Median Cycle Length Research Articles

The value of ripple mapping in the age of coherent mapping in scar-related atrial tachycardia.

An accurate display of scar-related atrial tachycardia (ATs) is a key determinant of ablation success. The efficacy of ripple mapping (RM) in identifying the mechanism and critical isthmus of scar-related ATs during coherent mapping is unknown. A total of 97 patients with complex ATs who underwent radiofrequency catheter ablation at our center between October 2018 and September 2022 were included. ATs was mapped using a multielectrode mapping catheter on the CARTO3v7 CONFIDENCE module. Coherent and RM were used to identify the reentrant circuit. The mechanisms of 128 ATs were analyzed retrospectively (84 anatomic-reentrant ATs and 44 non-anatomic reentrant ATs). The median AT cycle length was 264±25ms. The correct diagnosis was achieved in 83 ATs (68%) using only coherent mapping. Through coherent mapping plus RM, 114 ATs (84.2%) were correctly diagnosed (68% vs. 89%, p=.019). In non-anatomical reentrant ATs, 81% of the diagnostic rate was achieved by reviewing both coherent and ripple mapping compared to reviewing coherent mapping alone (81% vs. 52%, p=.03). Reviewing coherent mapping and ripple mapping showed a higher diagnostic rate in patients who underwent cardiac surgery than those with Coherent mapping alone (64% vs. 88%, p=.04). Coherent mapping combined with RM was superior to coherent mapping alone in identifying the mechanism of scar-related ATs post-cardiac surgery and non-anatomic reentrant ATs.

Disparities and outcomes of immune checkpoint inhibitor therapies in LMICs: Retrospective study on current state, efficacy, and challenges in Armenia.

e23315 Background: The escalating incidence of cancer in Armenia is a global trend, underscoring the urgency for innovative treatments, including immune checkpoint inhibitors (ICIs). This study, a first in the region, investigates ICIs' real-world impact, emphasizing the current state and critical gaps in access to care. Methods: We conducted a retrospective review of 224 patients, excluding 32, resulting in 192 patients treated with ICIs between 2017 and 2023 across four major oncology centres. The review covered demographic and clinical data, genetic testing, treatment regimens, and survival outcomes, analyzed using the STATA 18 BE. Results: The mean age of the patients was 61.4 years, with 69.27% being male. Lung cancer was the most common diagnosis (42.19%, n = 81), followed by melanoma (11.98%, n = 23) and gastric cancer (10.94%, n = 21). Survival outcomes varied, with melanoma patients exhibiting a mean overall survival (OS) of 33.26 months, lung cancer patients 19.69 months, and gastric cancer patients 20.50 months; the survival difference between patients with metastases and without was not statistically significant. Patients receiving ICIs in the second or later lines of treatment had a 2.12-fold lower chance of survival compared to those receiving them as first-line treatment (95% CI 1.16-3.88, p = 0.014). 78% of patients received ICIs in the metastatic setting and only 22% in curative. In two centres, among 185 patients with metastatic lung cancer, only 23.2% (43 patients) received ICIs, and of these, about 50% underwent mutation testing, with only 4 assessed via broad panel NGS. A significant 76.8% (142 patients) did not receive immunotherapy. Furthermore, 34% of those starting ICI treatment were forced to discontinue due to financial hardships. Pembrolizumab and Nivolumab were the most widely used agents, but the choice varies significantly between centres. Conclusions: The financial barrier is substantial: the cost of one pembro cycle on the black market, at $3,000, is 3.8 times the annual income of those at the national poverty line, more than twice the income of the lower middle-income class, and represents over 60% of the country's GDP per capita. Median cycle lengths for ICIs, such as 6.5 for Ipil+Nivo and 5.61 for Pembro, are below the NCCN's standard recommendations, highlighting the profound impact of financial constraints on treatment adherence and duration. This study reveals the stark reality of ICI accessibility and affordability in Armenia, where a significant portion of cancer patients are unable to benefit from these potentially life-extending treatments. Additionally, a preference bias towards selecting treatments without nationwide guidelines was observed, alongside the absence of a national E-health database, underscoring the need for policymaker attention, insurance adjustments, and more precise, prospective data collection.

Incidence and Impact on Quality of Life of Heavy Menstrual Bleeding in Women on Oral Anticoagulant Therapy.

Heavy menstrual bleeding affects up to two thirds of women on oral anticoagulation. The rates of heavy menstrual bleeding, its impact on quality of life and associated risk factors in women attending anticoagulation clinics in South Africa are largely unknown. A prospective cohort study was performed over an eight-month period in women on Warfarin (n = 30) and Rivaroxaban (n = 27) for a median [interquartile range] duration of 15.5 [78.0] months attending an anticoagulation clinic in Johannesburg, South Africa. Heavy menstrual bleeding was assessed over one menstrual cycle using the validated pictorial blood loss assessment charts (PBAC) and the menstrual bleeding questionnaire (MBQ). In this population of predominantly African ethnicity, with a median age of 39 [8] years, 39 (68.4%) women experienced heavy menstrual bleeding, defined as a PBAC score of >100. Median cycle length on anticoagulation and MBQ scores were significantly higher among women with a PBAC score of >100 (p > 0.05). Univariate analysis identified Rivaroxaban as a risk factor for heavy menstrual bleeding (OR 5.03, 95% CI 1.40-18.12). Heavy menstrual bleeding required treatment in 29 (74.4%) women which included management of iron deficiency, anti-fibrinolytics, modification of anticoagulation and hormonal contraception. Heavy menstrual bleeding was associated with a considerable negative impact on quality of life. This was most significant for women on Rivaroxaban as compared to Warfarin. It is essential to monitor and appropriately treat heavy menstrual bleeding in at risk women on anticoagulant treatment.

Dose reduction in sequence scanning 4D CT imaging through respiratory signal-guided tube current modulation: A feasibility study.

Respiratory signal-guided 4D CT sequence scanning such as the recently introduced Intelligent 4D CT (i4DCT) approach reduces image artifacts compared to conventional 4D CT, especially for irregular breathing. i4DCT selects beam-on periods during scanning such that data sufficiency conditions are fulfilled for each couch position. However, covering entire breathing cycles during beam-on periods leads to redundant projection data and unnecessary dose to the patient during long exhalation phases. We propose and evaluate the feasibility of respiratory signal-guided dose modulation (i.e., temporary reduction of the CT tube current) to reduce the i4DCT imaging dose while maintaining high projection data coverage for image reconstruction. The study is designed as an in-silico feasibility study. Dose down- and up-regulation criteria were defined based on the patients' breathing signals and their representative breathing cycle learned before and during scanning. The evaluation (including an analysis of the impact of the dose modulation criteria parameters) was based on 510 clinical 4D CT breathing curves. Dose reduction was determined as the fraction of the downregulated dose delivery time to the overall beam-on time. Furthermore, under the assumption of a 10-phase 4D CT and amplitude-based reconstruction, beam-on periods were considered negatively affected by dose modulation if the downregulation period covered an entire phase-specific amplitude range for a specific breathing phase (i.e., no appropriate reconstruction of the phase image possible for this specific beam-on period). Corresponding phase-specific amplitude bins are subsequently denoted as compromised bins. Dose modulation resulted in a median dose reduction of 10.4% (lower quartile: 7.4%, upper quartile: 13.8%, maximum: 28.6%; all values corresponding to a default parameterization of the dose modulation criteria). Compromised bins were observed in 1.0% of the beam-on periods (72 / 7370 periods) and affected 10.6% of the curves (54/510 curves). The extent of possible dose modulation depends strongly on the individual breathing patterns and is weakly correlated with the median breathing cycle length (Spearman correlation coefficient 0.22, p<0.001). Moreover, the fraction of beam-on periods with compromised bins is weakly anti-correlated with the patient's median breathing cycle length (Spearman correlation coefficient -0.24; p<0.001). Among the curves with the 17% longest average breathing cycles, no negatively affected beam-on periods were observed. Respiratory signal-guided dose modulation for i4DCT imaging is feasible and promises to significantly reduce the imaging dose with little impact on projection data coverage. However, the impact on image quality remains to be investigated in a follow-up study.

Catheter ablation of atrioventricular nodal reentrant tachycardia, when AVNRT presented as a fetus or infant.

Atrioventricular nodal reentrant tachycardia (AVNRT) does not commonly present during infancy. Although relative safety of catheter ablation of AVNRT has been demonstrated in pediatrics, this procedure is rarely indicated in children <15kg. Retrospective review of seven cases of AVNRT that presented in children younger than 1 year of age and required catheter ablation for definitive management. Electrophysiology (EP) study was planned with two or three catheters. Area of ablation determined by voltage mapping, propagation sinus wave collision and slow pathway potential location. Ablation performed with cryothermal energy. No fluoroscopy was used. Presentation ranged from 36weeks of gestation to 11 months of age. Two presented in fetal life and two in the neonatal period. The median age of ablation was 20months (range 17-31 months). The median weight at ablation was 11.4kg (range 8.9-14.9kg). Median follow-up time was 16 months. All had typical AVNRT. The median tachycardia cycle length was 216ms. 100% successful rate using cryoablation. No complications. No recurrence of tachycardia during the follow-up period. Slow AV nodal pathway cryoablation may be safely performed, with good short and medium-term outcomes in patients under 15kg.

Catheter ablation as first line treatment in patients with ischemic cardiomyopathy, tolerated ventricular tachycardia and left ventricular ejection fraction over 35%: long term outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with ischemic cardiomyopathy (ICM) and monomorphic, sustained ventricular tachycardia (VT) are considered to be at risk for arrhythmia-related sudden cardiac death (SCD). Prior studies have suggested that patients with well-tolerated VTs and preserved or moderately reduced left ventricular ejection fraction (LVEF) and successful VT ablation may not benefit from cardioverter defibrillator implantation (ICD Current guidelines indicate that in selected patients catheter ablation should be considered instead of ICD, but supporting evidence is limited. Aim This study aims to analyze arrhythmia outcomes of ICM patients referred for VT ablation without prior ICD implantation according to LVEF, hemodynamical stability during VT and ablation outcome. Methods ICM patients without prior ICD implantation undergoing VT ablation in a tertiary center between 2009 and 2022 were included. Patients who presented with a first episode of tolerated VT and w a LVEF≥35% were offered catheter ablation (CA) as first-line therapy. Patients were categorized according to (1) LVEF, (2) clinical presentation (hemodynamically tolerated/non-tolerated VT) and (3) acute ablation outcome. According to the institutional protocol, ICD was offered to all patients after ablation, but was subject to shared decision making, explaining the available evidence supporting ICDs for the different categories. Results Eighty-six ICM patients without ICD underwent ablation for VT. Mean age was 69±9 years and 72 (84%) were men, mean LVEF was 41±9% and 34 patients (28%) were using anti-arrhythmic drugs (AAD). The median VT cycle length (VTCL) at presentation was 323ms [300 – 375] and VT was tolerated in 58 (67%) patients (median tolerated VTCL 325ms [300 – 371]). In 66 (77%) patients, the LVEF was ≥35% of which 51 had well-tolerated VT. Of these 51 patients, 37 (73%) were rendered non-inducible after ablation and in 14 patients non-clinical VTs remained inducible (median remaining VTCL 238ms [203-288]). In 5/37 non-inducible and in 11/14 inducible patients, an ICD was implanted. Of the 35 patients who had LVEF&amp;lt;35% and/or non-tolerated VTs, 7 refused ICD implantation. (Figure 1) During a median follow-up of 35 [22 – 53] months, 10 patients (12%) had VT-recurrence and one patient with an ICD had SCD. Mortality was 22%. In the 37 patients with LVEF≥35%, tolerated VT and non-inducibility post procedure, no SCD or VT-recurrence was observed. Also, in this group no patient was using AAD for VT at last follow-up. In the 14 remaining patients with LVEF≥35% and tolerated VT who were still inducible after ablation, no SCD occurred but VT recurred in 29% (median VTCL 303ms [200-374]) with AAD-use for VT in 29%. Conclusion This study supports that ICM patients without prior ICD and LVEF≥35% who present with hemodynamically well-tolerated VT and are non-inducible after ablation have an excellent prognosis. Successful CA without ICD implantation seems to be safe in these selected patients.

PO-05-031 CATHETER ABLATION AS FIRST LINE TREATMENT IN PATIENTS WITH ISCHEMIC CARDIOMYOPATHY, TOLERATED VENTRICULAR TACHYCARDIA AND LEFT VENTRICULAR EJECTION FRACTION ≥35%: LONG TERM OUTCOMES

Patients with ischemic cardiomyopathy (ICM) and ventricular tachycardia (VT) are at risk for sudden cardiac death (SCD). Prior studies have suggested that patients with well-tolerated VTs and preserved/moderately reduced left ventricular ejection fraction (LVEF) and successful VT ablation may not benefit from cardioverter defibrillator implantation (ICD). Current guidelines indicate that in selected patients catheter ablation should be considered instead of ICD. This study aims to analyze arrythmia outcomes of ICM patients referred for VT ablation without prior ICD implantation according to LVEF, tolerance of VT and ablation outcome. ICM patients without prior ICD implantation undergoing VT ablation in a single center between 2009 and 2022 were included. Patients who presented with tolerated VT and who had a LVEF≥35% were offered catheter ablation (CA) as first-line therapy. Patients were categorized according to (1) LVEF, (2) hemodynamical tolerance of VT, and (3) acute ablation outcome. According to the institutional protocol, ICD was offered to all patients after ablation. Eighty-six patients (mean age 69±9 years, 84% male, mean LVEF 41±9%) underwent VT ablation. The median presenting VT cycle length (VTCL) was 323ms [300 – 375] and was tolerated in 67% (tolerated VTCL 325ms [300 – 371]). In 66 patients, the LVEF was ≥35%, of which 51 had well-tolerated VT. Of these 51 patients, 37 (73%) were rendered non-inducible and in 14 patients non-clinical VTs remained inducible (median VTCL 238ms [203-288]). In 5/37 non-inducible and in 11/14 inducible patients, an ICD was implanted. Of the 35 patients who had LVEF<35% and/or non-tolerated VTs, 7 refused ICD implantation. During a median follow-up of 35 [22 – 53] months, 10 patients (12%) had VT-recurrence and one patient with an ICD had SCD. Overall mortality was 22%. In the 37 patients with LVEF≥35%, tolerated VT and non-inducibility post procedure, no SCD or VT-recurrence was observed. Also, in this group no patient was using AAD for VT at last follow-up. In the 14 remaining patients with LVEF≥35% and tolerated VT who were inducible after ablation, no SCD occurred but VT recurred in 29% (median VTCL 303ms [200-374]). This study supports that ICM patients without prior ICD and LVEF≥35% with hemodynamically well-tolerated VT and are non-inducible after ablation have an excellent prognosis. Successful catheter ablation without ICD implantation seems to be safe in these selected patients.

PO-02-169 PATTERNS OF PULMONARY VEIN ACTIVITY RECORDED DURING PERSISTENT AF MAY HELP IDENTIFY THEIR CONTRIBUTION TO THE MECHANISM OF AF

Pulmonary vein isolation (PVI) is the cornerstone interventional treatment for AF but the success of this approach is more limited in persistent AF (PsAF). In these pts, the main challenge is to discriminate those who will respond to PVI only, from those who may require an extended ablation strategy. We sought to characterize the patterns of the electrical activity recorded within the PVs based on their postulated contribution to the mechanism of PsAF. Three subgroups of consecutive pts who underwent PVI for PsAF were considered based on the mechanism of AF: 1) definitely PV-related: procedural AF termination during PVI (“PVI-term” group) 2) likely PV-related: absence of AF recurrence > 18 months off-AAD after PVI only (“PVI-success” group) 3) definitely/likely PV-unrelated: PsAF recurrence despite isolated PV or at least one redo, respectively (“PVI-failure” group). Each PV and the left atrial appendage were evaluated before ablation. An automatic detection algorithm was developed to extract atrial activations from intra-cardiac electrograms in order to perform further analyses. Epochs of 60-sec were used. Different methods based on the atrial cycle length (CL) variability were assessed to best characterize the potential markers of PV activity such as the occurrence of bursts of rapid activity. A total of 40 pts were included (mean age: 60 ± 10 years, mean AF duration: 11 ± 10 months): PVI-term group (n=10), PVI-success group (n=17), PVI-failure group (n= 13). The dynamics of PV activation intervals was assessed using the envelope of the PV intervals time series. Among all features evaluated, the best feature that could discriminate similarly both the PVI-term and the PVI-success group from the PVI-failure group, was the standard deviation of the inferior envelope relative to the median CL of the PV (p <0.001 and p = 0.005, respectively) (Fig. A-B). Cut-off selected by ROC analysis provided a 100% sensitivity and 85% specificity to discriminate the PVI-term from the PV-failure group (AUC 0.931) and a 88% sensitivity and 77% specificity to discriminate the PVI-success from the PV-failure group (AUC 0.805). This feature performed better than the recently reported “Fastest PV run” (mean CL of the fastest 10-beat run) (AUC = 0.762 and AUC = 0.738, respectively) (Fig. C). Patterns of the electrical activity recorded within the PV differ according to the mechanism of PsAF. Their evaluation may provide the key to discriminate pts who may be cured by PVI only.

Effect of COVID-19 vaccine on menstrual experience among females in six Arab countries: A cross sectional study.

There have been varying reports on the potential occurrence and severity of changes to menstruation including the median cycle length, days of bleeding, bleeding heaviness, and menstrual pain, following receipt of COVID-19 vaccinations. We aimed to assess potential postvaccination menstrual changes in women residing in the Middle East. We implemented a cross-sectional online survey-based study. Data about the participants' demographic characteristics, menstruation experience, and vaccination status were collected and analyzed among six Arab countries. Among 4942 menstruating females included in this study, females who had received one or more doses of COVID-19 vaccination reported a higher frequency of back pain, nausea, tiredness, pelvic pain with periods, unprescribed analgesics use, and passage of loose stools. They also reported higher scores describing average and worst menstrual pain. Fully vaccinated females reported heavier flow and more days of bleeding. Our findings indicate that COVID-19 vaccine may have an effect on menstruation in terms of menstrual pain and bleeding heaviness. The evidence needs to be further investigated in longitudinal studies.

Myoinositol vs. Metformin in Women with Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial.

Polycystic ovary syndrome (PCOS) is associated with insulin resistance. Few randomized controlled trials (RCT) compared myoinositol (MI) with metformin (MET) regarding insulin resistance in PCOS. This was an open-label six-month RCT in women with PCOS (n = 45) with interventions MI 4 g/day or MET 2 g/day. Primary outcome was the homeostasis model assessment of insulin resistance (HOMA-IR). Secondary outcomes were fasting glucose, weight, cycle length, lipids, testosterone, adverse effects, quality of life, and depression scores. Median age was 26 years. Body mass was index was 34.4 kg/m2. HOMA-IR was unchanged during MI (p = 0.31) and MET (p = 0.11) (MI vs. MET, p = 0.09). Median fasting glucose changed +0.2 mmol/L during MI (p < 0.001) and −0.1 mmol/L during MET (p = 0.04) (MI vs. MET p < 0.001). Median weight changed −2.3 kg during MI (p = 0.98) and −6.1 kg during MET (p < 0.001) (MI vs. MET, p = 0.02). Median cycle length decreased nine days during MI (p = 0.03) and 13 days during MET (p = 0.03) (MI vs. MET, p = 0.93). High-density lipoprotein (HDL) changed +0.1 mmol/L during MET (p = 0.04) (MI vs. MET, p = 0.07). All other blood parameters and scores of quality of life and depression remained unchanged during MI and MET (all p > 0.06) (MI vs. MET, all p > 0.27). Adverse effects appeared in four women during MI and 16 women during MET (MI vs. MET, p = 0.001). In conclusion, there was no effect on the metabolic outcomes during MI, but positive effects on fasting blood glucose, weight, and HDL during MET. The effect on cycle length was comparable during MI and MET. Adverse effects were less frequent during MI.

The characteristics of pre-excitation syndrome concomitant with atrial tachyarrhythmia and the effect of radiofrequency ablation.

Wolff-Parkinson-White (WPW) concomitant with atrial tachyarrhythmia (ATA) has not been systemically characterized. Detailed electroanatomical mapping of the right atrium (RA) and/or left atrium (LA) was performed using three-dimensional mapping and the accessory pathway (AP) was mapped. WPW syndrome with ATA was diagnosed in 11 patients (median age 60 years). The characteristic of unidirectional anterograde conduction over the AP was displayed in nine patients, six of whom were intermittent. Sustained atrial tachycardia, that is, counterclockwise atrial flutter (AFL) with a median tachycardia cycle length (TCL) of 225 (220-275) ms, was mapped in eight patients; furthermore, "figure 8" right atrial reentry was mapped with TCL 250ms in one patient with a surgical history of ventricular septal defect repair. The remaining two patients underwent mitral annulus-dependent AT after paroxysmal atrial fibrillation (PAF) ablation and LA micro-reentry AT, respectively. In four patients, the location of the APs was left posterior. Left-lateral APs were identified in four patients. The locations of the APs in the remaining three patients were the right posterior and middle septum. All ATAs and APs were successfully ablated. After a median follow-up of 37 (15-72) months, no anterograde conduction over the AP was recorded, new onset of PAF was recorded in three patients, and all of them underwent circumferential pulmonary vein isolation. WPW with concomitant ATA frequently had continuous anterograde conduction over the AP with a rapid ventricular rate. Most WPWs displayed the characteristic of unidirectional anterograde conduction.

How Lifestyle Changes during the COVID-19 Global Pandemic Affected the Pattern and Symptoms of the Menstrual Cycle.

This research investigated the implications that the COVID-19 pandemic had on the menstrual cycle and any contributing factors to these changes. A questionnaire was completed by 559 eumenorrheic participants, capturing detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period. Over half of all participants reported to have experienced lack of motivation (61.5%), focus (54.7%) and concentration (57.8%). 52.8% of participants reported an increase in cycle length. Specifically, there was an increase in the median cycle length reported of 5 days (minimum 2 days, maximum 32 days), with a median decrease of 3 days (minimum 2 days and maximum 17 days). A lack of focus was significantly associated with a change in menstrual cycle length (p = 0.038) reported to have increased by 61% of participants. Changes to eating patterns of white meat (increase p = 0.035, decrease p = 0.003) and processed meat (increase p = 0.002 and decrease p = 0.001) were significantly associated with a change in menstrual cycle length. It is important that females and practitioners become aware of implications of environmental stressors and the possible long-term effects on fertility. Future research should continue to investigate any long-lasting changes in symptoms, as well as providing education and support for females undergoing any life stressors that may implicate their menstrual cycle and/or symptoms.

Antitachycardia pacing success in implantable cardioverter-defibrillators by patient, device, and programming characteristics

Antitachycardia pacing (ATP) is an established implantable cardioverter-defibrillator (ICD) therapy that terminates ventricular tachycardias (VTs) without painful ICD shocks. However, factors influencing ATP success are not well understood. The purpose of this study was to examine ATP success rates by patient, device, and programming characteristics. This retrospective analysis of the PainFree SmartShock Technology study included spontaneous ATP-treated monomorphic VT episodes. ATP success rates were calculated for various factors. Also, the relationship of ATP programming on shock burden and syncope were investigated. Of the 2770 enrolled patients (2200 [79%] male; mean age 65 years), 1699 (61%) received an ICD and 1071 (39%) a cardiac resynchronization therapy - defibrillator. ATP had >80% rate of success for terminating VTs overall, with similar rates observed between ICD and cardiac resynchronization therapy - defibrillator devices (82.2% vs 80.3%, respectively; P = .81) as well as between primary and secondary prevention patients with ICDs (77.2% vs 83.9% respectively; P = .25). Arrhythmias with a median cycle length of ≥320 ms had a significantly higher ATP success rate (88.0%; 95% confidence interval 84.8%-90.6%). The cumulative percentage of ATP success increased from 71% at 1 ATP sequence delivered to 87% at ≥8 sequences delivered. Programming more ATP sequences was associated with lower shock burden (P = .0005). There was no evidence that more sequences were associated with higher rates of syncope (P = .16). Delivering more ATP sequences resulted in a higher overall success of terminating VTs, while programming more ATP was associated with decreased shock burden and no evidence of increased syncope or acceleration. This suggests that more ATP sequences should be programmed when possible, but confirmation in prospective studies will be necessary.

Right atrial appendage firing in atrial fibrillation.

The role of atrial fibrillation (AF) drivers located at the left atrium, superior vena cava, crista terminalis and coronary sinus (CS) is well established. While these regions are classically targeted during catheter ablation, the role of right atrial appendage (RAA) drivers has been incompletely investigated. To determine the prevalence and electrophysiological characteristics of AF driver's arising from the RAA. We conducted a retrospective analysis of clinical and procedural data of 317 consecutive patients who underwent an AF ablation procedure after bi-atrial mapping (multipolar catheter). We selected patients who presented with a per-procedural RAA firing (RAAF). RAAF was defined as the recording of a sustained RAA EGM with a cycle length shorter than 120 ms or 120 < RAAF CL ≤ 130 ms and ratio RAA CL/CS CL ≤ 0.75. Right atrial/atrium appendage firing was found in 22 patients. The prevalence was estimated at 7% (95% CI, 4-10). These patients were mostly men (72%), median age: 66 yo ± 8 without structural heart disease (77%). RAAFs were predominantly found in paroxysmal AF patients (63%, 32%, and 5% for paroxysmal, short standing and long-standing AF, respectively, p > 0.05). RAAF median cycle length was 117 ms ± 7 while CS cycle length was 180 ms ± 10 (p < 0.01). In 317 consecutive AF ablation patients (22 patients, 7%) the presence of a high-voltage short-cycle-length right atrial appendage driver (RAAF) may conclusively be associated with AF termination. This case series exemplifies the not-so-uncommon role of the RAA in the perpetuation of AF.

New onset of AV-nodal reentrant tachycardia (AVNRT) in the elderly- an uncommon diagnosis?

Abstract Funding Acknowledgements Type of funding sources: None. Background Arrhythmias in elderly patients (pat) are common. In this subset of pat, atrial fibrillation is by far the most frequent sustained arrhythmia but not the only one. Clinical, ECG and electrophysiological (EP) features of AV-nodal reentrant tachycardia (AVNRT) have rarely been described in the elderly, and this represents the aim of the current study. Methods At 2 EP-centres in Germany, data from all pat undergoing an EP-study (EPS) and diagnosed with AVNRT between January 2018 and May 2021 were collected and analysed. Pat &amp;gt; 65 years constituted the study population. Results During the study period AVNRT was diagnosed in a total of 329 pat. 93 pat (28%) were &amp;gt; 65 years and represent the study population [median age 74 (65-89) years, 48% female]. In the majority (85%), the duration of symptoms was short (&amp;lt; 1 year), 14 pat had symptoms of paroxysmal tachycardia for longer than 10 years. Most of the pat (n=88, 94%) had at least one ECG-documentation. In SR, the PR interval was relatively long [median 180 (120-380) ms)]. In 84% of pat, sustained AVNRT [median cycle length (CL) 400 (270-800) ms] was induced during EPS. In the remaining pat, at least 2 typical AV-nodal-echo beats were induced. Slow pathway (SP) ablation/modification was performed in all but one patient presenting with a very long baseline PR-interval, low antegrade Wenckebach-point (WP) and very slow AVNRT. In this case, the pat was treated with ß-blocker after pacemaker (PM) implantation. In 3 additional pat, PM implantation was necessary after ablation due to intermittent high-degree AV-block. In comparison to the rest of the study population, these four pat had a longer baseline PQ interval [median 275 (IQR 248- 303) ms vs. 180 (IQR 160- 192) ms], a longer baseline AH interval [median 207ms (IQR 185- 234) ms vs. 95 (IQR 80- 107) ms], a lower baseline antegrade WP CL [median 510 (IQR 435- 645) vs. 390ms (IQR 355- 470) ms], and a longer tachycardia CL [TCL 557 (IQR 454- 661) ms vs. 400 (IQR 364- 443) ms; p value &amp;lt;0,01 for all comparisons]. The overall complication rate (other than AV block) was low (2 pat with AV fistula treated conservatively) and comparable to the one described in younger pat. Discussion Elderly pat also have AVNRT, there are a slight differences in physiology (i.e. relatively long baseline PR-interval and TCL, likely due to changes of the conduction system with aging), and as in young pat, ablation is curative treatment with similar (low) complication rate. A subset of pat, characterized by longer PR- and AH-intervals, lower WP and longer TCL may be at higher risk for AV-block after SP modification. Whether this is due to pre-existing damage or to posterior location of the FP remains unknown. SP ablation is safe and effective even in elderly pat. In pat presenting with EP characteristics presumptive of a baseline impairment of the conduction properties of the FP, ablation of the FP could be attempted to avoid postprocedural high degree AV block.

Delayed detection programming significantly reduces inappropriate ICD therapies in patients with left-ventricular assist devices

Abstract Funding Acknowledgements Type of funding sources: None. Background Implantation of a left ventricular assist device (LVAD) is an established therapy for end-stage heart failure, either as bridge to transplantation or as destination therapy. Virtually all LVAD patients carry an implantable cardioverter-defibrillator (ICD) for primary or secondary prevention. The risk of ventricular tachyarrhythmias is significant in LVAD patients, but so is the burden of supraventricular tachycardia and the ensuing risk of inappropriate ICD therapies. The present retrospective study sought to quantify the impact of standard ICD programming vs. a ICD programming with long detection delays on the occurrence of inappropriate ICD therapies. Methods and results We retrospectively identified 337 consecutive patients (292 male, mean age 54.2 ± 12.3 years) who received a continuous-flow LVAD at our institution. Median follow-up duration was 2.3 (IQR 1.3, 3.7) years. Heart failure etiology was ischemic cardiomyopathy in 155 patients (46.0 %) and non-ischemic dilated cardiomyopathy in 150 (44.5 %). Other etiologies accounted for 32 patients (9.4 %). ICDs implanted at the time of LVAD implantation were single chamber devices in 176 patients (52.2 %), dual chamber devices in 45 patients (13.4 %), and CRT-D in 116 patients (34.4 %) A total of 2228 ICD-treated arrhythmia episodes occurred in 153 patients. 2066 (92.6 %) episodes were appropriate interventions for ventricular arrhythmias. 162 (7.3 %) treatments were inappropriate due to supraventricular tachyarrhythmias (n=115; 71.4 %), sinus tachycardia (n=15; 9.3 %) or oversensing (n=21; 12.9%). We retrospectively compared a standard programming (number of intervals for detection [NID] in the slowest therapy zone ≤ 40) and a long delay programming (NID &amp;gt; 40) and investigated the time to the first inappropriate therapy. A total of 285 patients were programmed to NID ≤ 40 at the first ICD interrogation after LVAD implant, 47 were programmed to NID &amp;gt; 40. Therapies were inactive in the remaining 5 patients. Median NID was 30 (IQR 23, 35) in the standard programming group and 60 (IQR 50, 76) in the long delay group, with similar rates for detection (median cycle lengths 340 [IQR 330, 350] ms and 330 [IQR 322, 340] ms for standard and long delay, respectively). Long delay programming was associated with significantly higher freedom from inappropriate therapies during follow-up (Hazard ratio 0.14, p [log rank] 0.027). No significant difference was observed between groups with regard to time to first appropriate therapy. Conclusion A number of intervals for detection greater than 40 in the slowest therapy zone was associated with a significantly increased freedom from inappropriate therapies in this large retrospective single-center cohort of LVAD patients with an ICD and should be considered as the default ICD programming strategy in this population.

Female Reproductive Health Disturbance Experienced During the COVID-19 Pandemic Correlates With Mental Health Disturbance and Sleep Quality.

The COVID-19 pandemic has adversely affected population mental health. Periods of psychological distress can induce menstrual dysfunction. We previously demonstrated a significant disruption in women’s reproductive health during the first 6 months of the pandemic. The present study investigates longer-term reproductive and mental health disturbances. A cross-sectional online survey was completed by 1335 women of reproductive age in April 2021. It included validated standardized measures of depression (PHQ-9), anxiety (GAD-7) and sleep quality (PSQI). 581 (56%) of women reported an overall change in their menstrual cycle since the beginning of the pandemic. There was no change in median cycle length [28 days (28-30)] or days of menses [5 (4-5)], but there was a wider variability in minimum (p<0.0001) and maximum (p<0.0001) cycle length. There was a significant increase in heavy menstrual bleeding, painful periods and missed periods compared to pre-pandemic (all p<0.0001). 64% of women reported worsening pre-menstrual symptoms. Rates of severe depression, anxiety and poor sleep were more than double those from large scale representative community samples. Poor sleep quality was an independent predictor of overall change in menstrual cycle (OR=1.11, 95%CI 1.05-1.18), and missed periods (OR=1.11, 95%CI 1.03-1.19) during the pandemic. Increased anxiety was independently associated with a change from non-painful to painful periods (OR=1.06, 95%CI 1.01-1.11) and worsening of pre-menstrual symptoms (OR=1.06, 95%CI 1.01-1.07) during the pandemic. The COVID-19 pandemic continues to bear a significant impact on female reproductive health. Increased levels of psychological distress and poor sleep are associated with menstrual cycle disruption.

Application of Ensite™ LiveView function for identification of scar-related ventricular tachycardia isthmus.

Dynamic display of real-time wavefront activation pattern may facilitate the recognition of reentrant circuits, particularly the diastolic path of ventricular tachycardia (VT). We aimed to evaluate the feasibility of LiveView Dynamic Display for mapping the critical isthmus of scar-related reentrant VT. Patients with mappable scar-related reentrant VT were selected. The characteristics of the underlying substrates and VT circuits were assessed using HD grid multielectrode catheter. The VT isthmuses were identified based on the activation map, entrainment, and ablation results. The accuracy of the LiveView findings in detecting potential VT isthmus was assessed. We studied 18 scar-related reentrant VTs in 10 patients (median age: 59.5 years, 100% male) including 6 and 4 patients with ischemic and nonischemic cardiomyopathy, respectively. The median VT cycle length was 426 ms (interquartile range: 386-466 ms). Among 590 regional mapping displays, 92.0% of the VT isthmus sites were identified by LiveView Dynamic Display. The accuracy of LiveView for isthmus identification was 84%, with positive and negative predictive values of 54.8% and 97.8%, respectively. The area with abnormal electrograms was negatively correlated with the accuracy of LiveView Dynamic Display (r = -.506, p = .027). The median time interval to identify a VT isthmus using LiveView was significantly shorter than that using conventional activation maps (50.5 [29.8-120] vs. 219 [157.5-400.8] s, p = .015). This study demonstrated the feasibility of LiveView Dynamic Display in identifying the critical isthmus of scar-related VT with modest accuracy.

Venetoclax Combined with FLAG-IDA Induction and Consolidation in Newly Diagnosed Acute Myeloid Leukemia

Venetoclax Combined with FLAG-IDA Induction and Consolidation in Newly Diagnosed Acute Myeloid Leukemia

AML-204: Venetoclax Combined with FLAG-IDA Induction and Consolidation in Newly Diagnosed Acute Myeloid Leukemia

Context: FLAG-IDA induction results in complete remission in approximately 85% of newly diagnosed patients with acute myeloid leukemia (ND-AML), however 30-40% experience relapse. Combining the BCL-2 inhibitor venetoclax (VEN) with chemotherapy improves efficacy, inferring FLAG-IDA+VEN may improve outcomes in ND-AML. Objectives: The primary P2 objective was determination of the overall activity of FLAG-IDA+VEN. Key secondary objectives include overall response rate (ORR: CR+CRi+CRh+MLFS+PR), CRc (CR+ CRh+CRi), overall survival (OS), event-free survival (EFS), and duration of response (DOR). Design: A Phase 1b/2 study evaluating FLAG-IDA+VEN in ND and relapsed/refractory (R/R) AML patients ≥ 18 years of age. Phase 1b results were previously reported (DiNardo, JCO 2021). The Phase 2 (P2) portion enrolled patients into two cohorts: ND-AML (n=38), and R/R-AML (n=39). ND-AML outcomes are reported herein. Results: Thirty-eight patients with ND-AML (sAML: n=7, therapy-related AML: n=5) enrolled. Median age was 44 years (range 20-65). ELN risk was favorable, intermediate, and adverse in 18%, 37%, and 45% of patients. Three patients were too early for response evaluation. The ORR was 94% (CR: n=24 [69%], CRh: n=5 [14%], CRi: n=1 [3%], MLFS: n=3 [9%]) and corresponding CRc rate was 86% (n=30). 93% of CRc patients attained MRD-negative status. Patients received a median of 2 (range: 1-6) cycles. 57% (n=20) transitioned to allogeneic stem-cell transplant (HSCT). Median DOR was 18.4 (95% CI: 13.1-21.1) months. Median cycle length for cycles 1 and 2 were 31 and 41 days. No 30 or 60-day mortality occurred. Common adverse events included febrile neutropenia (34%), pneumonia (28%), cellulitis (16%), and bacteremia (16%). Eight patients relapsed (ELN intermediate: N=3, ELN adverse: N=5) including 100% of patients with baseline TP53 mutations (N= 4); and there have been 4 deaths, all in relapsed patients. Five relapses and three of four deaths occurred post-HSCT. After a median study follow up of 15 months, median EFS and OS were NR, with 1-year EFS and OS rates of 76% and 96%, respectively. Conclusions: FLAG-IDA+VEN induction and consolidation results in high MRD-negative composite CR rates in ND-AML with an expected safety profile. Durable responses were observed at 12-months. Long-term follow up is ongoing to confirm these results. FLAG-IDA induction results in complete remission in approximately 85% of newly diagnosed patients with acute myeloid leukemia (ND-AML), however 30-40% experience relapse. Combining the BCL-2 inhibitor venetoclax (VEN) with chemotherapy improves efficacy, inferring FLAG-IDA+VEN may improve outcomes in ND-AML. The primary P2 objective was determination of the overall activity of FLAG-IDA+VEN. Key secondary objectives include overall response rate (ORR: CR+CRi+CRh+MLFS+PR), CRc (CR+ CRh+CRi), overall survival (OS), event-free survival (EFS), and duration of response (DOR). A Phase 1b/2 study evaluating FLAG-IDA+VEN in ND and relapsed/refractory (R/R) AML patients ≥ 18 years of age. Phase 1b results were previously reported (DiNardo, JCO 2021). The Phase 2 (P2) portion enrolled patients into two cohorts: ND-AML (n=38), and R/R-AML (n=39). ND-AML outcomes are reported herein. Thirty-eight patients with ND-AML (sAML: n=7, therapy-related AML: n=5) enrolled. Median age was 44 years (range 20-65). ELN risk was favorable, intermediate, and adverse in 18%, 37%, and 45% of patients. Three patients were too early for response evaluation. The ORR was 94% (CR: n=24 [69%], CRh: n=5 [14%], CRi: n=1 [3%], MLFS: n=3 [9%]) and corresponding CRc rate was 86% (n=30). 93% of CRc patients attained MRD-negative status. Patients received a median of 2 (range: 1-6) cycles. 57% (n=20) transitioned to allogeneic stem-cell transplant (HSCT). Median DOR was 18.4 (95% CI: 13.1-21.1) months. Median cycle length for cycles 1 and 2 were 31 and 41 days. No 30 or 60-day mortality occurred. Common adverse events included febrile neutropenia (34%), pneumonia (28%), cellulitis (16%), and bacteremia (16%). Eight patients relapsed (ELN intermediate: N=3, ELN adverse: N=5) including 100% of patients with baseline TP53 mutations (N= 4); and there have been 4 deaths, all in relapsed patients. Five relapses and three of four deaths occurred post-HSCT. After a median study follow up of 15 months, median EFS and OS were NR, with 1-year EFS and OS rates of 76% and 96%, respectively. FLAG-IDA+VEN induction and consolidation results in high MRD-negative composite CR rates in ND-AML with an expected safety profile. Durable responses were observed at 12-months. Long-term follow up is ongoing to confirm these results.