Predictor Of Ventricular Arrhythmias Research Articles

Diagnostic and Prognostic Value of Right Ventricular Fat Quantification from Computed Tomography in Arrhythmogenic Right Ventricular Cardiomyopathy.

Background: In arrhythmogenic right ventricular cardiomyopathy (ARVC) non-invasive scar evaluation is not included among the diagnostic criteria or the predictors of ventricular arrhythmias (VA) and sudden death (SD). Computed tomography (CT) has excellent spatial resolution and allows a clear distinction between myocardium and fat; thus, it has great potential for the evaluation of myocardial scar in ARVC. Objective: The objective of this study is to evaluate the feasibility, and the diagnostic and prognostic value of semi-automated quantification of right ventricular (RV) fat replacement from CT images. Methods: An observational case-control study was carried out including 23 patients with a definite (19) or borderline (4) ARVC diagnosis and 23 age- and sex-matched controls without structural heart disease. All patients underwent contrast-enhanced cardiac CT. RV images were semi-automatically reconstructed with the ADAS-3D software (ADAS3D Medical, Barcelona, Spain). A fibrofatty scar was defined as values of Hounsfield Units (HU) <-10. Within the scar, a border zone (between -10 HU and -50 HU) and dense scar (<-50 HU) were distinguished. Results: All ARVC patients had an RV scar and all scar-related measurements were significantly higher in ARVC cases than in controls (p < 0.001). The total scar area and dense scar area showed no overlapping values between cases and controls, achieving perfect diagnostic performance (sensitivity and specificity of 100%). Among ARVC patients, 16 (70%) had experienced sustained VA or aborted SD. Among all clinical, ECG and imaging parameters, the dense scar area was the only one with a statistically significant association with VA and SD (p = 0.003). Conclusions: In ARVC, RV myocardial fat quantification from CT is feasible and may have considerable diagnostic and prognostic value.

Implantable Loop Recorders in patients with Brugada Syndrome: the BruLoop Study

Abstract Aims Available data on continuous rhythm monitoring by implantable loop recorders (ILRs) in patients with Brugada syndrome (BrS) are scarce. Aim of this multicentre study was to evaluate the diagnostic yield and clinical implication of a continuous rhythm monitoring strategy by ILRs in a large cohort of BrS patients, and to assess the precise arrhythmic cause of syncopal episodes. Methods and Results A total of 370 patients with BrS and ILRs (mean age 43.5±15.9, 33.8% females) from 18 international centers were included. Overall, 274 (74.1%) were implanted due to symptoms (69.3% syncope, 30.7% palpitations). Over a median follow-up of 3 years, an arrhythmic event was recorded in 30.7% of symptomatic patients (18.6% atrial arrhythmias (AAs); 10.2% bradyarrhythmias (BAs) and 7.3% ventricular arrhythmias (VAs)). In patients with recurrent syncope, the etiology was arrhythmic in 22.4% (59.3% BAs, 25.0% VAs and 15.6% AAs). The ILR led to drug therapy initiation in 11.4%, ablation procedure in 10.9%, implantation of PM in 2.5% and ICD in 8%. At multivariate analysis, the presence of symptoms (HR 2.5, p=0.001) and age &amp;gt;50 years (HR 1.7, p=0.016) were independent predictors of arrhythmic events, while inducibility of VF at EP study (HR 9.0, p&amp;lt;0.001) was predictor of ventricular arrhythmias. Conclusion ILR detects arrhythmic events in nearly 30% of symptomatic BrS patients, leading to an appropriate therapy in 70% of them. The most commonly detected arrhythmias are AAs and BAs, while VAs are detected only in 7% of cases. Symptom status can be used to guide ILR implantation.General ResultsArrhythmias

Atrial and Ventricular Strain Imaging Using CMR in the Prediction of Ventricular Arrhythmia in Patients with Myocarditis

(1) Objective: Myocarditis can be associated with ventricular arrhythmia (VA), individual non-invasive risk stratification through cardiovascular magnetic resonance (CMR) is of great clinical significance. Our study aimed to explore whether left atrial (LA) and left ventricle (LV) myocardial strain serve as independent predictors of VA in patients with myocarditis. (2) Methods: This retrospective study evaluated CMR scans in 141 consecutive patients diagnosed with myocarditis based on the updated Lake Louise criteria (29 females, mean age 41 ± 20). The primary endpoint was VA; this encompassed ventricular fibrillation, sustained ventricular tachycardia, nonsustained ventricular tachycardia, and frequent premature ventricular complexes. LA and LV strain function were performed on conventional cine SSFP sequences. (3) Results: After a median follow-up time of 23 months (interquartile range (18–30)), 17 patients with acute myocarditis reached the primary endpoint. In the multivariable Cox regression analysis, LA reservoir (hazard ratio [HR] and 95% confidence interval [CI]: 0.93 [0.87–0.99], p = 0.02), LA booster (0.87 95% CI [0.76–0.99], p = 0.04), LV global longitudinal (1.26 95% CI [1.02–1.55], p = 0.03), circumferential (1.37 95% CI [1.08–1.73], p = 0.008), and radial strain (0.89 95% CI [0.80–0.98], p = 0.01) were all independent determinants of VA. Patients with LV global circumferential strain &gt; −13.3% exhibited worse event-free survival compared to those with values ≤ −13.3% (p &lt; 0.0001). (4) Conclusions: LA and LV strain mechanism on CMR are independently associated with VA events in patients with myocarditis, independent to LV ejection fraction, and late gadolinium enhancement location. Incorporating myocardial strain parameters into the management of myocarditis may improve risk stratification.

Predictors of ventricular arrhythmias in patients with left ventricular assist devices

Predictors of ventricular arrhythmias in patients with left ventricular assist devices

Relationship between corrected QT prolongation and new-onset atrial fibrillation in the general Japanese population

Abstract Background The QT interval, an electrocardiogram (ECG) parameter, can be corrected for heart rate, giving the QTc. The QTc is an indicator of ventricular repolarisation and is widely used as a predictor of ventricular arrhythmia. Recent studies have reported a relationship between prolonged QTc and atrial fibrillation (AF) development. Purpose We investigated whether a relationship between QTc prolongation and new-onset AF could be identified in the general Japanese population. Methods This retrospective study evaluated the annual health check-up data of 103,304 adults (50,438 males; age, 54±15 years) that did not have AF at baseline, from April 2005 to October 2018. Most participants underwent annual health examinations as recommended by the Japanese health welfare policy. The QTc times were calculated with the Bazett formula (QTc=QT/√RR), using the mean QT and RR intervals. Participants were grouped according to QTc time: long-QTc group (males, &amp;gt;440 ms; females, &amp;gt;460 ms) and normal-QTc group. AF was diagnosed using a 12-lead surface ECG. Logistic regression analyses were performed to determine the strength of the association between prolonged QTc and new-onset AF. Multivariate analyses were adjusted for clinical variables (age, sex, obesity, hypertension, dyslipidaemia, diabetes, estimated glomerular filtration rate, and habitual drinking). Results The median follow-up time for the total study population was 6 years. During follow-up, 341 (0.3%) new cases of AF were recorded. Univariate analysis revealed a significant increase in new-onset AF in the long-QTc group (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.85–4.25; p&amp;lt;0.001). After adjusting for clinical variables, multivariate analysis revealed that a long QTc was significantly associated with new-onset AF (OR, 1.71; 95% CI, 1.12–2.61; p=0.013). In the multivariate analysis, age (OR, 1.06; 95% CI, 1.05–1.07; p&amp;lt;0.001), sex (OR, 2.55; 95% CI, 1.95–3.33; p&amp;lt;0.001), obesity (OR, 1.46; 95% CI, 1.16–1.84; p=0.001), and habitual drinking (OR, 1.90; 95% CI, 1.50–2.41; p&amp;lt;0.001) were also significant predictors of new-onset AF. Conclusions Prolonged QTc is associated with an increased risk of new-onset AF in the general Japanese population. The mechanism of this causal relationship requires further investigation.

Abstract 12905: Epicardial and Intramyocardial Fat as Predictors of Ventricular Arrhythmia in Ischemic and Non-Ischemic Cardiomyopathy

Background: Sudden cardiac death from ventricular arrhythmia (VA) is a global concern. While emerging evidence suggests a role for myocardial fat in the development of VA among ischemic (ICM) and non-ischemic cardiomyopathy (NICM) patients, the volume and distribution of epicardial adipose tissue (EAT) and intramyocardial fat (IMF) linked to VA remain underexplored. Objective: To evaluate the predictive value of LV tissue heterogeneity, EAT, and IMF volumes in assessing the risk of VA in ICM and NICM patients. Methods: Patients enrolled in the PROSE-ICD registry, who underwent contrast-enhanced computed tomography were included. The designated endpoint was ventricular arrhythmia, defined as appropriate ICD shock or sudden arrhythmic death. IMF volume (voxels between -180 and -5 HU), EAT volume (voxels between -200 to -50 HU), and myocardial fat tissue heterogeneity (defined as the magnitude of change between nearby voxels) were calculated. Logistic regression models were employed to assess the association between explanatory variables and outcome. Results: 98 patients (47 ICM, 51 NICM) were included with a mean follow up time of 5.6±3.4 years. Participants’ mean age was 56±13.2 years, and 66% were male. LV tissue heterogeneity (per HU/mm) was associated with VA incidence (OR = 1.11; P &lt; 0.01) in the ICM cohort, whereas EAT and IMF volume were associated with VA in the NICM subgroup [(OR = 1.12; P &lt; 0.01), and (OR = 1.21; P = 0.01), respectively]. Even after adjusting for various covariates, LV tissue heterogeneity in the ICM group and EAT in the NICM group maintained a significant association with VA. Conclusion: In ICM, increased fat distribution heterogeneity is associated with VA, while in NICM, increased IMF and EAT volume are linked to a higher risk for VA. These findings suggest that LV tissue heterogeneity and EAT volume offer valuable prognostic insights in cardiomyopathy patients, indicating that the contribution of fat to VA depends on the underlying substrate.

Abstract 13785: QT Prolongation and QT Variability Predict New-Onset Atrial Fibrillation in the General Japanese Population

Background: The QT interval, an electrocardiogram (ECG) parameter, can be corrected for heart rate to obtain the QTc, an indicator of ventricular repolarization widely used as a predictor of ventricular arrhythmia. Although prolonged QTc and atrial fibrillation (AF) development are linked, there are few reports of QTc variability and AF development. Purpose: To identify a relationship between QTc prolongation and variability and new-onset AF in the general Japanese population. Methods: This retrospective study evaluated the annual health check-up data of 103,304 adults (50,438 males; age, 54±15 years) without AF at baseline, between April 2005 and October 2018. Most participants underwent annual health examinations as recommended by the Japanese health welfare policy. The QTc times were calculated with the Bazett formula (QTc=QT/√RR), using the mean QT and RR intervals. QTc variability was evaluated as the difference between the maximum and minimum QTc values at multiple checkups. AF was diagnosed using a 12-lead surface ECG. The strength of the association between QTc prolongation and variability and new-onset AF was determined using logistic regression analyses. Multivariate analyses were adjusted for clinical variables (age, sex, obesity, hypertension, dyslipidemia, diabetes, estimated glomerular filtration rate, and habitual drinking). Results: The median follow-up time was 6 years. During follow-up, 341 (0.3%) new AF cases were recorded. Univariate analysis revealed a significant increase in new-onset AF in the QTc prolongation (odds ratio [OR] per 10 ms, 1.08; 95% confidence interval [CI], 1.03-1.13; p&lt;0.001) and the QTc variability (OR per 10 ms, 1.15; 95% CI, 1.07-1.23; p&lt;0.001). After adjusting for clinical variables, multivariate analysis revealed that QTc prolongation and variability were significantly associated with new-onset AF (OR per 10 ms, 1.09; 95% CI, 1.04-1.14; p&lt;0.001) (OR per 10 ms, 1.16; 95% CI, 1.09-1.24; p&lt;0.001). Conclusions: QTc prolongation and variability are associated with an increased risk of new-onset AF in the general Japanese population. Although they have been reported to be involved with the autonomic nervous system, the mechanism of this causal relationship requires further investigation.

Determinants of ventricular arrhythmias in sickle cell anemia: toward better prevention of sudden cardiac death

AbstractSudden death is 1 of the leading causes of death in adults with sickle cell anemia (SCA) but its etiology remains mostly unknown. Ventricular arrhythmia (VA) carries an increased risk of sudden death; however, its prevalence and determinants in SCA are poorly studied. This study aimed to identify the prevalence and predictors of VA in patients with SCA. From 2019 to 2022, 100 patients with SCA were referred to the physiology department to specifically analyze cardiac function and prospectively included in the DREPACOEUR registry. They underwent a 24-hour electrocardiogram monitoring (24h-Holter), transthoracic echocardiography, and laboratory tests on the same day. The primary end point was the occurrence of VA, defined as sustained or nonsustained ventricular tachycardia (VT), >500 premature ventricular contractions (PVCs) on 24h-Holter, or a recent history of VT ablation. The mean patient age was 46 ± 13 years, and 48% of the patients were male. Overall, VA was observed in 22 (22%) patients. Male sex (81% vs 34%; P = .02), impaired global longitudinal strain (GLS): –16% ± 1.9% vs –18.3% ± 2.7%; P = .02), and decreased platelet count (226 ± 96 giga per liter [G/L] vs 316 ± 130 G/L) were independently associated with VA. GLS correlated with PVC load every 24 hours (r = 0.39; P < .001) and a cutoff of –17.5% could predict VA with a sensitivity of 82% and a specificity of 63%. VAs are common in patients with SCA, especially in men. This pilot study uncovered GLS as a valuable parameter for improving rhythmic risk stratification.

PO-03-226 MACHINE LEARNING IDENTIFIES FEATURES OF ARRHYTHMOGENIC QRS FRAGMENTATION IN HUMAN CARDIOMYOPATHY: IMPLICATIONS FOR IMPROVING AND AUTOMATING RISK STRATIFICATION

Slow, heterogeneous ventricular activation can provide the substrate for reentrant ventricular arrhythmias (VA), but its manifestation on the surface ECG as a risk stratifier is not well-defined beyond the presence of QRS duration (QRSd) >120ms or QRS fragmentation (fQRS). Our aim was to use machine learning (ML) to characterize the spatiotemporal features of QRS fragmentation that best predict VA in patients with cardiomyopathy (CM). Prospectively enrolled ischemic and non-ischemic CM patients with prophylactic defibrillators (n=95) underwent digital, high-resolution 12-lead ECG recordings for 5-minutes during intrinsic rhythm. Abnormal intra QRS peaks in the signal-averaged precordial leads (V1-V6) were identified using our previously validated time-domain algorithm. For each spatial location (V1-V6), QRS peak characteristics including width, amplitude and relative temporal location within the QRS were transformed into 4-bin histograms. Random forest models of the QRS peak counts and characteristics in each lead were trained on groups of 76 patients and tested on groups of 19 patients with stratified repeated random subsampling cross-validation to determine the features that predicted VA outcome. QRS peak counts and characteristics were additionally modelled with QRSd and other relevant clinical characteristics. CM patients (age 62±11 yrs, male 85%, LVEF 27±7%, ischemic etiology 62%) were followed for 24 (15-43) months and 22% had VA (+VA). QRSd was longer in +VA than -VA (135±25 vs. 114±26ms, p=0.001), but age, LVEF, CM etiology and fQRS were similar. The individual ML models determined (ROCAUC) QRS peak count (0.87), width (0.88) and location (0.84) to be predictors of VA (Table). In these models, the features most predictive of VA were a greater peak count in V1, a greater # of peaks less <6.25% of the QRSd in V1 and a greater # of peaks in the final quarter of the QRS of V1 (Figure). ML models of peak amplitude, QRSd and fQRS were not predictive of VA. The addition of clinical variables to the QRS peak count, width and location models did not improve VA prediction. Arrhythmogenic ventricular substrate can be independently identified during intrinsic rhythm by QRS fragmentation in V1 characterized by either a greater total # of peaks, a greater # of very narrow peaks, or a greater # of peaks at the end of the QRS according to our ML model. These findings require external validation and may improve risk stratification in defibrillator-eligible CM patients.Tabled 1Table. Performance of Random Forest ML Model.ModelROC [95% CI]Prespecified SensitivitySpecificityPPVNPVF1-ScoreQRS duration0.57 [0.35-0.87]90%0.220.270.490.42Qualitative fQRS0.56 [0.33-0.73]90%0.120.240.350.38All clinical characteristics∗0.46 (0.22-0.70]90%0.220.260.930.41QRS peak characteristics- Total Count0.87 [0.65-1.00]90%0.640.501.000.64- Width0.88 [0.70-1.00]90%0.730.541.000.69- Amplitude0.66 [0.36-0.93]90%0.250.290.710.44- Temporal Location in QRS0.84 [0.66-1.00]90%0.630.471.000.62QRS peak + clinical characteristics*- Total Count0.79 [0.55-0.97]90%0.560.421.000.57- Width0.82 [0.58-0.97]90%0.630.451.000.61- Amplitude0.68 [0.42-0.93]90%0.360.320.960.48- Temporal Location in QRS0.76 [0.52-0.95]90%0.530.391.000.55Age, Sex, Cardiomyopathy, QRS duration, Heart Rate, LVEF, NYHA Class, Comorbidities and Cardiac Medications Open table in a new tab

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Abstract Background Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction. Methods We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into “core” DCF and “peri-infarct” GZF zones based on signal intensity (&amp;gt;5 SD, and 2–5 SD above the mean of reference myocardium, respectively). The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device. Results A total of 88 patients (median age 61 years [IQR 54–73], 84% male, median LVEF 30% [IQR 23–36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9–38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4±14.7 g vs. 28.0±15.3 g; P=0.601) but a greater amount of GZF (18.1±9.6 g vs. 11.9±6.7 g; P=0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95% CI: 1.02–1.15; P=0.006), whereas DCF was not (HR: 1.01 per gram; 95% CI: 0.98–1.05; P=0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01–1.12; P=0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9 g, but in only 2 of the 53 patients (3.8%) with GZF &amp;lt;11.9 g – Figure 1. Conclusions The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events. Funding Acknowledgement Type of funding sources: None.

Right ventricular longitudinal strain on CMR predicts ventricular arrhythmias and mortality in cardiac sarcoidosis

BackgroundRight ventricular (RV) dysfunction and late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) are associated with ventricular arrhythmias (VA) and mortality in cardiac sarcoidosis (CS). However, image resolution limits the detection of RV LGE. Global longitudinal RV strain (RVS) correlates to RV scar on electroanatomical mapping and RV function. ObjectiveWe evaluated the association between RVS on CMR and VA/death (combined-primary-endpoint (CPE)) in patients with CS. MethodsRVS and RV LGE on MRI were retrospectively compared to variables known to predict outcomes in 66 patients with CS. Outcomes were obtained from electronic medical records and implantable cardioverter defibrillator (ICD) interrogations over median [IQR] 3.7[1.7, 6.3] years. Cox proportional hazard models were used to evaluate survival. Harrell's C-statistic was used to compare variables in risk prediction models. Results62.1 % of patients were male, with a mean age [SD] of 52.3 [9.6] years and left ventricular ejection fraction (LVEF) of 51.1[17.5]%. 9 patients with the primary endpoint were more likely to be Caucasian (p = 0.01) with prior VAs (p = 0.002), be on anti-arrhythmic drugs (p = 0.001) with an ICD (p = 0.002). In multivariable analyses adjusted for age, race, and history of VA, RVS (1.18 [1.05–1.31], p = 0.004), RV EDVI (1.08[1.01, 1.14], p = 0.02), and LV LGE (1.07[1.00, 1.13], p = 0.04) predicted the CPE. Risk prediction models including RVS (Cstatistic 0.94), outperformed those including RV and LV LGE (0.89–0.92). ConclusionRVS on CMR was the best predictor of VA and mortality in CS.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct "gray zone" of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction. Methods We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into "core" DCF and "peri-infarct" GZF zones based on signal intensity (&amp;gt;5 SD, and 2-5 SD above the mean of reference myocardium, respectively). The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device. Results A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P = 0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P = 0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P = 0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF &amp;lt;11.9g – Figure. Conclusions The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Programmed ventricular stimulation for predicting arrhythmic events in patients with myocardial infarction: a systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background Left ventricular ejection fraction (LVEF) is at present the main parameter used to guide the implantation of cardioverter-defibrillators (ICD) in patients with ischaemic cardiomyopathy. However, LVEF alone is a poor predictor of ventricular arrhythmias (VA) and sudden cardiac death (SCD). The majority of ICDs implanted for the primary prevention of SCD never deliver appropriate therapies, while being an expensive therapy and being potentially iatrogenic. Therefore, insertion of ICDs based solely on LVEF is not efficient and calls for an improvement in the risk-stratification of post-myocardial infarction patients. Inducibility of ventricular arrhythmias with programmed ventricular stimulation (PVS) has been used in the past to assess the risk of malignant arrhythmias. However, its current role in clinical practice is unknown. Purpose The aim of this meta-analysis was to study the role of PVS to predict future arrhythmic events in patients with previous myocardial infarction. Methods We performed a systematic review and a random-effect meta-analysis of studies reporting VAs –defined as SCD, sudden cardiac arrest, sustained monomorphic ventricular tachycardia (SMVT) or appropriate ICD therapies– after PVS in patients with ischaemic heart disease. Whenever possible, we used inducibility of SMVT as the positive response to PVS. Otherwise, we used the definition pre-specified in the corresponding study. The primary outcome was to estimate the positive and negative predictive value (PPV and NPV, respectively) of PVS. Subgroup analyses were performed according to the PVS timing (&amp;lt;1 or ≥1 month after infarction), definition of a positive PVS, use of ICD, or study era (before or after 2000). We searched in MEDLINE, EMBASE and Cochrane Library electronic databases up to November 2021. Results Thirty studies were included with a total of 8253 patients (mean age 58.5 years, mean LVEF 38.8%). A total of 909 arrhythmic events occurred after a mean follow-up of 24.5 months. Overall, 23% (95% confidence interval [CI] 18-29%) of subjects had inducible arrhythmias with PVS. Inducibility was associated with a higher risk of subsequent VAs (odds ratio 6.26, 95% CI 3.97-9.89, p&amp;lt;0.001). The pooled NPV was 95%, (95% CI 93-96%, p&amp;lt;0.001) and the PPV was 25% (95% CI 20-31%, p&amp;lt;0.001). There was significant heterogeneity between studies (I2 78% for the odds ratio, 96% for the NPV and 68% for the PPV). There were no statistically significant differences in any of the values according to the pre-specified subgroups. Meta-regression showed a reduction of the NPV with longer follow-up (B coefficient –0.033; p=0.012). Conclusion PVS has a high NPV (95%) and could be useful to rule out subjects at low risk of arrhythmic events. However, it decreases with longer follow-ups and, thus, the arrhythmic risk may need to be reassessed.

PO-626-04 THE PERI-INFARCT “GRAY ZONE” OF MYOCARDIAL FIBROSIS IS A BETTER PREDICTOR OF VENTRICULAR ARRHYTHMIAS THAN DENSE CORE FIBROSIS IN PATIENTS WITH PREVIOUS MYOCARDIAL INFARCTION

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as arrhythmogenic substrates. We aimed to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction. We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into “core” DCF and “peri-infarct” GZF zones based on signal intensity (>5 SD, and 2-5 SD above the mean of reference myocardium, respectively). The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device. A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%]) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint. Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P=0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P=0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P=0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF <11.9g - Figure. The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

PO-656-01 PSEUDOINFARCT PATTERN IN CARDIAC SARCOIDOSIS: CORRELATION OF Q WAVES ON 12-LEAD ELECTROCARDIOGRAM WITH LATE GADOLINIUM ENHANCEMENT ON CARDIAC MRI AND PREDICTION OF VENTRICULAR TACHYARRHYTHMIAS

Screening for cardiac sarcoidosis (CS) with a 12-lead ECG is recommended in all patients with extra-cardiac sarcoidosis. Previous studies have characterized the poor sensitivity of AV conduction disease in screening for CS, but few have evaluated the presence of a pseudoinfarct pattern as a screening tool and a possible predictor of ventricular arrhythmias (VA).

Prognostic stratification of patients with low-risk hypertrophyc cardiomyopathy: the role of myocardial deformation imaging and myocardial fibrosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Hypertrophic cardiomyopathy (HCM) is associated with a high incidence of adverse cardiovascular events. Risk stratification for major cardiac events and management of HCM patients are still a serious challenge in cardiology. Current ESC guidelines recommend stratifying the risk of sudden cardiac death (SCD) at 5 years using a prediction model which evaluates clinical and echocardiographic criteria but this model does not include parameters of myocardial deformation at echocardiography and myocardial fibrosis at cardiac magnetic resonance. Purpose The aim of this study was to evaluate the predictive prognostic role of myocardial deformation imaging parameters derived by echocardiography (left ventricular global longitudinal strain GLS and PALS) and magnetic resonance parameters (extension of delayed enhancement DE) in a population of patients with HCM with low-risk of SCD, considering ESC prediction model. Methods We enrolled 166 patients, mean age 56.25 ± 16 with hypertrophic cardiomyopathy. A complete echocardiogram and a cardiac magnetic resonance were performed. After a period of 2.5 years, adverse cardiovascular events were evaluated: number of ICD shocks and ventricular arrhythmias, occurrence of atrial fibrillation (AF) or other supraventricular arrhythmias, symptoms of heart failure (HF) and or hospitalizations, heart transplant and death. Results 7 heart transplants, 8 deaths, 29 patients developed AF, 6 patients developed ventricular arrhythmias and/or ICD shock, 17 patients were hospitalized, 16 patients developed HF. Patients with cardiovascular events had significantly lower PALS values than patients without events (PALS 4.6 ± 2.6 vs 17.5 ± 3.26, p-value &amp;lt; 0.0001) and higher values left atrial volume (179 ± 81 vs 76 ± 37, p-value &amp;lt; 0.001); significantly greater DE extension (57 ± 20 vs 17 ± 19, p-value 0.0082), lower GLS and EF values (GLS 10 ± 3 vs 15 ± 4, p value 0.0033; EF p-value 0,0001). Patients who developed ventricular arrhythmias, did not show significant changes in EF (p-value 0.26), left atrial volume (90 ± 17, p-value 0.36) and PALS (18 ± 1, p-value 0.7), but they had significantly lower GLS values (5.7 ± 12, p-value 0.02) and a greater extent of DE (p-value 0.04). Patients with AF showed a significantly increased left atrial volume (100 ± 43, p 0.0034) and the PALS (10.8+ 5.9, p-value &amp;lt; 0.0001) was significantly reduced compared to patients without events; EF, GLS (-11.8 ± 8, p-value 0.08) and DE were not significantly reduced (14.8 ± 8, p-value 0.14). In patients who developed HF, both EF, GLS (p-value 0.035), left atrial volume , PALS (p-value &amp;lt; 0.0001) and DE (65 ± 22.5 p-value &amp;lt; 0.0001) were altered compared to patients without events. Conclusion Low PALS, reduced EF and GLS and higher DE extension and left atrial volume, appear to be prognostic factors in patients with HCM. PALS and left atrial volume are predictors of death, heart failure and AF. Low GLS and DE are predictors of ventricular arrhythmias and heart failure.

Disease progression rate is a strong predictor of ventricular arrhythmias in patients with cardiac laminopathy in a prospective cohort study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Area Network on Cardiovascular Diseases (ERA-CVD) Background/Introduction: Cardiac laminopathy is a highly malignant and pro-arrhythmic familial dilated cardiomyopathy, caused by LMNA gene mutations. The optimal timing of primary preventive implantable cardioverter defibrillator (ICD) is a challenge in this patient population. Purpose We aimed to explore whether disease progression rate assessed by echocardiography can predict ventricular arrhythmias in LMNA genotype positive patients, and to describe the cardiac phenotype at time of first ventricular arrhythmia. Methods We prospectively included consecutively recruited LMNA genotype positive patients in a primary prevention cohort study. Patients underwent repeated clinical and echocardiographic examinations during long-term follow-up. Ventricular arrhythmia was defined as sustained ventricular tachycardia, appropriate therapy by ICD or aborted cardiac arrest. We used generalized estimating equation analyses to assess whether individual patient disease progression could predict first-time ventricular arrhythmia. Graphical illustration of disease progression rate was presented as linear prediction by patient age. Cardiac function and volumes at time of ventricular arrhythmia was assessed from echocardiograms acquired ±12 months of the arrhythmic event. Results We included 94 patients with no ventricular arrhythmia at baseline (age 38 ± 15 years, 32% probands, 53% female). Nineteen (20%) patients experienced ventricular arrhythmia during 4.6 (inter quartile range 2.1-7.3) years follow-up, at mean age 50 ± 11 years. We analysed 536 echocardiographic examinations. Individual patient disease progression were strong predictors of subsequent ventricular arrhythmia with OR 1.3 (95% CI 1.2-1.5) per 5% reduction in left ventricular ejection fraction (LVEF), OR 1.3 (95% CI 1.2-1.5) per 1% worsened left ventricular global longitudinal strain (LVGLS), and OR 1.2 (95% CI 1.1-1.3) per 5 ml/m2 increase in left ventricular end diastolic volume index (LVEDVi). Comparison of disease progression by LVEF between patients with and without ventricular arrhythmias is illustrated in Figure. At arrhythmic event, there was left ventricular structural- and functional pathology (LVEF 40 ± 12%, LVGLS -11.7 ± 4.3%, LVEDVi 83 ± 22 ml/m2), while right ventricular function was preserved in most patients (tricuspid annular plane systolic excursion 20 ± 7 mm). Conclusions First time ventricular arrhythmic event occurred in 20% of LMNA genotype positive patients during 4.6 years of follow up. Individual patient disease progression by structural and functional parameters were strong predictors of ventricular arrhythmias, indicating that the disease progression rate may have additional value to absolute measurements when considering primary preventive ICD implantation. Abstract Figure

Obstructive sleep apnea syndrome as a predictor of ventricular arrhythmias in patients with coronary artery disease

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Определить распространенность и структуру желудочковых нарушений сердечного ритма (ЖНР) у пациентов с синдромом обструктивного апноэ сна (СОАС) и ишемической болезнью сердца (ИБС) и установить факторы, ассоциированные с ЖНР. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В исследование включены 65 мужчин с избыточным весом и индексом массы тела (ИМТ) более 25 кг/м² (средний ИМТ 29,7±9,3 кг/м²) в возрасте 20—79 лет (средний возраст 49,7±20,1 года). Больные были госпитализированы в кардиологическое отделение по поводу болей в области сердца неясного генеза, по характерным симптомам был также заподозрен СОАС. По результатам обследования (нагрузочный тредмил-тест, стресс-эхокардиография, коронароангиография) пациенты распределены в две группы: 1-я группа — 26 пациентов с ИБС, 2-я группа — 39 пациентов с болью в области сердца неишемического характера. Всем больным также было проведено кардиореспираторное мониторирование (КРМ) во время сна с последующим расчетом индекса апноэ/гипопноэ с одновременным мониторированием ЭКГ. На момент включения в исследование пациенты не получали антиаритмических препаратов I, III и IV классов. <h3>РЕЗУЛЬТАТЫ</h3> У всех пациентов по результатам КРМ верифицирован СОАС. Оценивали тяжесть СОАС (легкий, средний и тяжелый). Среди всех больных тяжелая форма СОАС встречалась у 59 (90,8%) больных, включая 6 (9,2%) пациентов с крайне тяжелой формой синдрома обструктивного апноэ сна. Среди пациентов с ЖНР без ИБС тяжелая форма СОАС встречалась достоверно чаще (22 (84,6%) и 37 (94,9%) случаев соответственно). Полученные результаты большей распространенности тяжелого СОАС среди пациентов без ИБС (2-я группа) привели к необходимости формирования групп сравнения, сопоставимых по возрасту. В результате анализа распространенности тяжелой формы СОАС среди пациентов с ИБС старше 40 лет (1-я группа) и пациентов без ИБС (3-я группа) было выявлено, что тяжелый СОАС также преобладает среди пациентов с ЖНР без ИБС (<i>p</i>&lt;0,05). <h3>ВЫВОД</h3> У пациентов, страдающих ИБС и СОАС, отмечена более высокая частота ЖНР по сравнению с пациентами с СОАС без значимого коронарного атеросклероза. При этом именно сочетание ИБС и СОАС, а не собственно степень тяжести СОАС определяет распространенность ЖНР у этих пациентов.

Heart failure with recovered ejection fraction and the utility of defibrillator therapy: a review.

Heart failure with recovered ejection fraction (HFrecEF) involves those who have previously had reduced cardiac function that has subsequently improved. However, there is not a single definition of this phenomenon and recovery of cardiac function in terms of left ventricular ejection fraction (LVEF) itself does not necessarily correlate with remission from the detrimental physiology of heart failure (HF) and its consequences. There is also the question of the utility of defibrillators in these patients, and whether they should be replaced at the time of battery depletion. To address this, several studies have shown specific predictors of ensuing LVEF recovery, including patient demographics, co‐morbidities, and medication use, as well as predictors of ventricular arrhythmias (VA) following LVEF recovery. Recent studies have also shown novel imaging parameters that may aid in predicting which patients would have a higher risk of these arrhythmias. Additional data describe a small, yet appreciable risk of VA, in addition to appropriate shocks as well. In this review, we describe predictors of LVEF recovery, carefully analyse and characterize the continued risk for VA and appropriate shocks following LVEF recovery, and explore additional novel modalities that may aid in decision‐making.

The gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than total myocardial fibrosis in patients with previous myocardial infarction

Abstract Background Current sudden cardiac death (SCD) risk stratification relies heavily on the assessment of left ventricular ejection fraction (LVEF), but markers that could refine risk assessment are needed. Total fibrosis mass (TFM) and “gray zone” of myocardial fibrosis (GZF) on late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether TFM and GZF can predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction. Methods We performed a single centre retrospective study enrolling all consecutive patients with previous myocardial infarction undergoing LGE-CMR before implantable cardioverter-defibrillator (ICD) implantation for primary or secondary prevention. TFM and GZF were defined as myocardial tissue with signal-intensities &amp;gt;6 SD and 2–6 SD above the mean of reference myocardium, respectively. The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device. Results A total of 55 patients (mean age 62±12 years, 87% male, mean LVEF 30% ± 8%) were included. During a mean follow-up period of 34±15 months, 10 patients reached the primary endpoint (8 appropriate ICD shock, 2 sustained VT or VF). Patients who attained the primary endpoint had similar TFM (28.6g ± 14.5 vs. 23.1g ± 14.5; P=0.283) but larger GZF (25.3g ± 11.0 vs 15.6g ± 7.3; P=0.001). After adjustment for LVEF, GZF remained independently associated with the composite arrhythmic endpoint (adjusted hazard ratio [aHR]: 1.10; 95% CI: 1.03–1.17; P=0.005), whereas TFM did not (aHR: 1.02; 95% CI: 0.98–1.06; P=0.394). Decision tree analysis identified 16.4g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 9 out of the 22 patients (41%) with GZF &amp;gt;16.4g, but in only 1 of the 33 patients (3%) with GZF ≤16.4g – Figure. Conclusions The extent of GZF seems to be a better predictor of ventricular arrhythmias than TFM. This LGE-CMR parameter may be useful to identify a subgroup of patients with previous myocardial infarction at an increased risk of life-threatening arrhythmic events. Funding Acknowledgement Type of funding sources: None.