarrhythmia events was compared between patients with ICD indications (ICD-candidate group) and those without (non-ICD-candidate group). Furthermore, we investigated the associated factors with bradyarrhythmia events using a Cox proportional-hazards model.ResultsDuring 5.5 ± 4.4 years follow-up, bradyarrhythmia events occurred in 8% (13 patients) of whole patients, and in 15% of the ICD-candidate group (n = 74). In contrast, only 2 events (2%) occurred in the non-ICD-candidate group. The incidence of bradyarrhythmia in the ICD-candidate group was significantly higher than that in the non-ICD-candidate group (log-rank p = 0.015). In the ICD-candidate group, a Cox proportional-hazards model demonstrated that lower heart rate at the time of diagnosis (HR: 1.072, 95%CI: 1.012 to 1.135, p = 0.018), and an eligibility of ICD implantation for secondary prevention of SCD (HR: 9.092, 95%CI: 2.644 to 31.258, p < 0.001) were significantly associated with future bradyarrhythmia.ConclusionsHCM patients with eligibility for ICD implantation, especially for secondary prevention of SCD, more frequently suffered from bradyarrhythmia events.

Benefits of cardiac pacing in ICD recipients with hypertrophic cardiomyopathy.

Implantable cardiac defibrillator (ICD) is the only definitive therapy for prevention of sudden cardiac death in hypertrophic cardiomyopathy (HCM). Conventional transvenous ICDs can provide cardiac pacing unlike new subcutaneous ICD, but the usefulness of cardiac pacing in HCM patients is not well defined. We sought to assess the usefulness of ICD pacing in HCM. We retrospectively analyzed 93 HCM patients who had undergone ICD implantation at our center. Usefulness of pacing was defined as follows: 1) need of pacing due to bradycardia or AV conduction disturbances, 2) improvement of LV outflow tract obstruction by sequential AV pacing, 3) need for CRT pacing, or 4) successful antitachycardia pacing without a subsequent shock. Independent predictors of useful pacing were investigated by multivariable analysis. During a mean follow-up of 91.3 ± 5.5 months, 43 patients (46.2%) reached the composite endpoint. Independent predictors of pacing usefulness were older age (HR 1.36; 95%CI: 1.088-1.709; p=0.007) and NYHA functional class ≥ II (HR 2.15; 95%CI: 1.083-4.301; p=0.029). Twenty-eight (30.1%) patients had appropriate ICD interventions, triggered by a monomorphic ventricular tachycardia (MVT) in 22 of them (78.5%). In 17 individuals with MVT (77%), antitachycardia pacing successfully treated MVT. In our HCM series of patients with ICD, 46% of individuals benefitted from cardiac pacing. MVT were documented in nearly 80% of the patients with ventricular arrhythmias and antitachycardia pacing successfully treated them in 77% of cases.

Cardiac pacing procedures during coronavirus disease 2019 lockdown in Southern Italy: insights from Campania Region.

Aim of our study was to assess the association between COVID-19 lockdown and cardiac pacing (CP) procedures rates in Campania Region, the third-most-populous region of Italy with about 5.8 million residents. Data about type of CP procedures and unit admissions were obtained from 14 CP centers throughout Campania region from March 10th and May 4Th 2020 and compared with the same time frame in 2019. A remarkable reduction in both temporary (reduction rate: -62.5%), definitive pace maker (reduction rate: -30.2%), ICD (reduction rate: -48.3%) and CRT (reduction rate: -48.4%) implantation and in CRT replacement (reduction rate: -88.8%) procedures has been shown between the two observation periods among 951 hospitalized patients. Planned hospitalizations showed a reduction rate of 69.3%. Conversely, urgent intra-hospital admissions (increase rate +430%; P < 0.001) increased during COVID-19 lockdown and no significant difference in attendance rate to the emergency department (increase rate +6.7%; P = 0.254) has been shown. COVID-19 lockdown was associated with a remarkable decrease in CP procedures due to the reduction of planned hospitalizations in Campania Region; however, no significant difference in emergency department admission rate was shown.

Necrotizing Myopathy Resulting In Myocarditis And Sudden Death

AbstractNecrotizing myopathy (NM), a type of idiopathic inflammatory myopathy (IIM), is an autoimmune disorder in which immune cells target skeletal muscle, resulting in muscle breakdown and weakness. Cardiac involvement in this disorder is rare. We highlight a case of autoantibody-negative NM complicated by myocarditis and sudden cardiac death.Case Report: A 45-year-old male with a history of hypertension, previous hepatitis B, and obesity presented with 6 months of progressive proximal lower extremity weakness. Workup revealed elevated creatinine phosphokinase, ESR and CRP, elevated troponin, and electromyography notable for a myopathic process. Age appropriate malignancy screening, infectious workup, and myositis panel were negative. The patient underwent left bicep biopsy which revealed muscle fiber necrosis and regeneration, consistent with the diagnosis of seronegative NM. Patient was discharged on mycophenolate and intravenous immunoglobulin with improvements in peripheral strength. Unfortunately, while recovering, he was readmitted with palpitations and dyspnea. Electrocardiogram showed a new trifascicular block and telemetry revealed frequent runs of non-sustained ventricular tachycardia (NSVT). A Cardiac MRI revealed evidence of myocarditis (Image 1). Endomyocardial biopsy showed fibrosis with entrapped myocytes (Image 2). He was treated with pulse dose intravenous glucocorticoids and mycophenolate was increased. EP study (EPS) was performed which did not reveal inducible VT; therefore, implantable cardiac defibrillator (ICD) was not implanted. Three months later the patient had sudden unexplained death at home.Discussion: Cardiac involvement in IIM—especially seronegative NM—is rare and not well described. Our patient had worsening cardiac involvement despite improvements in his skeletal myopathy. Despite a recent negative EPS, the patient had sudden unexplained death. Perhaps, a lower threshold for ICD implantation should be considered in this population. This case raises awareness for cardiac involvement in seronegative NM and raises the question of whether these patients are at increased risk of sudden cardiac death.