Predictors Of Procedural Failure Research Articles

Conduction system pacing: procedural success and failures over the years

Abstract Background Conduction system pacing (CSP) ensures physiological ventricular activation and avoids the dyssynchrony. New tools (sheaths and leads) can better assist the implant thus increasing procedural successes. Objective Retrospective analysis of CSP implants from the last 4 years, analyzing procedural success and failures. Methods From 2019 to 2022, 820 CSP implant were performed, being 66% of the overall implants (excluding SR and DR ICDs). 89% were PMs and 11% were ICDs. 32.6% were styled-driven leads while 67.4% were lumenless. Pacing indications were standard with prevalence of AV block (53.6%); AF with slow ventricular rate 14.8%; sinus node disease 12.9%; ablate&pace 3.7%; heart failure 12.8%, re-interventions after malfunction of a previous implant 2.2%. Mean age was 78±9 years; 61.8% were males. Results From 2019 to 2022, CSP was successfully achieved in 756 cases (92.2%) considering all indications. In 64 (7.8%) cases, CSP lead implant failed (17 lumenless leads; 47 stylet driven leads) and the lead was then implanted in RV septum or coronary sinus. Reasons for failure were: 2.7% suboptimal electrical parameters (mainly high threshold); 1.1% uncorrected BBB; 0.9% intraprocedural lead dislodgement; 1.4% impossibility to penetrate the septum; 1.4% severe right atrial enlargement; 0.3% unavailable venous access. Heart failure and left ventricular dysfunction (EF<45%) were found more frequently in the failed implant subgroup. Procedural failures were more frequently associated with more than 1 sheath and more than 1 lead utilization during the procedure. Interestingly, in 12.8 % of successful procedures the sheath was changed intraprocedurally; and in the 5.4% of successful procedures the lead was changed (from lumenless to styled-driven or viceversa). No predictors of procedural failure were found in the logistic regression analysis. IInterestingly, failed implants have not decreased over the years. Conclusions conduction system pacing is feasible in daily clinical practice. Both lumenless and stylet-driven lead can be utilized. Different sheaths allow to customize the procedure based on the anatomy. During a 4-year experience, the overall procedural success rate was 92.2% while 7.8% of the procedures failed. Interestingly the failure rate has not decreased over the years, likely being related to increasingly complex cardiac conditions where CSP has been attempted.CSP implant success and failures

Safety and Efficacy of Excimer Laser Powered Lead Extractions in Obese Patients: A GALLERY Subgroup Analysis.

The incidence of cardiac implantable electronic device (CIED)-related complications, as well as the prevalence of obesity, is rising worldwide. Transvenous laser lead extraction (LLE) has grown into a crucial therapeutic option for patients with CIED-related complications but the impact of obesity on LLE is not well understood. All patients (n = 2524) from the GermAn Laser Lead Extraction RegistrY (GALLERY) were stratified into five groups according to their body mass index (BMI, <18.5; 18.5-24.9; 25-29.9; 30-34.9; ≥35 kg/m2). Patients with a BMI ≥ 35.0 kg/m2 had the highest prevalence of arterial hypertension (84.2%, p < 0.001), chronic kidney disease (36.8%, p = 0.020) and diabetes mellitus (51.1%, p < 0.001). The rates for procedural minor (p = 0.684) and major complications (p = 0.498), as well as procedural success (p = 0.437), procedure-related (p = 0.533) and all-cause mortality (p = 0.333) were not different between groups. In obese patients (BMI ≥ 30 kg/m2), lead age ≥10 years was identified as a predictor of procedural failure (OR: 2.99; 95% CI: 1.06-8.45; p = 0.038). Lead age ≥10 years (OR: 3.25; 95% CI: 1,31-8.10; p = 0.011) and abandoned leads (OR: 3.08; 95% CI: 1.03-9.22; p = 0.044) were predictors of procedural complications, while patient age ≥75 years seemed protective (OR: 0.27; 95% CI: 0.08-0.93; p = 0.039). Systemic infection was the only predictor for all-cause mortality (OR: 17.68; 95% CI: 4.03-77.49; p < 0.001). LLE in obese patients is as safe and effective as in other weight classes, if performed in experienced high-volume centers. Systemic infection remains the main cause of in-hospital mortality in obese patients.

P29 LVOTO IN HCM: HYBRID TREATMENT MAY STILL NOT SOLVE CHALLENGING CASES

Abstract MA, a 28 years old male with a diagnosis of OHCM since 2008, came to our attention for effort dyspnea (NYHA II) and fatigue limiting his greengrocer activity. Decompensated T1DM (HbA1C 12%), HTN, obesity (BMI 37). In 2017 he implanted a bicameral ICD in primary prevention, later extracted for sepsis and replaced with S–ICD. In the last 2 years he had 3–4 episodes of FAP, the latter causing an AHF requiring hospitalization in ICU. CV therapy: metoprolol 100 mg bid; disopyramide 100 mg x 3; rivaroxaban 20 mg die, insulin. Resting ECG: sinus bradycardia, HR 50 bpm, LVH with secondary repolarization abnormalities, long QTc (&amp;gt;500 ms). At basal and stress echocardiography (Fig. 1) he had a maximum wall thickness at medium IVS of 21 mm and severe dynamic obstruction due to complete SAM (Gmax 50 –&amp;gt; 135 mmHg); moderate mitral regurgitation, secondary to SAM, with eccentric jet; worsening of obstruction and MR at peak of stress (Gmax 145 mmHg; MR 3+); absence of pulmonary hypertension; severe left atrial dilatation (53ml/mq). He was considered not eligible for Morrow myectomy due to unfavorable anatomy (basal IVS of 11–14 mm, maximum thickness at medium IVS). Mitral valve area was &amp;gt; 4cmq. After Heart Team evaluation the patient was proposed for a reparative approach of mitral valve, and TEER was preferred to open surgery for favorable anatomy and to avoid an increased peri–operative risk in a patient with different comorbidities. The procedure was successfully conducted with the implantation of 1 MitraClip (MITRACLIP® Evalve – Abbott) in central position, with echocardiographic evidence (Fig. 2) of complete SAM resolution, reduction of MR to 1+ and gradient abolition (13 mmHg post–Valsalva maneuver). MVA at intraoperative TEE: &amp;gt;2 cmq. At six–months follow–up the patient reported a satisfactory reduction of symptoms without limitations in non–agonist physical activity and work, yet he still was not asymptomatic. Although on best medical treatment and after TEER, transthoracic echocardiographic control showed a recurrence of SAM and LVOTO (40 mmHg at basal, 70 mm Hg post – Valsalva maneuver). He is still candidate to myosin inhibition treatment. This case highlights the multiple challenges of LVOTO in HCM patients. Although a hybrid approach may be a promising treatment of OHCM, especially in youngers, an increase of expertise in this field and further research is needed, focusing on predictors of procedural failure and success.

&lt;i class="fa fa-video-camera" aria-hidden="true"&gt;&lt;/i&gt; Quince a�os de intervencionismo percut�neo de la oclusi�n total coronaria cr�nica. Experiencia, resultados y pron�stico cl�nico

Introduction and objectives: Chronic total coronary occlusion (CTO) is often a complex entity to deal with through a percutaneous coronary intervention, and the clinical benefits of successful recanalization still remain uncertain. Most registries feature data in limited time periods and do not reflect the impact that specific dedicated programs have on recanalization. Our study evaluates the results of a CTO program on a long-term period of time. Methods: All patients’ CTOs treated with percutaneous coronary interventions at our center from 2002 through 2017 were prospectively included in the registry. The clinical, angiographic and procedural data were collected, and clinical follow-up was conducted. Three consecutive periods of time were considered for the analysis of temporal trends. Results: A total of 424 CTOs (408 patients) were included. In 339 patients (80%) the procedure was successful. The rate of success increased over time, from 57% in 2002-2006 to 87% in 2012-2017 (P = .001). The most important independent predictor of procedural failure was lesion tortuosity. After a median follow-up of 39.7 months, the rates of major adverse cardiovascular events and cardiovascular mortality in success vs failed groups were 13.9% vs 24.7% (P = .015) and 3.6% vs 14.1% (P = .001), respectively. These were the independent predictors of cardiovascular mortality: chronic kidney disease, left anterior descending artery occlusion, and procedural failure. Conclusions: Our series shows a high rate of success in CTO recanalization, which has increased over the last few years due to greater expertise and improved program-specific technical advances. Several angiographic and procedural variables have been identified as predictors of failure. Successful procedures, especially on the left anterior descendent coronary artery, were associated with lower rates of cardiovascular mortality.

Procedural Predictors and Outcomes of Percutaneous Secundum Atrial Septal Defect Closure in Children Aged

Percutaneous atrial septal defect (ASD) closure is the treatment of choice for patients with a suitable ASD anatomy; however, the procedural characteristics and outcomes in children aged <6 years are unclear. The feasibility and safety of percutaneous ASD closure in children aged <6 years was evaluated and the predictors of procedural failure and challenging cases were identified. Patients from a single center between 2006 and 2018 (n=407) were retrospectively evaluated. There were 265 (65.1%) female patients. The median age at the time of the procedure and ASD size were 3.4 (0.9-5.9) years and 13.3 (3.8-27.0) mm, respectively. Medical records and echocardiographic images were analyzed. A challenging case was indicated by the use of non-conventional techniques. The procedure was completed in 399 patients (98.0%). Post-procedural acute complications occurred in 5 patients, including 1 with device embolization. Two patients underwent surgical device removal. During the follow up (30.3 [3.6-140.8] months), aggravated mitral regurgitation occurred in 5 patients. A multivariate logistic regression revealed large-sized ASD as a predictor of procedural failure (odds ratio=1.828, 95% confidence interval: 1.139-2.934, P=0.012) and challenging cases (odds ratio=1.371, 95% confidence interval: 1.180-1.593, P<0.001). Percutaneous ASD closure is feasible and safe in children aged <6 years; however, patients with large-sized ASD are at high risk of procedural failure and becoming a challenging case.

Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation.

In patients undergoing atrial fibrillation (AF) ablation, an enlarged left atrium (LA) is a predictor of procedural failure as well as AF recurrence on long term. The most used method to assess LA size is echocardiography-measured diameter, but the most accurate remains computed tomography (CT).The aim of our study was to determine whether there is an association between left atrial diameters measured in echocardiography and the left atrial volume determined by CT in patients who underwent AF ablation.The study included 93 patients, of whom 60 (64.5%) were men and 64 (68.8%) had paroxysmal AF, who underwent AF catheter ablation between January 2018 and June 2019. Left atrial diameters in echocardiography were measured from the long axis parasternal view and the LA volume in CT was measured on reconstructed three-dimensional images.The LA in echocardiography had an antero-posterior (AP) diameter of 45.0 ± 6 mm (median 45; Inter Quartile Range [IQR] 41–49, range 25–73 mm), longitudinal diameter of 67.5 ± 9.4 (median 66; IQR 56–88, range 52–100 mm), and transversal diameter of 42 ± 8.9 mm (IQR 30–59, range 23–64.5 mm). The volume in CT was 123 ± 29.4 mL (median 118; IQR 103–160; range 86–194 mL). We found a significant correlation (r = 0.702; P < .05) between the AP diameter and the LA volume. The formula according to which the AP diameter of the LA can predict the volume was: LA volume = AP diam3 + 45 mL.There is a clear association between the left atrial AP diameter measured on echocardiography and the volume measured on CT. The AP diameter might be sufficient to determine the increase in the volume of the atrium and predict cardiovascular outcomes.

Atrial fibrillation inducibility after pulmonary vein isolation under general anaesthesia.

Atrial fibrillation (AF) inducibility with rapid atrial pacing following AF ablation is associated with higher risk of AF recurrence. The predictive value of AF inducibility in paroxysmal AF patients after pulmonary vein isolation (PVI), done under general anaesthesia (GA), remains questionable since GA might alter AF inducibility and/or sustainability. Consecutive patients (n = 120) with paroxysmal AF without prior catheter ablation (CA) were enlisted in the study. All patients were ablated under GA. We have used a point-by-point CA and elimination of dormant conduction after adenosine in all patients. A predefined stimulation protocol was used to induce arrhythmias after PVI. Regular supraventricular tachycardias were mapped and ablated. Patients were divided into 3 subgroups - noninducible, inducible AF with spontaneous termination in five minutes, inducible AF without spontaneous termination. During 12 months of follow-up, all patients were examined four-times with 7-day ECG recordings. There was no statistical difference between the three subgroups in a rate of arrhythmia recurrence (11.1 vs. 27.5 vs. 27.3%, P=0.387), despite a clear trend to a better success rate in the non-inducible group. The subgroups did not differ in left atrial (LA) diameter (41.0±6, 43.0±7, 42.0±5 mm, P=0.962) or in any other baseline parameter. AF inducibility as well as presence or absence of its early spontaneous termination after PVI done under general anaesthesia in paroxysmal AF patients were not useful as predictors of procedural failure.

Multidisciplinary therapeutic and active follow-up protocols to reduce the rate of amputations and cardiovascular morbidities in patients with critical limb ischemia: IRANCLI study design and rationale – A prospective single-center registry in Iran

Objectives: The endovascular treatment (EVT) of patients with critical limb ischemia (CLI) has received considerable interest in recent years and has significantly affected the associated amputation and survival rates. Nonetheless, that this management modality may be influenced by various logistical and regional situations prompted us to design a local registry to evaluate its applicability and efficacy in our community.Methods: The IRANCLI study is a prospective, observational study that has been established as a registry. The therapeutic and follow-up protocols of this study have been approved by a multidisciplinary team. Recruited patients with CLI are followed up after in-hospital therapeutic management, endovascular revascularization, or minor amputations or debridement in cases with ulcers. The follow-up consists of active monitoring to spot patients with a recurrence of CLI signs and symptoms at early stages. Within 3 years, eligible patients are recruited to the study and are followed up for 3 years. Analyses are carried out to evaluate outcomes – comprising major adverse limb events (the primary outcome), amputation-free survival, limb salvage, event-free survival, major adverse cardiovascular and cerebrovascular events, 30 days' postprocedural adverse events, and procedural success. The predictors of procedural failure and long-term follow-up adverse events are assessed. Result and Conclusion: The IRANCLI study evaluates postendovascular revascularization outcomes and the long-term follow-up of patients with CLI. Uncovering the predictors of EVT failure and adverse events during the follow-up may improve the prospect of cases with CLI by streamlining the determination of both the patients who would benefit the most from EVT and those who would need a closer active follow-up.

PREDICTIVE SCORE FOR CHOOSING STRATEGY FOR CHRONICALLY OCCLUDED CORONARY ARTERY RECANALIZATION

Background. Despite signifcant progress in the feld of coronary interventions, chronic total occlusion (CTO) represents a signifcant challenge for interventional cardiologists.Aim. To develop the score, able to predict technical success of CTO PCI and facilitate the choice of recanalization strategy.Methods. A total of 665 CTO patients who underwent 681 PCI in the period from 2014 to 2018 in Meshalkin National Medical Research Center were included in this study. Clinical and angiographic characteristics were analyzed. 477 CTO PCI were randomly assigned to the derivation set, 204 CTO PCI – validation set. The prognostic model was developed by assigning a score for each independent predictor of procedural failure in accordance with beta coeffcients and summing up all scores.Results. Procedural success was 76.7%. Five predictors of procedural success were included into the fnal multivariable model: bending (1 score), calcifcation (1 score), ambiguous stump (1 score), “donor” artery disease (1 score), non-RCA CTO (0.5 scores). Based on these predictors, 4 categories of CTO complexity were highlighted: 0–1 scores (easy), 1–2 scores (intermediate), 2–3 scores (diffcult), &gt; 3 scores (very diffcult). The score demonstrated a good discriminatory ability (AUC 0.709, 95% CI 0.658–0.760). According to the novel score retrograde approach may have an advantage in patients with a &gt; 3 scores, which corresponds to the "very diffcult" class of complexity.Conclusion. The novel score can be used in clinical practice for predicting the success of CTO PCI and determining initial crossing strategy.

Outcome of direct current cardioversion for atrial arrhythmia in adult Fontan patients

BackgroundLimited data are available about direct current cardioversion (DCCV) in Fontan patients. MethodsRetrospective review of adult Fontan patients that underwent DCCV for atrial arrhythmias at Mayo Clinic, 1994–2014. Study endpoints were to determine procedural success, safety, and the freedom from arrhythmia recurrence after DCCV. Procedural success was defined as termination of the presenting atrial arrhythmia prior to leaving the cardioversion suite. Results86 patients underwent 152 DCCV; age 27±8years; male 49 (57%); atriopulmonary Fontan, 64 (74%); atrial flutter/interatrial reentry tachycardia 125 (82%). Freedom from recurrence was 84% and 47% at 12 and 36months; freedom from repeat DCCV was 91% and 64% at 12 and 36months. Procedural failure occurred in 41 (27%); predictors of procedural failure were older age (HR 1.91, CI 1.16–2.73 per decade) and prior DCCV (HR 2.71, CI 1.22–3.21). Concomitant oral class I or III antiarrhythmic medication was associated with an increased likelihood of success (HR 0.64, CI 0.41–0.87). Predictors of recurrence were older age (HR 3.26, CI 1.19–6.55 per decade); duration of arrhythmia (HR 1.87, CI 1.14–2.56 per decade); and presence of atriopulmonary Fontan (HR 1.54, CI 1.27–1.85). Procedural complications were symptomatic bradycardia in 2 cases (1%). No thromboembolic complications or deaths occurred. ConclusionDCCV in Fontan patients is safe but is associated with significant procedural failure and recurrence rates. Ideally, antiarrhythmic medication should be instituted prior to DCCV in stable patients and DCCV alone should be considered as a temporizing measure to maintain sinus rhythm.

Percutaneous occlusion of vascular malformations in pediatric and adult patients: 20-year experience of a single center.

A case series on different vascular malformations (VM) treated with percutaneous occlusion in children and adults is presented. Percutaneous occlusion is usually the preferred treatment method for VM. Previous series have mostly focused on single types of devices and/or VM. Retrospective analysis of all patients who underwent percutaneous occlusion of VM in a single center, from 1995 to 2014, excluding patent ductus arteriosus. Clinical and angiographic data, procedural details, implanted devices, and complications were assessed. Procedural success was defined as effective device deployment with none or minimal residual flow. Predictors of procedural failure and complications were determined by multivariate analysis. A total of 123 VM were intervened in 47 patients with median age of 12 years (25 days-76 years). The VM included 55 pulmonary arteriovenous fistulae, 39 aortopulmonary collaterals, 10 systemic venovenous collaterals, 8 peripheral arteriovenous fistulae, 5 Blalock-Taussig shunts, 4 coronary fistulae, and 2 Fontan fenestrations. The 143 devices used included 80 vascular plugs, 38 coils, 22 duct occluders, and 3 foramen ovale or atrial septal defect occluders. Median vessel size was 4.5 (2.0-16.0) mm and device/vessel size ratio was 1.4 (1.1-2.0). Successful occlusion was achieved in 118 (95.9%) VM, including three reinterventions. Four (3.3%) clinically relevant complications occurred, without permanent sequelae. Lower body weight was independently associated with procedural failure and complications. To our knowledge, this is the largest series on different VM occluded percutaneously in children and adults, excluding patent ductus arteriosus. Percutaneous occlusion was effective and safe, using different devices.

Succès et complications de l’angioplastie des occlusions coronaires chroniques

In the hands of experienced operators, the rate of success of percutaneous coronary intervention for chronic total occlusion lesion is about 85%. Major cardiac events rate is about 2%. A length of the occluded site more than 20 mm, severe calcifications, major tortuosity, blunt stump and a previous attempt by anterograde approach are predictors of procedural failure, previous CABG, distal vessel disease, occlusion duration have been involved too. Operator's experience is one of the major success component, especially his ability to perform retrograde approach. According to EuroCTO club recommendations, performing a minimum number of case to maintain competency seems to be very important.

Mechanism and Predictors of Failed Transradial Approach for Percutaneous Coronary Interventions

The study aimed to determine the mechanism and predictors of procedural failure in patients undergoing percutaneous coronary intervention (PCI) from the transradial approach (TR). Transradial approach PCI reduces vascular complications compared with a transfemoral approach (TF). However, the mechanism and predictors of TR-PCI failure have not been well-characterized. The study population consisted of patients undergoing TR-PCI by low-to-intermediate volume operators with traditional TF guide catheters. Baseline characteristics, procedure details, and clinical outcomes were prospectively collected. Univariate and multivariate analyses were performed to determine independent predictors of TR-PCI failure. A total of 2,100 patients underwent TR-PCI and represented 38% of PCI volume. Mean age was 64 +/- 12 years, and 17% were female. Vascular complications occurred in 22 (1%), and TR-PCI failure was observed in 98 (4.7%) patients. The mechanism of TR-PCI failure included inability to advance guide catheter to ascending aorta in 50 (51%), inadequate guide catheter support in 35 (36%), and unsuccessful radial artery puncture in 13 (13%) patients. The PCI was successful in 94 (96%) patients with TR-PCI failure by switching to TF. On multivariate analysis, age >75 years (odds ratio [OR]: 3.86; 95% confidence interval [CI]: 2.33 to 6.40, p = 0.0006), prior coronary artery bypass graft surgery (OR: 7.47; 95% CI: 3.45 to 16.19, p = 0.0002), and height (OR: 0.97; 95% CI: 0.95 to 0.99, p = 0.02) were independent predictors of TR-PCI failure. Transradial approach PCI can be performed by low-to-intermediate volume operators with standard equipment with a low failure rate. Age >75 years, prior coronary artery bypass graft surgery, and short stature are independent predictors of TR-PCI failure. Appropriate patient selection and careful risk assessment are needed to maximize benefits offered by TR-PCI.

AS-233: Predictors of Procedural Failure in the Recanalization of Coronary Chronic Total Occlusions

AS-233: Predictors of Procedural Failure in the Recanalization of Coronary Chronic Total Occlusions

An indeterminate occlusion duration predicts procedural failure in the recanalization of coronary chronic total occlusions

To identify the impact of occlusion duration (OD) and, in particular, an indeterminate occlusion duration (IOD) on immediate angiographic success and long-term clinical outcomes in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). From May 2003 to October 2006, all patients having PCI for a CTO were consecutively registered. In addition to an assessment of procedural outcomes, patients were followed long-term for occurrence of major adverse cardiac events (MACE). 202 consecutive patients were included. Of these, 123 (60.9%) had a known OD while in the remaining 79 (39.1%), OD was indeterminate. Overall technical success was 82.7% and was lower in the IOD group (70.9% vs. 90.2%, P = 0.0004). An IOD was a predictor of procedural failure (adjusted OR 4.51, 95% CI 1.7-11.5, P = 0.002). An IOD (HR 2.59, 95%CI 1.08-6.23, P = 0.032) and procedural success (HR 0.26, 95%CI 0.11-0.60, P = 0.002) were the only independent predictors of long-term MACE. Patients with a failed PCI and an IOD had a 5-fold increased risk of MACE compared to those with known OD (37.0% vs. 7.1%, log rank P = 0.0036). In addition to the traditional predictors of procedural success and clinical outcome, this study, for the first time uncovered the importance of OD and, in particular, of an IOD. Still, in patients who are successfully recanalized, a long or IOD bears the same low rate of MACE as the general CTO population while in patients with failed PCI, an IOD carries a considerable risk of adverse prognosis.

1052-224 Pre-existent left atrial scarring in patients undergoing pulmonary vein isolation: An independent predictor of procedural failure

1052-224 Pre-existent left atrial scarring in patients undergoing pulmonary vein isolation: An independent predictor of procedural failure