Permanent Pacemaker Placement Research Articles

Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad adams tricuspid annuloplasty ring.

The Tri-Ad Adams tricuspid annuloplasty ring (Medtronic, Minneapolis, MN) is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. This study aimed to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring. A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021. Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range : 56.0-71.5) years. The median EuroSCORE II was 4.3 (2.7-7.5%)%, with 37 patients (14.9%) having a history of prior cardiac surgery. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6)cm. Concurrent procedures included mitral valve replacement (n = 60,64.5%), mitral valve repair (n = 75,30.2%), aortic valve replacement (n = 72,29.0%), and the maze procedure (n = 170,68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early mortality occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18,0.3%), acute kidney injury (n = 14,5.6%), and permanent pacemaker placement (n = 15,6.0%). According to Kaplan-Meier analysis, the four-year rates of freedom from overall mortality and moderate to severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperation, ring detachment, or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg). Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and mid terms. Further studies are warranted to confirm the long-term results.

Short- and intermediate-term outcomes of transcatheter aortic valve replacement in low-risk patients: A meta-analysis and systematic review

BackgroundTranscatheter aortic valve replacement (TAVR) being currently employed in low surgical risk patients with severe symptomatic aortic stenosis (AS). The durability and extended outcomes of TAVR as compared to surgical aortic valve replacement (SAVR) in low-risk patients remains uncertain. MethodsWe selected randomized controlled trials (RCT) comparing outcomes of TAVR vs. SAVR in low surgical risk patients having severe AS using online databases. The primary outcome was all-cause death. The secondary outcomes were composite of all-cause death & disabling stroke, cardiovascular (CV) death, stroke, myocardial infarction (MI), permanent pacemaker (PPM) placement, new onset atrial fibrillation (AF), valve re-intervention and valve thrombosis. The outcomes were stratified at short- (1-year) and intermediate-term (≤5 years) follow-up. We used a random effect model to report outcomes as relative risk (RR) with a 95 % confidence interval (CI). ResultsThe analysis consisted of six RCTs comprising 5,122 subjects with a mean age of 75.4 years. At short-term follow up, there was a significant reduction in all-cause death (RR: 0.62, 0.46–0.82, p = 0.001) and composite of all-cause death and disabling stroke (RR: 0.62, 0.45–0.83, p = 0.002) in patients undergoing TAVR. At intermediate-term follow-up, there was no significant difference in survival (RR:0.95, 0.73–1.24, p = 0.71) and composite outcome (RR: 0.95, 0.74–1.22, p = 0.71). TAVR patients had lower incidence of new onset AF, however, higher PPM placement. ConclusionIn patients with severe AS having low-surgical risk, patients undergoing TAVR had improved short-term survival as compared to SAVR. This survival advantage was absent at intermediate-term follow-up. The long-term outcomes remain uncertain.

Serial GLS assessments over time in patients with preserved ejection fraction undergoing permanent cardiac pacemaker placement

Abstract Background Chronic right-ventricular (RV) pacing can exacerbate heart failure in patients with a low ejection fraction (EF), but little is known about pacing-induced cardiomyopathy (PICM) in patients with preserved EF. We aimed to investigate risk factors of PICM in these patients during long-term follow-up. Methods The prospective registry at our University Hospital, South Korea, included de novo patients with preserved EF undergoing transvenous permanent pacemaker (PPM) implantation for atrioventricular blockage from 2018 to 2022. Patients with EF > 50% and expected ventricular pacing > 40% were included. All patients were followed with serial echocardiography (preimplant, post implant, 12 months). All patients enrolled in this study were seen as outpatients every 3–6 months. Composite outcomes were cardiac death (pump failure), hospitalization because of heart failure, PICM, and biventricular pacing (BVP) upgrade. Results 71 patients (28 men, 73.1 ± 9.5 years) were included. After PPM implantation, EF and GLS were significantly decreased. During three years of follow-up, 2 patient died, 6 were hospitalized, 7 suffered PICM, and 3 underwent BVP upgrade. Cox regression analysis identified reduced post-implant global longitudinal strain (GLS) (HR, 1.524; 95% CI, 1.149–2.021; P = 0.003) as independent predictors of PICM. Post-implant GLS showed high predictive accuracy for PICM, with an area under the curve of 0.92 (95% CI 0.829–0.971; P < 0.001) Conclusion Post-implant GLS, rather than pre-implant GLS could help identify individuals at high risk of PICM. After PPM implantation, it is important to measure GLS, and patients with reduced GLS should be monitored more frequently and echocardiographic surveillance, with a view to an upgrade to BVP.Serial EF and GLS assessmentGLS ROC curve

Efficacy and safety of a transaortic approach to midventricular and apical septal myectomy

ObjectiveThe study objective was to evaluate the safety and efficacy of a transaortic approach to midventricular and apical septal myectomy in patients with hypertrophic cardiomyopathy with left ventricular outflow tract or midventricular obstruction. MethodsFrom January 2018 to August 2023, 940 patients underwent transaortic septal myectomy at the Cleveland Clinic, of whom 682 (73%) had midventricular or apical resection. Patients who underwent isolated basal myectomies were excluded. Templated operative reports designated septal regions resected as basal (opposition to mitral valve up to the leaflet tips), midventricular (leaflet tips to just beyond the papillary muscle heads), and apical (apical third of the ventricle). Myocardial resection specimen weights, intraventricular gradients, and clinical outcomes were assessed. ResultsOf the 682 patients, 582 (85%) had basal plus midventricular resection and 78 (11%) had basal, midventricular, and apical resection. Mean preoperative intraventricular gradient was 102 ± 41 mm Hg. Median resection weight was 10 g (15th, 85th percentiles: 7, 15), and mean postoperative intraventricular gradient was 16 ± 10 mm Hg, with 625 (96%) patients achieving gradients 36 mm Hg or less. There were no iatrogenic mitral or aortic valve injuries. Permanent pacemaker placement was required in 38 patients (5.6%), of whom 8 (1.2%) had normal preoperative conduction. Operative mortality occurred in 1 patient (0.1%) after an intraoperative ventricular septal defect. ConclusionsMost patients undergoing septal myectomy for relief of obstruction required resection beyond the basal septum. With specialized instrumentation, detailed imaging and knowledge of variable septal anatomy, resecting midventricular and apical septal muscle can be safely and effectively achieved through a transaortic approach.

The utility and impact of outpatient telemetry monitoring in post-transcatheter aortic valve replacement patients

BackgroundConduction disturbances are a common complication of transcatheter aortic valve replacement (TAVR). Mobile Cardiac Telemetry (MCT) allows for continuous monitoring with near “real time” alerts and has allowed for timely detection of conduction abnormalities and pacemaker placement in small trials. A standardized, systematic approach utilizing MCT devices post TAVR has not been widely implemented, leading to variation in use across hospital systems. ObjectivesOur aim was to evaluate the utility of a standardized, systematic approach utilizing routine MCT to facilitate safe and earlier discharge by identifying conduction disturbances requiring permanent pacemaker (PPM) placement. We also sought to assess the occurrence of actionable arrhythmias in post-TAVR patients. MethodsUsing guidance from the JACC Scientific Expert Panel, a protocol was implemented starting in December 2019 to guide PPM placement post-TAVR across our health system. All patients who underwent TAVR from December 2019 to June 2021 across four hospitals within Northwell Health, who did not receive or have a pre-existing PPM received an MCT device at discharge and were monitored for 30 days. Clinical and follow-up data were collected and compared to pre initiative patients. ResultsDuring the initiative 693 patients were monitored with MCT upon discharge, 21 of whom required PPM placement. Eight of these patients had no conduction abnormality on initial or discharge ECG. 59 (8.6 %) patients were found to have new atrial fibrillation or flutter via MCT monitoring. There were no adverse events in the initiative group. Prior to the initiative, 1281 patients underwent TAVR over a one-year period. The initiative group had significantly shorter length of stay than pre-initiative patients (2.5 ± 4.5 vs 3.0 ± 3.8 days, p < 0.001) and lower overall PPM placement rate within 30 days post-TAVR (16 % vs 20.5 %, P = 0.0125). ConclusionsIn our study, implementation of a standardized, systematic approach utilizing MCT in post-TAVR patients was safe and allowed for timely detection of conduction abnormalities requiring pacemaker placement. This strategy also detected new atrial fibrillation and flutter. Reduction in post TAVR pacemaker rate and length of stay were also noted although this effect is multifactorial.

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery.

Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk[RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

Outcomes of Valve-in-Valve Transcatheter Aortic Valve Replacement

Structural valve degeneration is increasingly seen given the higher rates of bioprosthetic heart valve use for surgical and transcatheter aortic valve replacement (TAVR). Valve-in-valve TAVR (VIV-TAVR) is an attractive alternate for patients who are otherwise at high risk for reoperative surgery. We compared patients who underwent VIV-TAVR and native valve TAVR through a retrospective analysis of our institutional transcatheter valve therapy from 2013 to 2022. Patients who underwent either a native valve TAVR or VIV-TAVR were included. VIV-TAVR was defined as TAVR in patients who underwent a previous surgical aortic valve replacement. The Kaplan-Meier survival analysis was used to obtain survival estimates. A Cox proportional hazards regression model was used for the multivariable analysis of mortality. A total of 3,532 patients underwent TAVR, of whom 198 (5.6%) underwent VIV-TAVR. Patients in the VIV-TAVR cohort were younger than patients who underwent native valve TAVR (79.5 vs 84years, p <0.001), with comparable number of women and a higher Society of Thoracic Surgeons risk score (6.28 vs 4.46, p <0.001). The VIV-TAVR cohort had a higher incidence of major vascular complications (2.5% vs 0.8%, p = 0.008) but lower incidence of permanent pacemaker placement (2.5% vs 8.1%, p = 0.004). The incidence of stroke was comparable between the groups (VIV-TAVR 2.5% vs native TAVR 2.4%, p = 0.911). The 30-day readmission rates (VIV-TAVR 7.1% vs native TAVR 9%, p = 0.348), in-hospital (VIV-TAVR 2% vs native TAVR 1.4%, p = 0.46), and overall (VIV-TAVR 26.3% vs native TAVR 30.8%, p = 0.18) mortality at a follow-up of 1.8years (0.83 to 3.5) were comparable between the groups. The survival estimates were comparable between the groups (log-rank p = 0.27). On the multivariable cox regression analysis, VIV-TAVR was associated with decreased hazards of death (hazard ratio 0.68 [0.5 to 0.9], p = 0.02). In conclusion, VIV-TAVR is a feasible and safe strategy for high-risk patients with bioprosthetic valve failure. There may be potentially higher short-term morbidity with VIV-TAVR, with no overt impact on survival.

Incidence and risk factors for permanent pacemaker implantation in patients undergoing tricuspid valve surgery

Abstract Background Bradyarrhythmias requiring permanent pacemaker (PPM) implantation are commonly described after cardiac surgeries. Numerous studies evaluated the demographic and clinical risk factors for PPM placement following aortic and mitral valve surgeries. However, a paucity of data exists when it comes to tricuspid valve surgery (TVS). Purpose Our study aimed to evaluate the incidence of PPM placement after TVS and investigate the demographic, clinical, and procedural risk factors associated with the need for a PPM. Methods We included 13 294 patients from the Medicare database who underwent isolated TV repair (N=1319 (10%)), isolated TV replacement (N=2123 (16%)), or concomitant TV repair or replacement with different combinations of surgical aortic valve replacement (SAVR), mitral valve repair or replacement (MVR), and coronary artery bypass graft (CABG). Patients who underwent TV surgery for endocarditis were excluded. The primary exposure of interest for the study was new pacemaker placement after TV surgery and before discharge, or within 30 days from discharge date. Each patient from the pacemaker group was matched to up to 3 controls from the no pacemaker group. Results Among the included patients, 2518 (18.9%) required a PPM placement after TVS. In the logistic regression including patients’ variables, subjects who needed PPM implantation were more likely to be women (64.4% vs. 57.6%, P&amp;lt;0.001) and had a higher prevalence of prior sternotomy (P=0.01), chronic kidney disease (P=0.03), heart failure (P=0.04) and tumor (P=0.02). Patients who underwent isolated TV replacement and TV replacement with concomitant surgeries had a significantly higher risk of PPM implantation when compared to isolated TV repair and TV repair with concomitant surgeries (P&amp;lt;0.0001) (Table). Conclusion Post-procedural PPM implantation is a very frequent complication of TVS, especially in TV replacement with or without concomitant left-sided heart surgeries. Numerous demographic and clinical factors are associated with an increased risk of PPM placement. Adequate risk stratification and counseling of patients before surgery decision is essential.Demographic &amp; Surgical Risk Factors

When valve needs electrical wires - estimating pacemaker implantation after TAVR

Abstract Introduction Widespread availability and expanded indication of transcatheter aortic valve replacement (TAVR) modified paradigm of aortic stenosis. Despite elevated success rate, there are procedure related complications that need to be considered. One of the most frequent is conduction defects requiring permanent pacemaker (PPM) implantation resulting in prolonged hospital length of stay and hospitalization cost. Several risk factors for PPM implantation after TAVI have been described, and, recently, the Emory Risk Score (ERS) was developed as a predictive tool for need of new PPM implantation post-TAVI in patients who implated a balloon-expandable valve. Purpose Our objective was to evaluate risk factors associated with PPM after TAVR and to validate the ERS in our population after implantation of balloon-expandable but also self-expanding valves. Methods Retrospective, observational and single center study involving patients submitted to TAVR between 2018 and 2021. Clinical, ECG data and procedure characteristics were obtained at time of TAVR and during follow-up. The predictive discrimination of the scoring system for the risk for PPM placement after TAVR was evaluated using ROC curve analysis in SPSS Statistics. To estimate additional predictors of pacemaker implantation we used Cox proportional hazards regression models. Results From January 2018 to December 2021, 416 patients were referred to our centre for TAVR. The mean age was 82,5 ± 6,1 years, 55% female. Most frequently implanted valves were Evolut Pro and Sapien 3 ultra in 39,4% and 26,6% of pts, respectively. During follow-up 110pts (26%) needed device implantation (94 % double chamber pacemaker; 6% CRT-P or CRT-D), most frequently due to AV block. On univariate analysis, QRS width was the only factor that showed a significant correlation with pacemaker implantation (HR 1,018, 95% CI 1,007-1028; p=0.027). We found no other clinical or procedural characteristics to be predictive of PM implantation. ERS is composed of 4 variables – history of syncope, right complete branch block, QRS width &amp;gt; 140mseg and valve oversizing &amp;gt; 16% - and revealed a good sensitivity and specificity in estimating device implantation. We applied this score to our population and ROC curve analysis showed a significant prediction capacity (AUC 0,761 95% CI 0,699-0,822, p=0,031). This analysis was also performed analysing separately both subgroups of self-expandable valves (Medtronic Evolut and Evolut R) and balloon expandable valves (Edwards Sapiens). ROC curve analysis in both showed a good correlation with events – figure 1. Conclusion PM implantation is one of the most common complications following TAVR. In our population, the use of ERS displayed a very positive accuracy in predicting device implantation. Routine use of such tool can select patients at significant higher risk and thus best define patient allocation and resource utilization to reduce number of hospitalization days.

Abstract 13661: In-Hospital Outcomes, Rates of Development of Complete Heart Block and Rates of Pacemaker Placement in TAVR and SAVR Cases: A 5-year Nationwide Inpatient Sample Analysis

Introduction: Complete Heart Block (CHB) is a commonly observed post-procedural complication associated with Transcatheter aortic valve replacement (TAVR) and Surgical aortic valve replacement (SAVR). Since 2016, limited data exists on In-hospital outcomes of TAVR and SAVR cases and rates of development of CHB. Methods: National Inpatient Sample 2016-2020 was used to identify and group TAVR and SAVR cases using appropriate ICD codes. Logistic regression was used to compare baseline characteristics and in-hospital outcomes. Results: 590,615 patients underwent aortic valve replacement (AVR) from 2016-2020, of which 49.6% were TAVR and 50.4% were SAVR. The most common diagnosis for AVR in both groups was nonrheumatic trileaflet aortic stenosis (AS) (86.6% in TAVR group and 53.5% in SAVR group, p&lt;0.001). In TAVR cases, development of CHB was more common (8.9%-vs-7.2%, p=0.235) along with increased need for transvenous pacing (16.6%-vs-8.7%, p=0.010) and permanent pacemaker placement (9.4%-vs-6.4%, p&lt;0.001). An upward trend in CHB occurrence and pacemaker placement (PPM) was noted in the TAVR group as shown in Image 1. TAVR group was observed to have higher rates of acute myocardial infarction (MI) (14.5%-vs-12.8%, p=0.074). SAVR group had higher rates of cardiogenic shock (8.10%-vs-2.20, p&lt;0.001) and in-hospital mortality (3.6%-vs-1.30%, p=0.02). Conclusions: Over the past few years, CHB has been more commonly observed with TAVR as compared to SAVR, necessitating increasing use for PPM placement. Despite these trends, in-hospital mortality and complications are lower with TAVR procedure.

Abstract 17676: An Electrocardiographic Deep Learning Model is Informative for the Prediction of Atrioventricular Block After Transcatheter Aortic Valve Replacement

Introduction: Atrioventricular block requiring a permanent pacemaker (PPM) is an important complication after transcatheter aortic valve repair (TAVR). While several risk factors have been identified, a clinically useful risk prediction algorithm has been challenging to develop. Furthermore, while artificial intelligence methods utilizing structured clinical data have been used, a deep learning approach using raw electrocardiogram (ECG) data is a novel method in this field. Research Question: The objective of our study was to develop an electrocardiographic artificial intelligence (ECG-AI) model to assess the risk of PPM placement after TAVR using only the pre-procedure ECG. Methods: We analyzed data from 651 patients that underwent TAVR at Atrium Health Wake Forest Baptist in the last 10 years. We obtained raw ECG files in XML format from General Electric (Boston, MA, USA). The ECG data were used as inputs within a convolutional neural network (CNN) model. The CNN was an adjusted residual network with a batch size of 64, had 100 epochs, and used Adam optimization with default parameters. The model was trained using a 5-fold cross-validation strategy on 80% of the data and validated on a 20% hold-out set. The CNN was supervised on need for new PPM within 30 days after TAVR. All model evaluations were performed on the hold-out set. Results: Of the 651 patients in our sample, 61 patients required PPM placement within 30 days after TAVR. The average age was 77.2±9 years and there were 260 females (40%). In our sample, 34/268 (12.7%) patients with self-expanding valves and 26/377 (6.9%) patients with balloon-expanding valves received a PPM. Results of our final model on the hold-out set yielded an area under the receiver-operator characteristic curve (AUC) of 0.74 (95% CI 0.56-0.92). The accuracy of our preliminary model was 77% with a sensitivity of 60% and specificity of 79%. Conclusion: Our ECG-AI model achieved a moderate AUC for the prediction of PPM after TAVR. This serves as a proof of concept that pre-TAVR ECGs alone are informative for prediction of PPM. Future work includes model optimization and adding demographic and clinical variables to refine and develop a robust predictive model with continual improvement of the accuracy for prediction of TAVR outcomes.

Abstract 17127: Rapid Progression of Conduction System Disease in Suspected Fulminant Nivolumab Myocarditis

Background: Immune checkpoint inhibitors (ICI) have shown efficacy in treating a wide spectrum of malignancies, but have a known risk of cancer therapy related cardiac toxicity. We present a case that demonstrates how conduction system disease can rapidly progress in a patient with suspected nivolumab (PD1) induced fulminant myocarditis. Case: An 82-year-old male with a history of esophageal carcinoma presented with agonal breathing and altered mental status. He had received his second dose of PD1 therapy three days prior. He was intubated and admitted for hypoxic respiratory failure and elevated troponin. His initial EKG demonstrated new marked 1st degree AV block with right bundle branch block (RBBB) morphology. A stat echocardiogram noted an EF of 60-65% with no wall motion abnormalities. Decision-making: On Day 2, Mobitz Type I block was appreciated on telemetry. The patient met criteria for acute myocarditis with his clinical presentation, new conduction system disease, and high sensitivity troponin of 13,000. Given recent PD1 therapy, lack of infectious prodrome, and lack of prior heart disease, suspicion for ICI induced myocarditis was high. High dose steroid therapy was initiated. On Day 3, the patient was noted to have alternating left bundle branch block and RBBB. On Day 4, he progressed to complete heart block, prompting transvenous pacemaker (PM) placement with subsequent permanent PM placement. A repeat echo showed global hypokinesis with an EF of 40-45% and reduced RV function. He also required vasopressor support meeting criteria for fulminant myocarditis. Due to his hemodynamic instability and low clinical suspicion, he did not receive cardiac catheterization. Cardiac MRI and cardiac biopsy were not readily available in this institution. Conclusion: The clinical findings, lack of infectious prodrome, and worsening arrhythmia requiring pacing and vasopressor support, in patient with recent PD1 treatment suggests nivolumab induced fulminant myocarditis. In institutions without advanced testing infrastructure, rapid recognition of progressive conduction system disease may be used as an early marker for diagnosis, treatment initiation, and referral to tertiary care centers for advanced management of fulminant ICI myocarditis.

Abstract 18597: Is Sleep Disordered Breathing Optimized in Patients With Bradycardic Rhythm Disorders Prior to Pacemaker Implantation? - A Retrospective Observational Study and a Quality Improvement Project

Introduction: Obstructive sleep apnea (OSA) is associated with cardiovascular (CV) morbidity and mortality ranging from asymptomatic bradycardia to sudden death. Studies have shown that sleep-related bradyarrhythmias, decrease with continuous positive airway pressure (CPAP) and are unlikely to develop symptomatic bradycardia in the long-term. AHA/ACC/HRS recommends to evaluate and treat suspected or documented conduction disorder during sleep including patients who have received or are being considered for permanent pacemaker (PPM). Objective We aim to examine the number of sleep studies and CPAP performed and address the barriers of under-diagnosis and treatment with post intervention quality improvement initiative. Methods: We performed retrospective analysis of patients &gt;18 years admitted for elective PPM placement from 01/10/2021-01/01/2023. Categorical variables were reported as number and percent and numerical variable was reported as mean. Multiple logistic regression was used to identify predictors for compliance and sleep study prescription. All statistical analyses were performed with SAS software, version 9.4. Results Of 423 patients, mean age was 78.1 years, 56.50% were males, 96.9% were Caucasians and mean BMI was 30.1 kg/m 2 . Only 34.75 % (N= 147/423) received sleep study. 93.2% (N=137/147) were diagnosed with OSA and 82.9% (N=122/137) were treated with CPAP. Only 63.1% were compliant with CPAP. Males were more complaint with CPAP [OR 3.13 (95% CI 1.36-7.18, p=0.0072)]. Mean BMI at OSA diagnosis was 33.7 kg/m 2 and 30.1 kg/m 2 at PPM implantation. Weight loss was noted but most patients remained obese. Males, age ≥80 and obesity were significant predictors to get sleep study. After study outcomes, we adopted a standardized algorithm for risk assessment, incorporated EHR reminder and educated doctors. The intervention is currently ongoing. Conclusion Data on underutilization of sleep study helped us to work with administration to produce a protocol for screening high risk patients. Treating sleep apnea not only alleviates apnea-related symptoms but also improves CV outcome by avoiding unnecessary pacemaker implantation and minimizing unnecessary health care cost. If effective, this strategy can be a model for other hospitals.

Abstract 18348: Causes and Predictors of 30-Day Readmissions Following Permanent Pacemaker Implantation in Patients With Cardiac Amyloidosis: From National Readmission Database (2016-2020)

Introduction: Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy where local deposition of amyloid fibrils causes heart failure, arrhythmias, and conduction system abnormalities. Involvement of the AV nodal and infra-hisian conduction system increases the need for a permanent pacemaker (PPM). Studies have noted worse outcomes in patients with implantable-cardioverter defibrillator placement in amyloidosis, but a comparison with PPM is lacking. We sought to analyze readmissions in CA patients following PPM placement utilizing National Readmission Database (NRD). Methods: NRD (2016 to 2020) was queried to identify adults with a diagnosis of CA who underwent PPM implantation using ICD-10 CM and PCS codes. The primary outcome was a 30-day readmission rate. Secondary outcomes were in-hospital mortality, length of stay (LOS), total hospital charge (THC), and predictors of readmission. Multivariate/univariate logistic and linear regression analyses were used to analyze the outcomes and adjust for possible confounders. Results: A total of 1,027 encounters of CA who underwent PPM were identified, of which 975 were discharged alive. Within 30 days from discharge, 141 (14.5%) were readmitted. Those readmitted had a longer LOS and higher burden of comorbidities while were similar in age, sex, hospital characteristics, and household income status. Readmissions lead to an additional mean THC of $55,079 and a mean LOS of 6.3 days. The top five causes of readmissions were heart failure (23%), sepsis (6.6%), hypertensive heart disease (4%), bradycardia (3.5%), and acute kidney injury (3.2%). Figure-1 shows the forest plot of a multivariate analysis of independent factors associated with readmissions. Conclusions: Our findings show that up to 15% of patients with CA who undergo PPM implantation get readmitted with heart failure being the most common etiology. Optimizing comorbidities with PPM implantation in CA may provide better outcomes and reduce admissions.

Use of glutaraldehyde-treated autologous pericardial patch in complete atrioventricular septal defect repair.

Synthetic patch materials, such as polytetrafluoroethylene and knitted polyester, are commonly used for the repair of complete atrioventricular septal defects using the double-patch technique. In our study, we investigated the impact of glutaraldehyde-treated autologous pericardial patch on postoperative atrioventricular valve function. In this retrospective study, patients who underwent repair of complete atrioventricular septal defects using the double-patch technique between January 1, 2018, and May 15, 2023, at our pediatric cardiac center were included in the study. Patients were divided into two groups based on the type of patch used for the repair of the ventricular component of the atrioventricular septal defect: autologous pericardial patch (group 1) and polytetrafluoroethylene patch (group 2). Postoperative data of the patients were retrospectively analyzed. Thirty-four patients (57.6%) were female, and 25 (42.4%) were male, with a median age of 7 (5-18) months. The median body weight at the time of surgery was 5.5 (4.1-10) kilograms. Down syndrome was present in 45 (76.3%) patients. The autologous pericardium was used for ventricular septal defect closure in 44 (74.6%) patients (Group 1), while polytetrafluoroethylene was used in 15 (25.4%) patients (Group 2). Permanent cardiac pacemaker placement was required in 4 (6.8%) patients due to postoperative atrioventricular block. Hospital mortality was 11.9% (n=7). Among these cases, 4 (6.8%) patients died from low cardiac output syndrome, and 3 (5.1%) patients died from sepsis. Postoperative echocardiographic evaluation revealed insignificant residual ventricular septal defects in 17 (28.8%) patients. No significant differences were observed between the groups in terms of mortality and postoperative atrioventricular valve insufficiency. The median follow-up duration for discharged patients was 5 months (7 days to 3.9 years). Throughout the follow-up period, there were no reoperations due to valve insufficiency or left ventricular outflow tract obstruction. Glutaraldehyde-treated autologous pericardium is a safe material that can be confidently used for the repair of the ventricular component of complete atrioventricular septal defects. This patch material does not adversely affect atrioventricular valve function and allows for the successful closure of ventricular septal defects.

Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p=0.001), complete heart block (13.54% vs 9.36%, p=0.01), and permanent pacemaker placement (8.03% vs 6.03%, p=0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p=0.679).

SAT484 High Degree AV Block And Sinus Arrest: Cardiovascular Manifestations Of Myxedema Coma

Abstract Disclosure: J. Bosques-Lorenzo: None. P. Rivera: None. J. Colon-Castellano: None. Y. Otero-Dominguez: None. Bosques-Lorenzo Jaymilitte, Rivera-Cariño Patricia, Colon-Castellano Janet, Otero-Dominguez Yomaira. Background: Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. The most common presenting symptoms are altered mentation, hypothermia, edema, and respiratory depression. The cardiovascular system is often involved, in the form of sick sinus syndrome, bradycardia, low voltage QRS complex, QT prolongation, and rarely cardiac arrest. Here we present a case of myxedema coma complicated with high degree AV block and sinus arrest. Clinical Case: A 84 year-old man with history of hypothyroidism on levothyroxine 125 mcg, presented to the ER due to disorientation, bilateral leg edema, and abdominal discomfort for 3 days. Vital signs revealed a temperature of 97.5 F, HR of 60bpm, BP 174/88 mmHg, and oxygen saturation of 100% at room air. Physical exam was pertinent for bilateral lower extremity edema, facial puffiness, macroglossia, slow mentation, and scattered rales on lung auscultation. Laboratories showed an elevated TSH (296.8 uIU/mL), with low total T3 and free T4 (45.03 ng/dL and 0.228 ng/dL respectively) with a myxedema score of 45. Altered renal parameters as per BUN and creatinine levels (83.4 mg/dL and 5.75 mg/dL) without electrolytes disturbances and elevated CPK (1250 U/L). Infectious process was ruled out. Chest X-ray showed vascular congestion. Echocardiogram showed a small pericardial effusion. Patient was admitted to ICU and started on IV Levothyroxine, along with hydrocortisone. Liothyronine was initially not available. On second admission day, the patient developed hypothermia (94.3 F) which was managed with passive warming. Telemetry monitoring recorded multiple episodes of bradycardia raging from 30 to 50 bpm, high-degree AV block, and one episode of sinus arrest of 15 seconds with self-resolution. Altered mentation persisted for which endotracheal intubation was performed to secure airway. A temporary transvenous pacing was placed emergently. Levothyroxine dose was further adjusted and liothyronine was initiated. After a few days of treatment, patient demonstrated clinical improvement that was supported with follow up thyroid function test. Patient was extubated and transitioned to oral levothyroxine. Nevertheless, he remained dependent of transvenous pacing for which permanent pacemaker placement was coordinated. Conclusion: Cardiovascular complications in myxedema coma are associated with poor prognosis with a mortality approaching 80%. Few cases of sinus or cardiac arrest associated to Myxedema coma have been reported in the literature. In this case, the patient developed high-degree AV block with concomitant sinus arrest despite prompt initiation of intravenous thyroid hormone. Prompt identification of cardiovascular involvement can prevent cardiovascular morbidity and mortality in myxedema coma. Presentation Date: Saturday, June 17, 2023

Pacing-induced cardiomyopathy in patients with preserved ejection fraction undergoing permanent cardiac pacemaker placement.

Chronic right-ventricular (RV) pacing can worsen heart failure in patients with a low ejection fraction (EF), but little is known about pacing-induced cardiomyopathy (PICM) in patients with preserved EF. We aimed to investigate risk factors of PICM in these patients during long-term follow-up. The prospective registry at Chosun University Hospital, South Korea, included de novo patients with preserved EF undergoing transvenous permanent pacemaker (PPM) implantation for atrioventricular blockage from 2017 to 2021. Patients with EF ≥ 50% and expected ventricular pacing ≥ 40% were included. Composite outcomes were cardiac death (pump failure), hospitalization because of heart failure, PICM, and biventricular pacing (BVP) upgrade. A total of 168 patients (69 men, 76.3 ± 10.4 years) were included. During three years of follow-up, one patient died, 14 were hospitalized, 16 suffered PICM, and two underwent BVP upgrade. PICM were associated with reduced global longitudinal strain (GLS), prolonged paced QRS duration (pQRSd) and diastolic variables (E/e', LAVI). Cox regression analysis identified pQRSd (hazard ratio [HR], 1.111; 95% confidence interval [CI], 1.011-1.222; P = 0.03) and reduced GLS (HR, 1.569; 95% CI, 1.163-2.118; P = 0.003) as independent predictors of PICM. GLS showed high predictive accuracy for PICM, with an area under the curve of 0.84 (95% CI 0.779-0.894; P < 0.001) [GLS -12.0, 62.5% sensitivity, and 86.1% specificity]. RV pacing increased the risk of PICM in patients with preserved EF. Reduced GLS and prolonged pQRSd could help identify individuals at high risk of PICM even with preserved EF.

Age-Based Outcomes in Patients Who Underwent Septal Reduction Therapy

There are no national data on age-based outcomes of septal reduction therapy. Using the National Inpatient Sample, we included all adult patients who underwent septal myectomy (SM) or alcohol septal ablation (ASA) from 2005 to 2019. The primary objective was to evaluate the in-hospital mortality and new permanent pacemaker (PPM) placement after SM and ASA in 3 age groups. In total, 9,564 patients underwent SM and 5,084 underwent ASA. Compared with the age group 18 to 39years, the odds of in-hospital mortality after SM were similar in age group 40 to 64years and 4.46 times higher than in age group ≥65years; the higher mortality in the older group was explained by higher co-morbidity burden on the risk-adjusted analysis. Furthermore, compared with age group 18 to 39years, the odds of new PPM placement after SM were higher in the age groups 40 to 64years and ≥65years, despite the risk adjustment (adjusted odds ratio [AOR] 3.17, 95% confidence interval [CI] 1.33 to 7.58 and AOR 4.39, 95% CI 1.78 to 10.8, respectively). The odds of in-hospital mortality after ASA were similar in age groups 65 to 79years and 18 to 64years. However, the odds of in-hospital mortality were higher in the age group ≥80years than in the age group 18 to 64years, although this difference were not present after risk adjustment. The odds of new PPM after ASA were higher for the age groups 65 to 79years and ≥80years than age group 18 to 64years, despite the risk adjustment (AOR 1.78, 95% CI 1.22 to 2.60 and AOR 3.10, 95% CI 2.09 to 6.57, respectively). Finally, we also estimated these absolute risks in different age groups. In conclusion, this national data will inform health care providers to better understand the aged-based risks of outcomes after septal reduction therapy.

Predictive value of the frontal QRS-T angle for a permanent pacemaker requirement in patients undergoing transcatheter aortic valve implantation.

Despite recent advances, the requirement for permanent pacemaker (PPM) implantation after transcatheter aortic valve implantation (TAVI) remains high. The frontal QRS-T angle (fQRS-Ta) indicates ventricular electrical instability as well as ventricular depolarization and repolarization heterogeneity. The predictive value of fQRS-Ta for the PPM requirement after TAVI is lacking. Therefore, we aimed to investigate the predictive value of baseline fQRS-Ta for the requirement of PPM after TAVI. This is a retrospective study conducted at a single tertiary care center. The patients were divided into two groups: those who required a pacemaker (PPM group) and those who did not (No-PPM group). The optimal fQRS-Ta cut-off value for predicting a PPM requirement was determined by using receiver operating characteristic (ROC) curve analysis. Univariate and multivariate Cox regression analyses were used to determine the independent predictors of post-TAVI PPM placement. Final study population consisted of 184 patients. The mean age of the patients was 79.41 ± 7.88 years, and 61% (n = 113) were women. Twenty-seven patients who required PPM after TAVI were considered as the 'PPM group'. The baseline frontal QRS and T axes did not differ between the groups, but the fQRS-Ta was significantly higher in the PPM group. ROC analysis performed for the prediction of post-TAVI PPM need, the fQRS-Ta cut-off value was found to be 100.5 with a sensitivity of 74.1% and a specificity of 60.5% [AUC (95% CI): 0.637 (0.520 - 0.755), p: 0.023]. In multivariate analysis, age [HR (95% CI): 1.071 (1.005 - 1.142), p: 0.034] and fQRS-Ta [HR (95% CI): 2.509 (1.084 - 6.399), p: 0.044] were identified as independent risk factors for PPM requirement after TAVI. This study demonstrated that age and baseline fQRS-Ta were independent predictors of PPM requirements after TAVI in patients with aortic stenosis.