Internal Cardiac Defibrillator Research Articles

Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial

BackgroundNo study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. ObjectiveTo assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. MethodsSubanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. ResultsThere were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. ConclusionIn patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.

Exploiting SMART pass filter deactivation detection to minimize inappropriate subcutaneous implantable cardioverter defibrillator therapies: a real-world single-centre experience and management guide.

The SMART Pass™ (SP) algorithm is a high-pass filter that aims to reduce inappropriate therapy (IT) in subcutaneous internal cardiac defibrillator (S-ICD), but SP can deactivate due to low amplitude sensed R waves or asystole. The association between IT and SP deactivation and management strategies were evaluated, hypothesizing SP deactivation increases the risk of IT and device re-programming, or lead/generator re-positioning could reduce this risk. Retrospective single-centre audit of Emblem™ S-ICD devices implanted 2016 to 2020 utilizing health records and remote monitoring data. Cox regression models evaluated associations between SP deactivation and IT. A total of 348 patients (27 ± 16.6 months follow-up) were studied: 73% primary prevention. Thirty-eight patients (11.8%) received 83 shocks with 27 patients (7.8%) receiving a total of 44 IT. Causes of IT were oversensing (98%) and aberrantly conducted atrial fibrillation (2%). SP deactivation occurred in 32 of 348 patients (9%) and was significantly associated with increased risk of IT (hazard ratio 5.36, 95% CI 2.37-12.13). SP deactivation was due to low amplitude R waves (94%), associated with a higher defibrillation threshold at implant and presence of arrhythmogenic right ventricular cardiomyopathy. No further IT occurred 16 ± 15.5 months after corrective interventions, with changing the sensing vector being successful in 59% of cases. To reduce the risk of IT, the cause of the SP deactivation should be investigated, and appropriate reprogramming, device, or lead modifications made. Utilizing the alert for SP deactivation and electrograms could pro-actively prevent IT.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Guideline-based audit of the hospital management of heart failure with reduced ejection fraction.

Heart failure is a major burden in Australia in terms of morbidity, mortality and healthcare expenditure. Multiple evidence-based therapies are recommended for heart failure with reduced ejection fraction (HFrEF), but data on physician adherence to therapy guidelines are limited. To compare use of HFrEF therapies against current evidence-based guidelines in an Australian hospital inpatient population. A retrospective review of patients admitted with a principal diagnosis of HFrEF across six metropolitan hospitals in Sydney, Australia, between January 2015 and June 2016. Use of medical and device therapies was compared with guideline recommendations using individual patient indications/contraindications. Readmission and mortality data were collected for a 1-year period following the admission. Of the 1028 HFrEF patients identified, 39 were being managed with palliative intent, leaving 989 patients for the primary analysis. Use of beta-blockers (87.7% actual use/93.6% recommended use) and diuretics (88.4%/99.3%) was high among eligible patients. There were large evidence-practice gaps for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB; 66.4%/89.0%) and aldosterone antagonists (41.0%/77.1%). In absolute terms, use of these therapies each increased by over 11% from admission. Ivabradine (11.5%/21.2%), automated internal cardiac defibrillators (29.5%/66.1%) and cardiac resynchronisation therapy (13.1%/28.7%) were used in a minority of eligible patients. Over the 1-year follow-up period, the mortality rate was 14.8%, and 44.2% of patients were readmitted to hospital at least once. Hospitalisation is a key mechanism for initiation of HFrEF therapies. The large evidence-practice gaps for ACEI/ARB and aldosterone antagonists represent potential avenues for improved HFrEF management.

Infective Endocarditis in Hypertrophic Obstructive Cardiomyopathy After Etonogestrel Implant Removal

The modified Duke criterion "predisposing heart condition" is poorly defined, and is based on outdated studies of the epidemiology of infective endocarditis (IE).Hypertrophic obstructive cardiomyopathy (HOCM) is not classified as a modified Duke criterion for the diagnosis of IE but is associated with a higher incidence of IE nonetheless. The presence of a cardiovascular implantable electronic device (CIED) is independently associated with an increased risk of IE. Patients with HOCM may be candidates for the implantation of an automated internal cardiac defibrillator (AICD) for the prevention of sudden cardiac death. Previous studies of the risk of IE in patients with HOCM did not make a distinctionfor patients with CIEDs. We present a case of a 25-year-old female with HOCM and an AICD for primary prevention, who presented with sudden right-sided hemiplegia, aphasia, dysarthria, and a low-grade fever. CT angiography demonstrated large vessel occlusion of the terminal left internal carotid artery and proximal middle cerebral artery (MCA), prompting emergent treatment with mechanical thrombectomy, which achieved full recanalization and full reperfusion. Cardioembolic stroke was suspected. She had no arrhythmias, a transthoracic echocardiogram showed new mitral valve vegetation. The etiology of the stroke was determined to be septic emboli from mitral valve subacute bacterial endocarditis and two blood cultures grew staph epidermidis. Ten days prior to presentation, she had undergone removal of an etonogestrel implant in her arm, and this was the suspected source of initial bacteremia and valvular seeding. She was treated with a six-week course of vancomycin with improvement and maintained on daily minocycline as long as the AICD were to remain in place. Our patient started developing symptoms of endocarditis after the removal of her etonogestrel implant, had no other recent procedures, and had good dentition. Hence, we maintainthat this was the likely source of her initial bacteremia that led to valvular seeding and resultant IE. This is the first reported case of etonogestrel implant removal-related endocarditis. Further studies of the association between etonogestrel implant removal, transient bacteremia, and valvular seeding leading to IE are warranted. Clinicians should be reminded of the increased risk of IE in patients with HOCM. Identifying HOCM patients at higher risk for IE, i.e. dilated left atrium and/or CIEDs is easier to accomplish with current cardiac imaging techniques.

What Aspects of Phenotype Determine Risk for Sudden Cardiac Death in Pediatric Hypertrophic Cardiomyopathy?

Sudden cardiac death due to hypertrophic cardiomyopathy (HCM), is the most common autopsy-proven cause of unexpected medical death in children after infancy. This mode of death is preventable by implantation of an internal cardiac defibrillator (ICD), a procedure that has considerable morbidity in childhood patients, and even mortality. Since HCM is an inheritable disease (usually autosomal dominant, occasionally recessive), family screening may identify subjects at risk. This review summarizes published studies carried out to identify which phenotypic markers are important risk factors in childhood patients with HCM and reviews the performance of existing risk-stratification algorithms (HCM Risk-Kids, PRIMaCY) against those of single phenotypic markers. A significant proportion of HCM-patients diagnosed in childhood are associated with RASopathies such as Noonan syndrome, but a knowledge gap exists over risk stratification in this patient group. In conclusion, pediatric risk-stratification algorithms for sudden cardiac death perform better in children than adult HCM risk-stratification strategies. However, current multivariable algorithms overestimate risk substantially without having high sensitivity, and remain ‘a work in progress’. To include additional phenotypic parameters that can be reproducibly measured such as ECG-markers, e.g., ECG risk score (which has high sensitivity and negative predictive value), tissue Doppler diastolic function measurements, and quantification of myocardial scarring on cardiac magnetic resonance imaging, has the potential to improve risk-stratification algorithms. Until that work has been achieved, these are three factors that the clinician can combine with the current algorithm-calculated per cent risk, in order better to assess risk.

Sudden Cardiac Arrest After Pediatric Heart Transplantation

<h3>Purpose</h3> Sudden cardiac arrest (SCA) is a prevailing cause of mortality after pediatric heart transplant (HT) but remains understudied. The purpose of this study was to analyze the incidence, outcomes and risk factors for SCA at our center. <h3>Methods</h3> Retrospective review of all pediatric HT patients at our center from 1/1/2009-9/1/2021. SCA was defined as an abrupt loss of cardiac function requiring cardiopulmonary resuscitation and/or mechanical circulatory support (MCS). Events that occurred in the first post-operative week, while on MCS, or in the setting of limited resuscitative wishes were excluded. Patient characteristics and risk factors were analyzed. <h3>Results</h3> Of 254 transplants during the study period, 16 (6%) experienced SCA at a median of 2 (1, 4) years post-HT. Thirteen (81%) died from their initial event, 4 of those (31%) after placement on MCS. SCA accounted for 30% of the 46 deaths during this time period. Seven (44%) events occurred at home. In univariate analysis, black race, internal cardiac defibrillator, history of post-HT extracorporeal membrane oxygenation (ECMO), prior cellular rejection (ACR) episode, retransplantation, and diagnosis of allograft vasculopathy (CAV) were associated with SCA (<i>P</i> =0.02-0.001, Table 1). In multivariable analysis, history of post-HT ECMO retained significance. [OR 14.5, 95% CI: 3.4-62.5, <i>P</i><0.001] <h3>Conclusion</h3> SCA occurs relatively early after pediatric HT and is often fatal. Nearly half of events happen at home. Patients with a history of ACR, CAV, retransplant, and prior history of ECMO are at increased risk. Multicenter investigation is needed to better understand SCA, reduce occurrence and improve outcomes.

Successful Recovery with Venovenous ECMO for ARDS After LVAD HeartMate 3 Implantation: A Case Report

<h3>Introduction</h3> ARDS following LVAD implantation is an unusual but devastating complication. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) can be used as a salvage treatment. We report the successful use of VV ECMO for ARDS Klebsiella pneumonia following urgent LVAD Heartmate 3 implantation. <h3>Case Report</h3> A 69-year-old male with past medical history significant for ischemic cardiomyopathy, status post CABG, and with known CHF presented to the emergency department after a witnessed cardiac arrest. He was found to have a wide-complex tachycardia and his internal cardiac defibrillator discharged. He was started on intravenous lidocaine which was transitioned to amiodarone and carvedilol. An echo demonstrated an EF of 10-15% and a dilated left ventricle. Left and right heart catheterization showed a patent LIMA to LAD bypass graft and a cardiac index of 1.64 L/min/m². The patient was optimized and underwent urgent LVAD Heartmate 3 implantation (HM3, Abbott, Chicago, IL). Post-operatively he was on 20 (ppm) inhaled nitric oxide (iNO) which was weaned and he was extubated on postoperative day 2 but subsequently re-intubated on the same day due to profound hypoxemia. On post-operative day 3 the hypoxemia was refractory despite maximal ventilator support with FiO2 100%, PIP 37, PEEP 13, 20 ppm iNO. The arterial blood gas (ABG) was a pH 7.4, pO2 54, pCO2 38, HCO3 24, BE -1,and the decision was made to cannulate for VV ECMO. The patient was cannulated with a dual-lumen cannula (Avalon Elite, Getinge, Gothenburg, Sweden) in the right internal jugular vein. Respiratory cultures were positive for Klebsiella aerogenes and the patient was treated with vancomycin and cefepime. He was supported with VV ECMO for 6 days then decannulated. Two days later, a percutaneous tracheostomy was performed and he was ambulating the halls. The tracheostomy was removed after 18 days. He was discharged to a rehab facility on post-operative day 18 where he stayed for 6 days. <h3>Summary</h3> When the ventilator is at maximal settings, with minimal changes in oxygenation, VV ECMO is the next step of care for otherwise appropriate candidates. Our case demonstrates that the use of VV ECMO is a successful treatment option for a patient with refractory hypoxemia, post-cardiotomy, s/p LVAD implantation. A multi-disciplinary approach along with early initiation of these interventions can result in successful weaning of VV ECMO.

Analysis of Three-Dimensional Scar Architecture and Conducting Channels by High-Resolution Contrast-Enhanced Cardiac Magnetic Resonance Imaging in Chagas Heart Disease.

We aimed to describe the morphology of the border zone of viable myocardium surrounded by scarring in patients with Chagas heart disease and study their association with clinical events. Adult patients with Chagas heart disease (n=22; 55% females; 65.5 years, SD 10.1) were included. Patients underwent high-resolution contrast-enhanced cardiac magnetic resonance using myocardial delayed enhancement with postprocessing analysis to identify the core scar area and border zone channels number, mass, and length. The association between border zone channel parameters and the combined end-point (cardiovascular mortality or internal cardiac defibrillator implantation) was tested by multivariable Cox proportional hazard regression analyses. The significance level was set at 0.05. Data are presented as the mean (standard deviation [SD]) or median (interquartile range). A total of 44 border zone channels (1[1-3] per patient) were identified. The border zone channel mass per patient was 1.25 (0.48-4.39) g, and the extension in layers of the border zone channels per patient was 2.4 (1.0-4.25). Most border zone channels were identified in the midwall location. Six patients presented the studied end-point during a mean follow-up of 4.9 years (SD 1.6). Border zone channel extension in layers was associated with the studied end-point independent from left ventricular ejection fraction or fibrosis mass (HR=2.03; 95% CI 1.15-3.60). High-resolution contrast-enhanced cardiac magnetic resonance can identify border zone channels in patients with Chagas heart disease. Moreover, border zone channel extension was independently associated with clinical events.

Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old?

Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n= 84) or MP (n= 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P= .24) or 15-year transplant-free survival (94.1% vs 87.5%, P= .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P= .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P= .78] vs 6.0 [95% confidence interval, 0.6-63.1; P= .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P= .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.

Abstract 13535: Cardiopulmonary Exercise Testing in Pediatric Patients With Hypertrophic Cardiomyopathy

Introduction: Data from exercise stress tests (EST) offer novel information about cardiovascular (CV) health of pediatric hypertrophic cardiomyopathy (HCM) patients and may have prognostic utility. Methods: A retrospective single center analysis of all HCM patients &lt;21 years old who had EST from 1/1/2000-1/1/2019 was performed. Clinical and demographic characteristics, and exercise capacity data were analyzed. The primary composite endpoint included death/aborted cardiac death, transplant, or internal cardiac defibrillator (ICD) placement, with each patient limited to a single outcome. Outcomes analysis was performed using a multivariate analysis. Results: 142 patients (53% with a recognized genetic variant) were identified: 70% were white, and 79% male. No tests were aborted due to safety concerns. By echo, the mean ejection fraction was 68.2% (SD 8.7), mean max septal diameter (MSD) was 1.6 cm (SD 0.7) and average peak left ventricular outflow tract (LVOT) gradient at rest was 26.9 mmHg (SD 53.1). The mean age at EST was 15.3 y (SD 3.5). 90% of patients were tested using cycle ergonometry, and 48% of patients were on a beta-blocker. The mean peak oxygen consumption (V02) was 36.0 ml/kg/min (SD 9.5), 79.7% predicted, mean anaerobic threshold (AT) was 22.1 ml (SD 5.8), and mean peak power (P) was 2.4 watts/kg (SD 0.7), 71.5% predicted. 45.5% of patients had ectopy during exercise, and 9% had an abnormal blood pressure response to exercise (ABPR). The primary endpoint was reached in 32 patients (cardiac death/aborted cardiac death/transplant in 5 and ICD placement in 27). Adjusting for clinical and demographic factors, and beta blocker use, low P, MSD &gt; 1.8 cm, and LVOT gradient &gt; 50 mmhg, but not ABPR were independent predictors of the composite endpoint. Conclusion: Pediatric patients with HCM have impaired CV fitness as measured by EST. EST can be performed safely, and may provide valuable information in the risk stratification in children with HCM.

The educational experiences and needs of patients with an internal cardiac defibrillator: An interpretive phenomenological study

<h2>ABSTRACT</h2><h3>Background</h3> Internal cardiac defibrillators (ICD) are the treatment option for primary and secondary prevention of sudden cardiac arrest and potential death. The majority of research to date has focused on the psychological and physical outcomes affecting patients, such as fear, anxiety, depression, and changes in quality of life post ICD insertion. There is, however, limited research exploring the adequacy of their educational preparation by nurses and other health care professionals. <h3>Aim</h3> The aim of this study was to understand the educational experiences and needs of adult patients with ICDs within a metropolitan tertiary hospital in Queensland. <h3>Methods</h3> An interpretive phenomenological approach was chosen to explore the everyday educational experiences and needs of patients with an ICD or Subcutaneous Internal Cardiac Defibrillator (S-ICD). Semi-structured interviews were conducted with a purposive sample of ten participants until data saturation was reached. Thematic analysis was used to analyse the data. <h3>Findings</h3> Five themes emerged and these were ‘understanding the information needs of patients'; ‘psychological aspects'; ‘fearful of the ICD shock'; ‘physical concerns'; and ‘importance of family inclusion'. <h3>Discussion</h3> The study's findings revealed that patients with ICD/S-ICDs had unmet educational needs that are important for nurses to understand and address. These specifically related to education and the relevance to each individual's particular needs. These included addressing their anxiety levels explaining changes to everyday activities and including family in the education sessions. Discharge care via telemonitoring may be useful for follow-up care for this unique and vulnerable patient group. <h3>Conclusion</h3> Interpretive phenomenology was used to understand the experiences and needs of people living with an ICD/S-ICD. This study has provided knowledge about the patient's desire for clarity of information relevant to their individual needs. The research found that patients with ICD/S-ICDs did not perceive the education that they received regarding the device to be adequate, nor did it address their specific needs. The research highlighted that nurses caring for patients undergoing ICD/S-ICD insertion need to provide education that is both patient and family specific, and that it continues for at least two months post-hospital discharge.

Left Mini Thoracotomy as a Method for Epicardial Implantable Cardioverter-Defibrillator Placement in a Child. An Effective Alternative to the Transvenous Approach

In infants and children, the small size of the systemic veins precludes safe and durable transvenous placement of automatic internal cardiac defibrillator (ICD). In such cases, an alternative method of implanting an automatic ICD is via thoracotomy. This report describes the technique used at Onassis Cardiac Surgery Center for the epicardial placement of an ICD system with a transvenous ICD coil placed in the posterior pericardium via a left thoracotomy, producing a stable location and excellent coil-to-can vector for successful defibrillation. To the best of our knowledge, this is the first case in Greece.

Prevalence and Outcomes of Patients with Wolff-Parkinson-White in Danon Disease: Results of a Retrospective Analysis

Danon Disease is a rare X-linked myopathy caused by defects in the lysosome-associated membrane 2 (LAMP2) gene. It is strongly associated with hypertrophic cardiomyopathy as well as Wolff-Parkinson-White (WPW) syndrome, but the prevalence of WPW in Danon is unclear. This study examined the prevalence of WPW and associated outcomes in a cohort of patients with Danon Disease. Records were reviewed for 41 patients with confirmed Danon Disease enrolled in a previously described retrospective registry, 31 of which had at least one electrocardiogram (EKG) on file. EKGs were assessed for the presence of WPW, as well as left and right ventricular hypertrophy (LVH, RVH), or both. WPW was defined as a PR interval ≤ 120 milliseconds, QRS interval ≥120 milliseconds, and delta wave. Charts were reviewed for internal cardiac defibrillator (ICD) placement, heart transplantation, and death. These outcomes were evaluated between patients with and without WPW on EKG using chi-square analysis, with p <0.05 noted to be significant. EKG criteria for LVH, RVH or both was met in 10 of the 11 WPW patients, compared to 9 of the 20 without WPW (p=0.012). ICD devices were present in 9 of the 11 WPW patients, 3 of which were placed for secondary prevention, compared to 9 of the 20 patients without WPW (p=0.119). Six of the 11 WPW patients eventually underwent heart transplant, compared to 4 of the 20 without WPW (p=0.058). Only one death was noted in this cohort, and was determined to not be cardiac related. In a cohort of patients with Danon Disease, approximately one-third had WPW syndrome on EKG. Those with WPW on EKG had higher rates of EKG criteria for LVH, RVH or both and were more likely to require advanced therapies such as ICD placement and cardiac transplant. Larger studies involving WPW in Danon Disease should seek to better characterize these outcomes.

2211Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. an analysis from the CLARIFY registry

Abstract Background The prevalence, and prognostic implication of left bundle branch block (LBBB) in general population and patients admitted for acute myocardial infarction (MI) as been extensively studied. However, data are scarce about patients with stable coronary artery disease (CAD) and it remains unclear whether LBBB is only a marker of a severe cardiomyopathy or an independent predictor of events in these patients. Purpose We aimed to describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. Additionally, we aimed to describe the incidence of newly diagnosed LBBB that occurred without recent myocardial infarction. Methods CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was collected at baseline and at each follow-up visit, and patients were considered to have LBBB if the length of the QRS complex was of more than 120 milliseconds. Patients with previous pacemaker implantation of internal cardiac defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation. Results From the 23.457 patients with available data regarding LBBB status, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) had at least one LBBB assessed during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2±10.1 versus 63.6±10.4 years, p&lt;0.0001), history of coronary artery bypass grafting (29.2% vs 23.7%, p&lt;0.0001), diabetes (35.1% vs 28.4%, p&lt;0.0001), and HF (25.2% vs 16.8%, p&lt;0.0001) (Table). In unadjusted analysis, patients with LBBB had a higher risk of primary outcome (13.4% vs 8.7%, p&lt;0.0001) and each secondary outcome. In multivariate analysis taking into account several possible confounders, there was no difference in the rate of CV death, MI or stroke between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). However, patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, p&lt;0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, p&lt;0.0001) (Figure). Outcomes according to LBBB status Conclusion The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The overwhelming majority of newly diagnosed LBBB were not contemporary of documented myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, including all cause mortality but with a higher risk of pacemaker implantation and hospitalization for heart failure. To our knowledge this is the first study reporting such results in a broad population of stable CAD patients. Acknowledgement/Funding None

Early- and Late-Onset Arrhythmias after Bioelectrical Impedance Analysis in End-Stage Heart Failure Patients under Inotropic Support

Purpose Bioelectrical impedance analysis (BIA) is a painless and safe way to measure body composition without radiation. It is feasible in immobile patients and may serve as a measure to assess frailty. BIA may lead to electromagnetic interference with the conduction system of the heart, provoking oversensing in pacemakers and internal cardiac defibrillators or arrhythmias. End-stage heart failure patients are at highest risk for these possible side effects. The aim of this study was to evaluate the safety of BIA in end-stage heart failure patients under pro-arrhythmogenic pharmacologic therapy. Methods We performed 56 BIA measurements in 32 hospitalized patients (28 male, 4 female), suffering from advanced heart failure (20 DCMP; 10 ICMP; 2 other) under constant ECG monitoring. Fourteen measurements were performed while the patient was in need of single inotropic support (9 dobutamine; 5 milrinone), 11 patients received combined inotropic therapy (7 milrinone/dobutamine; 1 dobutamine/noradrenalin; 1 dobutamine/adrenalin; 2 dobutamine, milrinone, noradrenalin, adrenalin). Their mean Inotropic Score was 10.03 (+/- 7.15). During 31 BIA measurements, the patient had an implantable cardiac device (ICD, pacemaker or CRT) in place; one patient had an external defibrillator (LifeVest). Thirty-eight BIA measurements were performed while the patient was receiving antiarrhythmic medication either with amiodarone (15), beta-blockers (26), sotalol (1) or glycosides (4) alone (34) or in combination (4). Eighteen assessments were performed without any antiarrhythmic medication. During 36 assessments, the patient received supplementary potassium and during 12 evaluations, the patient was treated with other medication such as ivabradine or magnesium. Results None of the patients showed any signs of clinically relevant arrhythmias following the BIA under ECG monitoring for 48 hours, but we observed some, probably coincidental, ventricular extrasystoles. No device malfunction was seen, especially no oversensing in ICDs resulting in inadequate shocks. Conclusion BIA measurement can be performed safely in end-stage heart failure patients with pro-arrhythmogenic pharmacologic therapy, who are the most vulnerable to arrhythmias.

Sacubitril/Valsartan in Real-Life Practice: Experience in Patients with Advanced Heart Failure and Systematic Review.

Sacubitril/valsartan reduced heart failure (HF) admissions and cardiovascular mortality in the PARADIGM-HF trial. However, real-life studies are scarce comparing daily practice patients with those of the trial. The aim of our study was to analyze the efficacy and safety of the drug in an advanced heart failure cohort and to review systematically the previous real-life studies published to date. We performed a retrospective analysis of consecutive patients prescribed sacubitril/valsartan in a single tertiary HF clinic between September 2016 and February 2018. HF admissions before and after the initiation of the drug were assessed in a paired fashion. A systematic review of real-life studies published to date was also conducted. Sacubitril/valsartan was started in 108 patients who were in a more advanced NYHA class and more frequently treated with mineral receptor antagonists, internal cardiac defibrillator, and cardiac resynchronization therapy than in the PARADIGM-HF trial. After a 6-month follow-up, we observed a significant reduction in the HF hospitalizations, median levels of NT-proBNP, and need for levosimendan ambulatory perfusion. Likewise, we found a significant improvement in mean LVEF and end diastolic left ventricle diameter. Regarding safety, sacubitril/valsartan was well-tolerated without any severe adverse effect. Sacubitril/valsartan in real-life is prescribed to a more advanced HF population, which could be responsible for the difficulties in reaching high doses of the drug. However, after a 6-month follow-up, sacubitril/valsartan significantly reduces HF hospitalization and induces cardiac reverse remodeling, without remarkable adverse events.

Remote monitoring of cardiovascular implantable electronic devices in France. The French Electra survey

Goal To evaluate routine Remote Monitoring (RM) of Cardiovascular Implantable Device (CID). A multiple choice questionnaire was e-mailed to 100 French physicians Implanters of CID in November 2017. A total of 73 answers were obtained (73%). Seventy five percent work in a public center, twenty three percent in a private center. The rate of Internal Cardiac Defibrillator implantation (ICD)/year per center is > 100 for 63%, 50–100 for 24,7%, < 50 for 6.8% and none for 5.5%. The number of patients followed with RM is > 1000 (9.6%), 500–1000 (27.4%), 200–500 (41.1%), < 200 (18%). 21.9% followed only ICD, 78.1% all type of CID; 80% declare proposing RM to almost all ICD implanted patients. A total of 75.3% of physicians are referent for RM, 23.3% receive information from referent RM team. Eighty five percent obtain systematic inform consent from patients before activation of RM. Onsite registration and transmitter delivery (or order card) is performed by paramedical staff (68%), engineer (25%), physician (4.1%) Follow-up is performed by paramedical staff collaborating with physicians (68.5%), physicians only (26%). A total of 71.3% communicate a phone number to patients but only 42.5% deliver opening office schedule. During programmed follow-up a specific report is systematically created by 42.5%; information is delivered only in case of significant alert by 30.1% and non-specific PDF report is sent by 8.2%. There are 76.7% archive data but only 43.8% are exhaustive. Remote monitoring of CID is a current practice in France especially for ICD follow up. Collaboration with paramedical staff is partial. Patients are informed but not systematically. Data are archived but partially. Absence of funding may explain incomplete and heterogeneous RM activity in France.

Cardiac Management of the Patient With Duchenne Muscular Dystrophy.

Duchenne muscular dystrophy (DMD) results in a progressive cardiomyopathy that produces significant morbidity and mortality. To improve the quality of life in patients with DMD, cardiac care is focused on surveillance and management, with the goal of slowing the onset and progression of heart failure complications. The current article is intended to be an expanded review on the cardiac management data used to inform the 2018 DMD Care Considerations recommendations as well as be a discussion on clinical controversies and future management directions. The new cardiac guidance includes changes regarding noninvasive imaging surveillance of cardiac function and pharmacologic therapy. Many emerging therapies lack sufficient evidence-based data to be recommended in the 2018 DMD Care Considerations. These are discussed in the present article as clinical controversies and future directions. Important emerging therapies include new heart failure medications, mechanical circulatory support with ventricular assist devices, heart transplantation, and internal cardiac defibrillators. Future research studies should be focused on the risks and benefits of these advanced therapies in patients with DMD. We conclude this review with a brief discussion on the relationship between the heart and the recently developed medications that are used to directly target the absence of dystrophin in DMD.

Syncope in a Young Man

Introduction: Syncope is a common complaint in the emergency department, accounting for 1%–3% of all visits and hospital admissions. Most causes are often benign and self-limited allowing safe discharge. However, others, particularly those resulting from cardiac syncope, are associated with significant morbidity and mortality. An electrocardiogram (ECG) is essential in addition to clinical history and physical examination for risk stratification. It is useful for identifying patients with inherited syndromes that predispose them to cardiac arrhythmias.Case Report: We report a case of a young man who presented with syncope to the emergency department. He was asymptomatic on arrival, but subsequently developed seizures secondary to ventricular fibrillation that required defibrillation. His initial ECG revealed characteristics of type 1 Brugada syndrome. The patient was fitted with an internal cardiac defibrillator and was discharged. We discuss the presentation, pathophysiology, and management of patients with Brugada syndrome.Conclusion: In patients presenting with syncope, ECG is essential for risk stratification and identifying patients with possible inherited syndromes. A high index of suspicion is necessary for diagnosing