Loop Recorder Research Articles

Rationale and design of the NEO-NORMAL-AF study examination of the usefulness of implantable loop recorder for arrhythmia detection including atrial fibrillation in heart failure with non-reduced ejection fraction cases: a pilot study

IntroductionThe incidence of arrhythmia in heart failure with non-reduced ejection fraction (HFnon-rEF) in patients who have a history of hospitalisation is unclear. The aim of this study is to investigate...

Remote Monitoring of Patients with Implantable Devices-Telemonitoring and Chronic Diseases.

The high health care costs and poor quality associated with heart failure have led to the development of remote patient monitoring (RPM or RM) systems and cost-effective disease management strategies. RM of cardiac implantable electronic devices (CIEDs) is the application of communication technology to patients carrying a pacemaker (PM), an implantable cardioverter defibrillator (ICD) for cardiac resynchronization therapy (CRT) or an implantable loop recorder (ILR). The aim of this study is to define and analyze the benefits of modern telecardiology to provide patients with remote clinical assistance especially for patients with implantable devices for early detection of the development of heart failure as well as the limitations inherent therein. Furthermore, the study examines the benefits of telemonitoring in chronic and cardiovascular diseases proposing holistic care. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-PRISMA methodology. The results highlight that telemonitoring has augmented beneficial effects on clinical outcomes of heart failure, including, a reduction in mortality, heart failure hospitalization, all cause hospitalization and also an improvement in Quality of Life.

389-P: Glycemia and Cardiac Arrhythmias in People with Type 1 Diabetes

The impact of hypoglycemia, hyperglycemia and glycemic variability on cardiac arrhythmia susceptibility in people with type 1 diabetes is uncertain. We performed a 12-month prospective observational study employing continuous glucose monitoring and implantable loop recorders to investigate potential associations between glycemia and cardiac arrhythmias. Thirty adults with type 1 diabetes ([mean ± SD] age 63 ± 8 years, BMI 26 ± 5 kg/m2, HbA1c 7.3 ± 1.1% [56.9 ± 11.9 mmol/mol]) and without any history of cardiac arrhythmias were included. Daytime and nighttime incidence rate ratios (IRR) of arrhythmias were determined for hypoglycemia (interstitial glucose (IG) < 3.9 mmol/L), hyperglycemia (IG > 10.0 mmol/L), and glycemic variability (standard deviation and coefficient of variation). Hypoglycemia was not associated with an increased risk of cardiac arrhythmias in comparison with euglycemia (IG 3.9 - 10.0 mmol/L) and hyperglycemia. However, during daytime, a trend of increased risk of arrhythmias was observed when comparing hypoglycemia with euglycemia (IRR 1.08 [95% CI 0.99 - 1.18]). Furthermore, during daytime both the occurrence of hyperglycemia and time spent in hyperglycemia within the same hour of an arrhythmia were associated with an increased risk of arrhythmias compared to euglycemia (IRR 2.03 [95% CI 1.21 - 3.40] and IRR 1.07 [95% CI 1.02 - 1.13], respectively). Nighttime hypoglycemia and hyperglycemia were not associated with increased risk of arrhythmias. Increased glycemic variability was not associated with an increased risk of arrhythmias during daytime, whereas a reduced risk was observed during nighttime. In conclusion, daytime hypoglycemia and hyperglycemia may contribute to an increased risk of cardiac arrhythmias compared to euglycemia, in people with type 1 diabetes. No associations were found between glycemic levels and cardiac arrhythmias during nighttime, indicating diurnal differences in arrhythmogenic susceptibility. Disclosure P.G.Hagelqvist: None. T.Vilsbøll: Consultant; AstraZeneca, Boehringer Ingelheim Inc., Gilead Sciences, Inc., Eli Lilly and Company, Mundipharma, Merck & Co., Inc., Novo Nordisk A/S, Sanofi, Sun Pharmaceutical Industries Ltd., Bristol-Myers Squibb Company. A.Andersen: None. K.Maytham: None. C.R.Andreasen: None. S.Engberg: Employee; Novo Nordisk A/S. T.B.Lindhardt: None. J.Forman: None. U.Pedersen-bjergaard: Advisory Panel; Novo Nordisk A/S, Sanofi, Vertex Pharmaceuticals Incorporated. F.K.Knop: Advisory Panel; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi, Consultant; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi, Research Support; Novo Nordisk, Zealand Pharma A/S, Speaker's Bureau; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi, Lundbeck. Funding Novo Nordisk Foundation (28300)

Epicardial adipose tissue and subclinical incident atrial fibrillation in a population at risk of stroke - a cardiac magnetic resonance imaging study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Innovation Fund Denmark. Background Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is associated with a substantially increased risk of morbidity and mortality, including heart failure and stroke(1,2). Epicardial adipose tissue (EAT) is believed to provide both thermoregulation and mechanical protection to the heart and coronary arteries in healthy human beings(3,4), but the role of EAT in the development and severity of AF suggests deleterious effects of EAT. Since EAT shares blood circulation with the myocardium, it offers the opportunity for paracrine- and neuroendocrine signaling(5), which contributes to an arrhythmogenic- and pro-inflammatory state. Purpose While EAT assessed by cardiac magnetic resonance imaging (CMR) has been found predictive of clinical AF(5,6), the association with subclinical AF has not yet been established. This study aimed to investigate the association between EAT, determined by CMR, and incident AF following long-term continuous heart rhythm monitoring by implantable loop recorder (ILR) in an at-risk population. Methods This study is a sub-study of the LOOP study. In total, 203 participants without a history of AF received an ILR and underwent advanced CMR. All participants were at least 70 years of age at inclusion and had at least one of the following conditions: hypertension, diabetes, previous stroke, or heart failure. Volumetric measurements of atrial- and ventricular EAT were derived from CMR, as seen in Picture 1, and the time to incident AF was subsequently determined. Results A total of 78 patients (38%) were diagnosed with AF during a median of 40 (37–42) months of monitoring. Of these, only 7 (9%) participants reported symptoms of AF during arrhythmia episodes, i.e., 91% had subclinical AF. In multivariate Cox regression analyses adjusted for age, sex, body mass index (BMI), and comorbidities, we found EAT to be an independent marker for time to AF with hazard ratios (95% confidence intervals) up to 1.66 (1.17–2.36; p = 0.005) when analyzing the risk of new-onset AF episodes lasting ≥ 24 hours. The Cox regression analyses are presented in Picture 2, where we furthermore have adjusted for left atrial size (LAMIN) and left atrial function (LATEF). Conclusion Atrial EAT assessed by volumetric measurements on CMR images was significantly associated with the incident AF episodes as detected by ILR.

Detection of atrial fibrillation in real world setting in patients with cryptogenic stroke and an implantable loop recorder.

Implantable loop recorders (ILR) are used to screen for atrial fibrillation (AF) in patients with cryptogenic stroke (CS). However, there is limited real-world data regarding the long-term rate of AF detection using ILR and management consequences in patients with CS. The objective is to assess the rate of AF detection in patients with CS in a real-world study over 36 months of follow-up and its consequences on stroke prevention. This retrospective study included patients with an ILR placed for CS at Baylor College of Medicine and Baylor St. Luke's Medical Center between January 2014 and July 2021. The primary outcome was AF detection in patients with ILR. The secondary outcome was the rate of subsequent strokes after ILR placement in patients with or without diagnosed AF. The AF detection rate in our cohort was compared to the rate in CRYSTAL-AF Trial at 36-month follow-up. The impact of AF detection on clinical management was examined. We identified 225 patients. 51.1% were women and 38.2% African American. Among 85 patients with ILR labeled AF, 43 patients had true AF, and 42 had incorrectly labeled AF (48.3% false positive). The estimated AF detection rate at 36 months follow-up was 28.6% (95% CI, 26.6%-30.6%). 58.1% of patients with AF were initiated on oral anticoagulation, 80.0% of whom were started on a direct oral anticoagulant. 13.8% of patients had recurrent strokes after ILR implantation; 4 of whom were diagnosed with AF. Compared to CRYSTAL-AF, the AF detection rate in our cohort is similar, but this cohort includes a higher proportion of female and African American patients. Most patients with recurrent strokes after ILR implant did not have AF during 36 months of monitoring.

#3001 PREVALENCE OF IMPLANTABLE CARDIAC DEVICES IN A COHORT OF PATIENTS WITH CHRONIC KIDNEY FAILURE: A MULTICENTER CROSS-SECTIONAL STUDY

Abstract Background and Aims Chronic kidney disease (CKD) increases the risk of arrhythmic events and sudden cardiac death. For preventive purposes, the use of cardiac implantable electronic devices (CIEDs), including pacemakers (PMs), implantable cardiac defibrillators (ICDs), pacemakers for cardiac resynchronization therapy (CRTs), and loop recorders, can be used. However, in the absence of large epidemiological studies, whether the use of CIEDs in hemodialysis patients is associated with a lower mortality benefit than in pre-dialysis patients remains controversial. In this cross-sectional study, we evaluate the prevalence of CIEDs in a cohort of patients with CKD. Method The study includes patients with CIEDs with estimated GFR <45 ml/min/1.73 m2 from two hospitals in Milan, divided into two groups based on treatment with conservative therapy (IRC stage IIIb-V) or hemodialysis. Results Of the 499 patients enrolled, 268 had CKD stage IIIb-V, and 231 were in hemodialysis (Table 1). Among CRT carriers, the prevalence in the CKD IIIb-V group is significantly higher than in the hemodialysis group (4.09% vs 0.86%; p = 0.025) (Figure 1), even if among the hemodialysis patients the prevalence of patients with previous stroke and hypertension was significantly higher (Table 1). Furthermore, in multiple logistic regressions, hemodialysis was a variable independently correlated with reduced use of CRTs (OR 0.27; 95% CI = 0.01-0.96; p 0.04), while the other devices (individually and cumulatively) correlated positively only with age and previous myocardial infarction (MI) (Table 2). Conclusion The reduced prevalence of CRT in hemodialysis patients is probably related to the shorter life expectancy and the higher rate of related complications, such as the increased risk of infectious complications and/or stenosis of the central venous vessels. Further studies are needed to evaluate the impact of these devices on the cardiac mortality of hemodialysis patients and the associated complication rate.

Remote monitoring of implantable loop recorders reduces time to diagnosis in patients with unexplained syncope: a multicenter propensity score-matched study.

There are little data on remote monitoring (RM) of implantable loop recorders (ILRs) in patients with unexplained syncope and whether it confers enhanced diagnostic power. To evaluate the effect of RM in ILR recipients for unexplained syncope for early detection of clinically relevant arrhythmias by comparison with a historical cohort with no RM. SyncRM is a propensity score (PS)-matched study prospectively including 133 consecutive patients with unexplained syncope and ILR followed up by RM (RM-ON group). A historical cohort of 108 consecutive ILR patients with biannual in-hospital follow-up visits was used as control group (RM-OFF group). The primary endpoint was the time to the clinician's evaluation of clinically relevant arrhythmias (types 1, 2, and 4 of the ISSUE classification). The primary endpoint of arrhythmia evaluation was reached in 38 patients (28.6%) of the RM-ON group after a median time of 46 days (interquartile range, 13-106) and in 22 patients (20.4%) of the RM-OFF group after 92 days (25-368). The PS-matched adjusted ratio of rates of arrhythmia evaluation was 2.53 (95% confidence interval, 1.32-4.86) in the RM-ON vs. RM-OFF group (p = 0.005). In our PS-matched comparison with a historical cohort, RM of ILR patients with unexplained syncope was associated with a 2.5-fold higher chance of evaluations of clinically relevant arrhythmias as compared with biannual in-office follow-up visits.

Value of morphological and laboratory markers in predicting the effectiveness of cryoballoon pulmonary vein isolation in atrial fibrillation

Aim. To determine the clinical, morphological, and biochemical pre­dictors of substrate-specific, non-vein-dependent atrial fibrillation (AF) by morphological and immunological examinations in patients with recurrent AF after pulmonary vein (PV) isolation.Material and methods. The study included 100 people (58 men and 42 women) with paroxysmal (n=89) and persistent (n=11) AF with a mean age of 58,2±9,4 years. After the primary operation, 15 people withdrew from the study due to refusal of reintervention, and 1 person withdrew due to suppuration of loop recorder bed and its explantation. A total of 100 patients underwent primary cryoballoon PV isolation with myocardial biopsy from the interventricular and interatrial septa, while 60 patients had subsequent hematoxylin-eosin and Van Gieson stains. Also, 100 patients were simultaneously implanted with ECG loop recorders for AF monitoring and blood was taken (before the intervention) for subsequent analysis of inflammation markers and antimyocardial antibodies. Patients underwent clinical observation during the year (visits after 3, 6, 12 months). Patients with relapses were referred for repeat electrophysiological examination and segmental ablation if PV ruptures were detected. After repeated intervention, the follow-up period was extended for a year with the same schedule of visits. According Two groups of patients were formed: without relapses (vein-dependent AF, group I) and with relapses (non-vein-dependent AF, group II), despite the achieved PV isolation as a result of 1 or 2 operations.Results. An analysis of morphological changes showed that an increase in AF recurrence risk by an average of 6,14 times (95% confidence interval: 1,14-47,6 (p=0,0462)) is associated with stage 2 interventricular septal fibrosis. Lymphocyte infiltration of the interventricular septum was associated with higher AF recurrence by an average of 9 times (95% confidence interval: 0,89-95,37) (p=0,0519).Among the laboratory parameters, a significantly higher concentration of the N-terminal pro-brain natriuretic peptide and a significantly lower concentration of antimyocardial antibodies were found in the group of patients with recurrent AF after LV isolation (p=0,0101).Conclusion. Inflammatory myocardium changes are an important link in the pathogenesis of AF and are associated with its recurrence.

Continuous long-term heart rate variability and risk assessment in pulmonary hypertension

ObjectiveCurrent multimodal risk assessment for pulmonary hypertension (PH) has been redefined with a simplified assessment for follow-up in the new European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines. Follow-up risk...

Left Atrial Function Predicts Atrial Arrhythmia Recurrence Following Ablation of Long-Standing Persistent Atrial Fibrillation.

Left atrial (LA) function following catheter or surgical ablation of de-novo long-standing persistent atrial fibrillation (AF) and its impact on AF recurrence was studied in patients participating in the CASA-AF trial (Catheter Ablation vs. Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation). All patients underwent echocardiography preablation, 3 and 12 months post-ablation. LA structure and function were assessed by 2-dimensional volume and speckle tracking strain measurements of LA reservoir, conduit, and contractile strain. Left ventricular diastolic function was measured using transmitral Doppler filling velocities and myocardial tissue Doppler velocities to derive the e', E/e', and E/A ratios. Continuous rhythm monitoring was achieved using an implantable loop recorder. Eighty-three patients had echocardiographic data suitable for analysis. Their mean age was 63.6±9.7 years, 73.5% were male, had AF for 22.8±11.6 months, and had a mean LA maximum volume of 48.8±13.8 mL/m2. Thirty patients maintained sinus rhythm, and 53 developed AF recurrence. Ablation led to similar reductions in LA volumes at follow-up in both rhythm groups. However, higher LA emptying fraction (36.3±10.6% versus 27.9±9.9%; P<0.001), reservoir strain (22.6±8.5% versus 16.7±5.7%; P=0.001), and contractile strain (9.2±3.4% versus 5.6±2.5%; P<0.001) were noted in the sinus rhythm compared with AF recurrence group following ablation at 3 months. Diastolic function was better in the sinus rhythm compared with the AF recurrence group with an E/A ratio of 1.5±0.5 versus 2.2±1.2 (P<0.001) and left ventricular E/e' ratio of 8.0±2.1 versus 10.3±4.1 (P<0.001), respectively. LA contractile strain at 3 months was the only independent predictor of AF recurrence. Following ablation for long-standing persistent AF, improvement in LA function was greater in those who maintained sinus rhythm. LA contractile strain at 3 months was the most important determinant of AF recurrence following ablation. URL: https://www. gov; Unique identifier: NCT02755688.

20-Year Audit of Community Issued Automated External Defibrillators, Auckland City Hospital 2002–2022

Early community defibrillation has been shown to improve survival in patients with cardiac arrest. Providing home automated external defibrillators (AEDs) to patients who do not meet guidelines for an implantable cardioverter defibrillator (ICD) implant, have significant contraindications for an ICD implant, or do not wish to have an ICD implanted is a service delivered by some hospitals. This was a retrospective audit of patients issued an AED by Auckland City Hospital 2002–2022. A telephonic survey of active patients was undertaken. Over the 20-year period, 34 patients were issued AEDs. Mean age was 18.5 years with 58.5% aged ≤15 years at date of issue; 58.8% were NZ European and 14.7% Māori. The predominant cardiac diagnosis was Long QT syndrome (41.2%) followed by hypertrophic cardiomyopathy/hypertrophic obstructive cardiomyopathy (23.5%). Twenty-one patients still have AEDs. Of four patients who had multiple prior cardiac implantable electronic device (CIED) implants and lead extractions, one proceeded to a heart transplant, and one died. Six patients proceeded to CIED implants: three ICDs and three implantable loop recorders (ILRs). No surveyed patients required AED therapy. All surveyed patients/caregivers reported that home AED gives them peace of mind. Issuing of home AEDs is not standard clinical practice, but for specific patients who do not meet guidelines, are unwilling to have or have contraindications to an ICD, it provides peace of mind. No surveyed patients required AED therapy.

Prevalence and Incidence of Atrial Fibrillation in Heart Failure with Mildly Reduced or Preserved Ejection Fraction: (Additive) Value of Implantable Loop Recorders.

Atrial fibrillation (AF) is common in heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) and has a negative impact on outcome. Reliable data on prevalence, incidence, and detection of AF from contemporary, prospective HFmrEF/HFpEF studies are scarce. This was a prespecified sub-analysis from a prospective, multicenter study. Patients with HFmrEF/HFpEF underwent 12-lead electrocardiography (ECG), 24 h Holter monitoring, and received an implantable loop recorder (ILR) at the study start. During the 2 year follow-up, rhythm monitoring was performed via ILR, yearly ECG, and two yearly 24 h Holter monitors. A total of 113 patients were included (mean age 73 ± 8 years, 75% HFpEF). At baseline, 70 patients (62%) had a diagnosis of AF: 21 paroxysmal, 18 persistent, and 31 permanent AF. At study start, 45 patients were in AF. Of the 43 patients without a history of AF, 19 developed incident AF during a median follow-up of 23 [15-25] months (44%; incidence rate 27.1 (95% confidence interval 16.3-42.4) per 100 person-years). Thus, after the 2-year follow-up, 89 patients (79%) had a diagnosis of AF. In 11/19 incident AF cases (i.e., 58%), AF was solely detected on the ILR. Yearly 12-lead ECG detected six incident AF cases and four of these cases were also detected on two yearly 24 h Holter monitors. Two incident AF cases were detected on an unplanned ECG/Holter. Atrial fibrillation is extremely common in heart failure with HFmrEF/HFpEF and may inform on symptom evaluation and treatment options. AF screening with an ILR had a much higher diagnostic yield than conventional modalities.

Subclinical postoperative atrial fibrillation: a randomized trial.

Postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery, requiring interventions and prolonging hospital stay. POAF is associated with increased mortality and a higher rate of systemic thrombo-embolism. The rates of recurrent AF, optimal follow-up and management remain unclear. We aimed to evaluate the incidence of recurrent atrial fibrillation (AF) events, during long term follow-up in patients with POAF following cardiac surgery. Patients with POAF and a CHA2DS2-VASc score of ≥2 were randomized in a 2:1 ratio to either implantation of a loop recorder (ILR) or ECG monitoring using periodic Holters. Participants were followed prospectively for 2 years. The primary end point was the occurrence of AF longer than 5 min. The final cohort comprised of 22 patients, of whom 14 received an ILR. Over a median follow up of 25.7 (IQR of 24.7-44.4) months, 8 patients developed AF, representing a cumulative annualized risk of AF recurrence of 35.7%. There was no difference between ILR (6 participants, 40%) and ECG/Holter (2 participants, 25% p = 0.917). All 8 patients with AF recurrence were treated with oral anticoagulation. There were no cases of mortality, stroke or major bleeding. Two patients underwent ILR explantation due to pain at the implantation site. The rate of recurrent AF in patients with POAF after cardiac surgery and a CHA2DS2-VASc score of ≥2 is approximately 1 in 3 when followed systematically. Further research is need to assess the role of ILRs in this population.

Invasive electrophysiology study guided loop recorder implantation in myotonic dystrophy type 1: a prospective single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In one third of the patients with myotonic dystrophy type 1 (DMT1) the cause of death is of cardiac origin. The most common cardiac manifestations are arrhythmias and conduction disturbances. Purpose Due to its extreme long monitoring properties, implantable loop recorders (ILRs) are highly suitable to detect rare cardiac arrhythmias. To date, there are only limited data using ILRs in DMT1. We aimed to evaluate the role of the invasive electrophysiology study (EPS)-guided loop recorder implantation in patients with DMT. Methods In our prospective study 18 genetically confirmed DMT1 patients underwent non-invasive cardiac examination including transthoracic echocardiography, 24-hour Holter monitoring and surface ECG. In addition, EPS was performed in all cases to evaluate the risk of sudden cardiac death and infra-Hisian conduction properties. Based on the performed non-invasive diagnostic evaluation and EPS findings, patients were divided into low, intermediate and high-risk groups. For patients with normal investigation results and normal HV interval (&amp;lt;55 ms) only annual cardiac follow-up visits were planned (low-risk group). Patients with increased PR interval (&amp;gt;240 ms), QRS duration (&amp;gt;120 ms), or slightly prolonged HV interval (55-70 ms) underwent implantable loop recorder (ILR) implantation (intermediate-risk group). Permanent pacemaker (PM) or implantable cardiac defibrillator (ICD) was implanted in patients with 2nd/3rd degree atrioventricular block (AVB), significantly prolonged HV interval (&amp;gt;100 ms) or if sustained ventricular tachyarrhythmia could be induced during EPS. All patients were followed for at least 3 years. Results According to our study criteria, 8 patients could be categorized as "intermediate risk", 7 of them received implantable loop recorder (ILR). 1 ILR had to be removed 3 weeks after implantation due to skin infarction. During three-years of follow-up, 2 patients had many asymptomatic atrial high-rate episodes, but no 2nd or 3rd degree AVB, significant asystole or malignant ventricular arrhythmia were detected. Conclusions Our single-center prospective study examined the EPS-guided ILR implantation for the risk stratification of DMT1 patients for the first time. A more extensive, multicenter study is warranted to define optimal management of DMT1 patients with slightly impaired infrahisian conduction.

Impact of increased physical activity in patients after pulmonary vein isolation - BE-ACTION trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical School Brandenburg and Local Government Concil Brandenburg Background Pulmonary vein isolation (PVI) is one of the key therapies for patients with atrial fibrillation (AF), however, there are numerous recurrences after ablation. Improving cardiorespiratory fitness (CF) may result in fewer recurrences of AF. The aim of the present study (Brandenburg Enhance ACTIvity ONset after pulmonary vein isolation - BE-ACTION) was to evaluate the impact of increased physical activity in patients after PVI on the recurrence of AF. Methods From January 2018 to April 2021, 200 patients with scheduled PVI were randomized at 4 different centres and fitted with an activity tracker for 24-hour activity monitoring via mobile phone. Patients aged between 50 and 77 years with a BMI between 23 and 35 kg/m2 were included. Patients with orthopaedic limitations were excluded. Patients in the ACTION group (n=99) were contacted regularly by telephone by a physical therapist and intensively motivated if the steps fell below 6,000 steps per day. Patients in the No-ACTION group (n=101) received standard of care. A loop recorder was implanted in 74 patients; those who refused loop recorder implantation underwent 7-day Holter monitoring at 6 and 12 months after PVI. Recurrence was defined as any atrial arrhythmia &amp;gt;30 sec, cardioversion or need of redo ablation after blanking period (3 month) up to 12 month. Results The number of steps per day increased in all pts from 7,918 (5,725-10,989) at week 2 after PVI to 9,511 (7,230-12,800) at 6 months and to 9,788 (6,962-12,152) at 12 months (p&amp;lt;0.001; Friedman), figure 1. In the ACTION group, the number of steps per day continued to increase between 6 and 12 months, whereas it decreased in the No-ACTION group. In total, recurrence of arrhythmia was found in 58 patients (29.9%: 31 patients with loop recorder, 14 with Holter monitoring and 13 with ECG). Recurrence occurred in 24 patients (25%) in the ACTION group and 34 patients (35%) in the No-ACTION group (p=0.140), table 1. Conclusion The level of daily physical activity was unexpectedly high in this study. The use of an activity tracker led to an increased daily physical activity in patients with AF after PVI. A further increase of activity did not reduce the recurrence of atrial arrhythmia in the ACTION group.

The tip of the eventberg: incidental rhythm disturbances by remote monitoring following pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Implantable loop recorders (ILR) are increasingly used for continuous rhythm monitoring following pulmonary vein isolation (PVI) for atrial fibrillation (AF). However, the impact of non-AF episodes in this patient population is unknown. Purpose Firstly, the aim of our study was to asses the incidence of clinically important non-AF events. Secondly, we wanted to identify possible risk factors leading to incidental non-AF events. Methods In this retrospective single center study, all patients implanted with ILR following PVI in our center between 2016 and 2022 were analysed. The indication to ILR implantation and remote monitoring after successful PVI was based on patient preference. Transmissions were carefully reviewed by two independent electrophysiologists. Bradycardic events were defined as documented symptomatic bradycardia, AV-Block II˚, AV-Block III˚ or Sick-Sinus Syndrom. Tachycardic events were defined as documented symptomatic supraventricular tachycardia (non-AF) or ventricular tachycardia &amp;gt;160/min with at least 30 seconds duration. Results A total of 219 patients underwent PVI and consequent ILR implantation. We evaluated a mean 2.1±1.1 years of follow up (FU) with a median 68 events/patient (25th–75th IQR: 13-590 events/patient). Overall, 49 patients (22.4%) developed at least one bradycardic event, 6 patients (2.7%) were later implanted with a pacemaker. In univariate logistic regression analysis age, persistent AF, left atrial diameter and prior cardioversion correlated with an increased risk of bradycardic events. Upon a multivariate logistic regression age and prior cardioversion predicted bradycardic events. At least one tachycardic non-AF event was observed in a total of 9 patients (3.6%). Supraventricular tachycardia was observed by 4 patients (1.8%), one (0.4%) were ablated by an atrioventricular nodal reentry tachycardia (AVNRT), others (1.4%) were ectopic atrial tachycardia treated conservatively. Sustained wide complex tachycardia was recorded in 5 patients (2.2%), thereof two (0.9%) received a secondary prophylactic implantable cardioverter defibrillator (ICD). The multivariate analysis did not show any statistically significant value predicting tachycardic events. Conclusion Use of ILR for rhythm monitoring following PVI could increase the early detection of incidental rhythm events, especially bradycardic episodes. However, to asses this possibly beneficial effect further prospective, multicenter studies are needed.

Trends in the use of implantable loop recordertrends and diagnostic rate of the implantable loop recorder in nationwide database

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Korea University Introduction Implantable loop recorder (ILR) is useful to reveal hidden arrhythmia. The real-world using trend of ILR implantation and indication were studied using nationwide database. Purpose To assess the indication of ILR and diagnostic rate of meaningful arrhythmia Method We analyzed the 1,460 patients who underwent ILR implantation (male 62%, mean age 62±16) from 2008 to 2019 using Korea Health Insurance review and assessment service database. Result The embolic stroke of undetermined source (ESUS) group, syncope group and palpitation group were 619 (42.3%), 765 (52.3%), 76 (5.2%) as implantation indication, respectively. From 2016 to 2019, the ESUS group increased by 14 times and the syncope group by 4 times. Among patients with ESUS, 191 patients (31%) were diagnosed with atrial fibrillation within 1 year. Bradycardia needed pacing therapy was revealed in 28%, tachycardia in 6% and atrial fibrillation in 24% in syncope group. The predictors of atrial fibrillation in ESUS group were age (OR: 1.024 per year, CI: 1.006-1.042, p=0.0072) and heart failure (OR: 2.215, CI:1.357-3.615, p=0.0015). The mean time from ILR to pacing therapy was 3±2 months in syncope group and that to anticoagulation in ESUS group was 6±3 months. Discussion The use of ILR for evaluation of ESUS is increasing, with atrial fibrillation diagnostic rate of 30%. The time to treatment differed by group.

Reorganizing the device clinic: remote monitoring-only of cardiac implantable electronic devices during the Covid-19 pandemic

Abstract Funding Acknowledgements Type of funding sources: None. Introduction COVID-19 pandemic has caused a necessary reorganization of the elective outpatient device clinic. Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has already been validated as a safe and effective tool to follow patients, limiting the need for in-person visits. Aim of our study was providing a snapshot of the current clinical practice in a tertiary electrophysiology center in Italy and suggesting a potential model of care for patients with CIEDs. Methods and Results Before the COVID-19 pandemic, patients with implantable cardioverter defibrillators/cardiac resynchronization therapy (ICD/CRTs) were evaluated in the device clinic twice a year and patients with pacemakers (PMs) once a year; loop recorder (ILR) patients were followed remotely only. In the COVID-19 period (March 2020-February 2021) RM was implemented for all compatible CIEDs. Patients with RM were not seen in clinic anymore and were followed with RM. In the COVID-19 period, 100% of newly implanted devices received RM (82 ILR, 194 PMs, 80 ICDs/CRTs), compared to 68% in the same months of 2019 (106/106 ILR, 83/203 PMs, 78/82 ICD/CRTs), p&amp;lt;0.01. In addition, 502 previously implanted patients with RM compatible devices were contacted and received RM in the COVID-19 period. By the end of February 2021, a total of 1676 patients were remotely monitored at our Institution, with a potential saving of outpatient visits of 1683 visits/year, against an average of 8514 RM transmissions/year needing evaluation. During the study period, we observed 213 clinical events that triggered an urgent manual transmission and/or required physician’s intervention (table 1), successfully resolved over the following 24 h. None of the 1676 patients presented to the emergency room with a problem that went unnoticed by the RM system. Conclusion RM of CIEDs is an essential tool to reduce in-person visits during the COVID-19 pandemic and seems to be safe in terms of events detection. The potential for elective outpatient appointments reduction has to be counterbalanced by the sustainability of a large number of transmissions and data to analyze.

ECG-patch assessment of atrial fibrillation during the very-early blanking predicts late blanking period recurrence: preliminary data from a prospective registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Ablation of atrial fibrillation (AF) is a procedure that causes significant atrial tissue lesions, with transient, albeit significant tissue oedema and inflammation. These mechanisms may trigger early rhythm abnormalities that do not necessarily correlate with future arrhythmias, and, therefore, evaluation of AF recurrence is currently validated by routine ECG and ambulatory 24h Holter monitoring, only after a 3-month blanking period. However, recent data have shown that AF episodes occurring during the blanking period are common and may predict late AF recurrences. The E-Patch (Bio Tel Heart) is an innovative, thin single-use adhesive electrode with extended continuous ECG monitoring for up to 120h. Aim To assess if continuous extended monitoring in the very-early blanking period can be associated with event recorder data performed in the late blanking period after AF ablation. Methods Single-centre, prospective, longitudinal study, including consecutive patients (P) 24h after AF ablation, monitored with the E-patch. The effectiveness of the device in continuously recording within 5 days after ablation was analyzed, as well as the occurrence of AF episodes during an external 7- day loop-recorder, obtained in the 2nd-month post-ablation. Results A total of 30P were included (57% male, 63±8 years). AF ablation was performed with radiofrequency (RF) energy in 14P and with a balloon of cryoenergy in 16P. All P were in sinus rhythm at the beginning of the recording. The mean number of hours of recording was 113±16, with no discomfort complaints in the use of the device or interpretation artefacts. During the E-patch monitoring, a total of 10P (33%) presented AF (AF burden 6.8% of the recording, IQR 3.0-20%). All 30P underwent an external loop recorder for 7 days 2 months post-ablation, with 40% showing AF periods (&amp;gt; 30 seconds duration). All 10P that had AF detection in the very-early E-patch recording had also recurrence in the 2 nd month of extended 7-day continuous recording. Very- early AF detection had a sensitivity of 83.3% and a specificity of 100% to detect late blanking period AF (ROC 0.916±0.06; 95%CI 080-1.0). Conclusions The use of the E-patch very-early after AF ablation is effective for AF detection and is highly predictive of AF recurrence in the late blanking period. These findings require validation in larger studies to assess the potential of very-early assessment in the determination of a higher risk for AF recurrence.

New onset, recurrence and progression of atrial fibrillation after cardiac surgery during 2.5 years of continuous rhythm monitoring

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Netherlands Heart Foundation (CVON2014-09, RACE V: Reappraisal of Atrial fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF). Background Atrial fibrillation (AF) in the early postoperative phase (POAF) is a frequent complication after cardiac surgery with an incidence of up to 50%. Recent studies have shown that early-POAF is a one of the strongest predictors of late recurrences. However, it is unknown how POAF-burden (percentage of time in AF) progresses in the months and years following surgery. Recent studies suggested that AF-burden is associated with increased risk of stroke and therefore identifying factors associated with a higher POAF-burden is desirable. Purpose To investigate AF-burden progression patterns and factors associated with increased AF-burden after cardiac surgery during 2.5 years of continuous rhythm monitoring. Methods Patients with and without history of AF undergoing cardiac surgery were included. Preoperatively, all patients underwent transthoracic echocardiography, electrocardiography, and blood biomarker analysis. Intraoperatively, all patients received an implantable loop recorder. Continuous rhythm monitoring was performed over a period of 2.5 years. AF-burden progression was calculated as percentage of time in AF for different time intervals (0-3, 3-12, and 12-30 months) and presented in alluvial-plots. Classification of burden was performed based on the cut-off values for tertiles. In addition, AF-characteristics such as episode duration and ventricular rate were analyzed as potential surrogate markers of AF-burden. Results The study population consisted of 134 patients undergoing cardiac surgery. Median follow-up (FU) was 2.7 years (IQR: 2.2-2.9 years) and 98 patients completed 2.5 years of FU. Eighty-one (60.4%) patients developed AF during the follow-up period. Early-POAF (first 3 months) occurred in 75 patients (56.0%) and late-POAF (after first 3 postoperative moths) in 47 patients (35.1%). Highest AF-burden was observed in the first 3 postoperative months with a significant reduction between 3-12 moths (p=0.007) (Figure 1). In the period between 12-30 months an increase in AF burden was observed for all groups (p&amp;lt;0.001), however the burden remained lower as compared to the first 3 postoperative months (Figure 1). Overall, 50% of patients showed a reduction of AF burden and only 11% an overall increase. Individual postoperative AF-burden was strongly associated with the longest AF-episode (Spearman’s rho=0.86, 95%CI: 0.75-0.92, p&amp;lt;0.001) (Figure 2A), and to a lower extent with the duration of the median episode (Spearman’s rho=0.38, 95%CI: 0.13-0.58, p=0.001) (Figure 2B). Conclusion POAF is a frequent complication in the early and late postoperative phase with the highest AF-burden present in the first 3 postoperative months. Also, AF-burden seems to be highly correlated to the longest individual episode duration.