Previous Pacemaker Research Articles

Implementing a novel selection criteria and pathway for same-day discharge after TAVI

Abstract Background The expansion in indications for transcatheter aortic valve implantation (TAVI) has fuelled an increase in demand worldwide. Prolonged waiting lists and waiting list mortalities are not infrequent and often arise from limited hospital capacity and infrastructure. Approaches to address this have included procedural modifications – ‘minimalist TAVI’ and more recently the development of pathways to facilitate early discharge post-TAVI, such as same-day discharge (SDD) post-procedure. Purpose This study aims to evaluate the safety and effectiveness of a novel SDD pathway a large volume tertiary referral cardiac centre. Methods A new SDD pathway was established between March 2023 and February 2024 at a large-volume tertiary cardiac centre in UK. All patients accepted for TAVI were screened for SDD suitability based on three factors: 1) availability of adequate social support, (defined as presence of able-bodies adult individual to assist in home recovery), 2) technically suitable for transfemoral approach and 3) presence of previous pacemaker or low risk for conduction abnormalities (defined as no baseline conduction disturbances). Following TAVI, patients were deemed suitable for SDD if they were clinically stable, the procedure was technically successful and there were no procedural complications. Demographic, clinical, procedural and outcome data were collected for all patients enrolled onto the SDD pathway and reasons for non-SDD were identified. Ethical approval was obtained in accordance with local institutional policies. Results From March 2023 to February 2024, 81 out of 305 patients (26.6%) were enrolled onto the SDD pathway (median age 82 years old, 66.7% male, median STS risk score 2.34%). Indications for TAVI were severe native aortic stenosis (74/81, 91.4%), severe native aortic regurgitation (2/81, 2.5%) and severe surgical valve degeneration (5/81, 6.2%). SDD was feasible for 58/81 (71.6%) of patients, with 10/81 (12.3%) discharged the following day and 13/81 (16.0%%) requiring >24 hours hospital admission (Figure 1). Reasons for non-SDD included new conduction abnormality (10/81, 12.3%), vascular complication (6/81, 7.4%), acute stroke (3/81, 3.7%), patient preference (2/81, 2.5%) and haemodynamic instability (2/81, 2.5%). Out of the 58 SDD patients, 25/58 (43.1%) had no previous permanent pacemaker system and in these patients a balloon-expandable valve was selected for 24/25 (96.0%) of patients (Figure 2). Conclusions Patient selection based on the presence of social support at home, low risk of conduction abnormalities or previous pacemaker combined with appropriate valve selection can facilitate a safe and effective SDD post-TAVI programme.

Safety of electrophysiological study in atrioventricular block risk stratification in new-onset persistent left bundle brunch block following transcathether aortic valve implantation

Abstract Background A significant percentage of patients develops a persistent complete left bundle branch block (LBBB) following TAVI. Electrophysiological (EP) study could be useful to stratify the risk of atrioventricular block (AVB) in these patients, guiding the need of follow-up and the indication of definite pacemaker. Purpose The primary objective of the study was describing the incidence of bradyarrhythmic events in the 30-day follow-up of patients with new-onset LBBB: AV block with ECG long-term monitoring system (Nuubo) in patients with negative EP study, and ≥ 5 % of ventricular stimulation in patients with positive EP study and pacemaker implantation. Methodology Observational prospective study of consecutive patients without previous permanent pacemaker implantation where transfemoral TAVI was implanted between 2021 and 2023. In case new-onset complete LBBB was present after TAVI, an EP study was performed. EP study was considered positive when His-Ventricule interval was more than 70ms, or after procainamide infusion at 10mg/kg, more than 100ms or more than double the basal HV interval. In case EP was positive, a permanent pacemaker was implanted. In case EP was negative, a 30-day follow-up with ECG long-term monitoring system (Nuubo) was performed. Results In this cohort, 266 patients without pacemaker following TAVI were included. Persistent new-onset left bundle branch block was present in 10,15% of patients (n=27). EP study was positive in 29.62% of patients (n=8), following a definite pacemaker implantation. During follow-up, only one patient (12.5%) was dependent of ventricular stimulation. The group with negative EP study (n=19) were monitored with a 30-day ECG long-term monitoring system (Nuubo). No bradyarrhythmic events were registered in this group. Conclusions Approximately one tenth of patients develop persistent new-onset LBBB after TAVI. Events were seldom in both study groups. Positive EP study patients were dependent of ventricular stimulation in 12.5% of cases, and there was no bradyarrhythmic event registered in EP negative group. EP study could be a safe tool to stratify AVB risk in new-onset LBBB following TAVI.

Undetected heart failure in tertiary care: prevalence, predictors and outcomes

Abstract Background Undetected heart failure (HF) seems to be unexpectedly common in primary care. We hypothesized that undetected HF may also be common in tertiary care, even in care pathways including cardiologists. Methods We assessed prevalence, predictors, and outcome of undetected HF in a large prospective cohort study enrolling patients referred for myocardial perfusion single photon emission tomography (MPI-SPECT) with central adjudication of HF according to guidelines. Findings were validated in two independent prospective cohorts (outpatient cardiac rehabilitation program, major noncardiac surgery). Prevalence of undetected HF, ratio of undetected HF to known HF and number needed to screen (NNS) were the primary endpoints. Results Among 3623 patients, median age 68 years, 31% women. 100 patients (3%) had known HF and 928 patients (25.6%) were adjudicated to have undetected HF, resulting in a ratio of undetected to known HF of 9.3-to-1 and a NNS of 2.8. Older age, atrial fibrillation, and previous pacemaker implantation were strong independent predictors of undetected HF. Patients with undetected HF were at significantly higher risk of cardiovascular death or HF hospitalization (adjusted HR 1.47 [95%CI, 1.17-1.85] versus no HF). These findings were confirmed in both validation cohorts: among 970 and 1563 patients the prevalence of undetected HF was 21.5% and 19%, ratio of undetected HF to known HF 0.7-to-1 and 2.8-to-1, NNS 2.2 and 3.7, respectively. Conclusion The prevalence of undetected HF is high also in tertiary care, even higher with older age, atrial fibrillation, and previous pacemaker implantation, and associated with increased risk of cardiovascular death or HF hospitalization.Prevalence of undetected HFKaplan-Meier cumulative incidence curves

Cusp-overlap technique to reduce permanent pacemaker implantation rate after transcatheter aortic valve implantation

Abstract Background Persistent conduction disturbances requiring permanent pacemaker (PPM) implantation are one of the most common complications after Transcatheter Aortic Valve Implantation (TAVI). Cusp-Overlap Technique (COT) is a novel approach for self-expandable valve implantation to minimize the rate of procedural complications, mainly PPM implantation. Purpose To determine if the COT during TAVI with self-expandable valves leads to a reduction of PPM implantation rate in the real-world setting. Methods A retrospective analysis of consecutive patients undergoing TAVI between January 2020 and November 2023 in one high-volume tertiary care center in Portugal was conducted. Two groups were defined, the COT group and the control group based on the fluoroscopic approach. A baseline comparison between the 2 groups was made using independent-samples t-test and chi-square analysis to determine if there was a difference between the prevalence of known risk factors for PPM implantation after TAVI. Afterwards, chi-square analysis was used to determine if COT led to a reduction in the PPM implantation rate. Results Of the 539 completed procedures in this timeframe, 289 were excluded due to previous pacemaker implantation, use of a valve not amenable to COT or valve-in-valve implantation. COT was used in 57.6% of eligible cases. Baseline comparison did not show a significant difference in the prevalence of several known risk factors for PPM implantation, including complete right bundle branch block, atrio-ventricular block, calcium score, aortic ring dimensions and pre/post-dilation. PPM implantation after TAVI was required in 31.6% of cases. In the COT group the PPM implantation rate was 22.9% and in the control group 43.4%. Chi-square analysis showed a very statistically significant difference between the 2 analyzed groups (p-value = 0.001). Conclusion PPM implantation remains a frequent complication of TAVI. However, this study showed that the utilization of COT leads to a reduction of the PPM implantation rate.

Incidence and predictors of sudden death in patients with cardiac amyloidosis

Introduction Although sudden death (SD) is a recognized complication of cardiac amyloidosis, there is scarce data about its incidence, mechanisms, and predictors. The aim of this study was to describe incidence of SD and to analyze possible risk factors. Methods Consecutive patients with ATTR or AL cardiac amyloidosis evaluated at two European centers were identified. SD was defined as unexpected death in clinically stable patients. Cox proportional hazard regression was performed to assess risk factors in univariate analysis. Those statistically significant were then assessed through age-adjusted multivariate analysis. Results Analysis included 784 patients, 569 with ATTR amyloidosis (mean age 74.1 ± 12.1 years) and 215 with AL amyloidosis (mean age 64.5 ± 10.8 years). After a median follow-up of 1.9 years, SD rate at 2 years was 1.8% in ATTR. Previous pacemaker implantation (PPM) was associated with increased risk after age-adjusted analysis (HR 4.97; 95%CI: 1.39–17.7; p = 0.01). SD rate in AL amyloidosis patients at 2 years was 8.0% after a median follow-up of 1.2 years. Betablockers and NYHA III-IV were independently associated with an increased risk after age-adjusted multivariate analysis (HR 7.06 95%CI (2.31–21.5) p = 0.001) and (HR 4.56 95%CI (1.51–13.8) p = 0.007) respectively. Conclusions SD is more frequent in AL than in ATTR cardiac amyloidosis. SD is associated with different risk factors in both entities.

Prognostic impact of permanent pacemaker implantation after cardiac surgery

Abstract Introduction Brady-arrhythmias with subsequent need for permanent pacemaker implantation is after cardiac surgery. It is not known whether the need of a permanent pacemaker influences long-term prognosis after cardiac surgery. Methods This large, nationwide study included all patients who underwent cardiac surgery in Sweden 2006-2020. Data was obtained from the Swedish Cardiac Surgery Registry, The Swedish ICD and Pacemaker Registry, The Swedish National Patient Register, and the Swedish Cause of Death Register. Patients who received a permanent pacemaker within 30 days were compared to those who did not. Exclusion criteria were previous pacemaker or implantable cardioverter defibrillator implantation and death within 30 days. Missing data were handled by multiple imputation. Cox regressions models were used to obtain hazard ratios (HR) with 95% confidence intervals (95%CI). The model was adjusted for age at operation, sex, left ventricular ejection fraction (EF), type of surgery, previous myocardial infarction, diabetes, peripheral artery disease, chronic respiratory disease, hypertension and atrial fibrillation. Results In total, 74 606 patients were included out of which 2 150 (2.9%) received a pacemaker within the first 30 days after cardiac surgery. Those who had a pacemaker implanted were older, more often female, had lower EF and significantly more often atrial fibrillation and peripheral artery disease. These patients were less likely to have diabetes, hypertension and previous myocardial infarction. Pacemaker implantation was associated with a higher risk of all-cause mortality (adjusted HR: 1.09 (95%CI=1.00-1.19), p=0.035, Figure 1) and heart failure hospitalization (adjusted HR: 1.45 (95%CI=1.30-1.62), p<0.001). Cardiovascular mortality had similar estimates but did not reach statistical significance (HR: 1.09 (95%CI=0.99-1.24), p=0.15). Conclusions The presence of brady-arrhythmias requiring permanent pacemaker implantation after cardiac surgery is associated with a higher risk of mortality and heart failure hospitalization. Measures should be taken to minimize the risk of injury to the conduction system leading to brady-arrhythmias during cardiac surgery.

Not too old to be treated: electrophysiological study and catheter ablation in eldery patients

Abstract Background The number of elderly patients referred for electrophysiological study (EPS) and catheter ablation (CA) is increasing. These patients are thought to have more complications due to age and comorbidity. Purpose The aim of our study was to evaluate the safety (EPS and CA) and acute success (CA) in a group of elderly patients (age ≥75 years old). Methods Between August 2020 and September 2023, consecutive elderly patients (32.7% older than 80 years) underwent EPS alone or EPS and CA at our center. Left atrial thrombus was ruled out performing transesophageal echocardiography when indicated. Anticoagulation (ACO) was not interrupted. Femoral veins, arteries and transeptal punctures were performed under ultrasound guidance. A navigation system was used for all CA procedures, except for pulmonary vein isolation, which was performed with a cryoballoon. We analysed procedural complications related to EPS and CA and the acute success of CA procedures. Results A total of 104 patients undergoing EPS±CA (79.9±4.6 years, 41.3% female, 75% HTA, 67.3% diabetes type 2, 19.4% COPD, 20.2% chronic renal disease, 25% structural heart disease, CHA2DS2VasC score 3.6±0.8, IMC 27.3±4.5 kg/m2, weight 72.3±13.6 kg, LVEF 52.7±10.8%, 31% history of atrial fibrillation (AF), 47.1% on ACO, 38.5% bundle-branch block, 34.6% first-degree atrioventricular block, 4.8% implanted pacemaker or ICD) were included. Indications for referral (Figure 1) were typical atrial flutter (TAF, 34.6%), atrioventricular nodal reentrant tachycardia (AVNRT, 26.9%), study of syncope (11.5%) atypical atrial flutter or atrial tachycardia (AAF/AT, 10.6%), AF (8.6%, 6 patients for AV node ablation, 3 for pulmonary vein isolation), ventricular tachycardia or ectopy (VT or VE, 5.7%), orthodromic reentrant tachycardia (ORT, 1.9%). 2 patients had TAF and AVNRT, treated in the same procedure. Acute success was achieved in 100% of AF, 94.6% of TAF, 89.6% of AVNRT, 66% of VT/VE, 50% of ORT, 45% of AAF/AT. There were 4 complications (2.9%) in 3 patients, all during the CA procedure: an AV block during an AVNRT ablation, another AV block during an ischaemic septal VT ablation, a femoral artery pseudoaneurism in the same patient (femoral artery approach), and a dislocation of the electrodes from a previous pacemaker during an AT ablation. None of the patients undergoing EPS alone had complications. Weight was the only variable associated with the development of complications (mean difference= -19.8, 95% CI(-38.9-0.7); p=0.04), being higher in those with than in those without complications (91.5±2.2 vs 71.6±13 Kg),(Table 1). Conclusions EPS and CA procedures in elderly patients with multiple comorbidities are safe and effective. Acute success and complication rates of CA procedures are substrate-dependent and similar to those reported in the literature for younger patients. We conclude that age is not a barrier to the study and treatment of arrhythmias.

Permanent pacemaker at the time of coronary artery bypass grafting and long-term outcome: a nationwide study from the SWEDEHEART registry

Abstract Introduction A permanent pacemaker is not rare in patients who undergo coronary artery bypass grafting (CABG). It is unknown if the presence of a pacemaker influences the long-term prognosis after surgery. Purpose To investigate if patients with permanent pacemaker have a higher risk for severe complications after CABG. Methods All patients who underwent CABG in Sweden 2006-2020 were included in a nationwide observational study based on prospectively collected data. Exclusion criteria were implantation of a cardioverter defibrillator at any time (prior to or after surgery) and death within 30 days. Individual patient data was merged from SWEDEHEART, The Swedish ICD- and pacemaker registry, the Cause of Death Register and the National Patient Register. Multivariable Cox regressions models were used to obtain hazard ratios (HR) with 95% confidence intervals (95%CI). The model was adjusted for age at operation, sex, left ventricular ejection fraction, heart failure, previous myocardial infarction, diabetes, peripheral artery disease, chronic respiratory disease, hypertension and atrial fibrillation. Results In total 41,722 patients underwent CABG during the study period, 555 (1.3%) of these had a previously implanted permanent pacemaker. Patients with a previous pacemaker were older, more often male, and had more often reduced left ventricular ejection fraction heart failure, atrial fibrillation, diabetes, hypertension and peripheral artery disease. Permanent pacemaker was not associated with higher risk for all-cause mortality (adjusted HR (aHR) 1.09 (95%CI=0.96-1.26), p=0.30, Figure 1), myocardial infarction (aHR: 1.01 (95%CI=0.73-1.41), p=0.94), or cardiovascular mortality (HR: 1.19 (95%CI=0.98-1.44), p=0.082). However, permanent pacemaker implantation was associated with increased risk for heart failure hospitalization (HR: 2.16 (95%CI=1.84-2.53), p<0.001). Conclusions A permanent pacemaker before CABG is not associated with increased mortality, cardiovascular mortality nor new myocardial infarction, but an increased risk for heart failure hospitalization after CABG. These patients could benefit from increased surveillance for heart failure symptoms after surgery to prevent hospitalizations.

Reverse Septal Movement: A Step Forward in the Comprehension of the Underlying Causes.

(1) Background: Reverse septal movement (RSM) often occurs after cardiac surgery, consisting of a paradoxical systolic movement of the interventricular septum. In this retrospective study, we aimed to investigate possible determinants of RSM after coronary artery bypass surgery (CABG). (2) Methods: Patients who underwent CABG with on- or off-pump techniques at our center from March 2019 to October 2021 were retrospectively included. Exclusion criteria were: exposure to combined procedures (e.g., valve implantation), prior cardiac surgery, intraventricular conduction delays, and previous pacemaker implantation. Laboratory tests and echocardiographic and cardiopulmonary bypass (CPB) duration data were collected. (3) Results: We enrolled 138 patients, of whom 32 (23.2%) underwent off-pump CABG. Approximately 89.1% of the population was male; the mean age was 70 ± 11 years. There was no difference in RSM incidence in patients undergoing the off-pump and on-pump techniques (71.9% vs. 62.3%; p = 0.319). In patients undergoing on-pump surgery, the incidence of RSM was slightly higher in longer CPB procedures (OR 1.02 (1.00-1.03) p = 0.012), and clamping aortic time was also greater (OR 1.02 (1.00-1.03) p = 0.042). (4) Conclusions: CPB length seems to be correlated with a higher RSM appearance. This better knowledge of RSM reinforces the safety of CABG and its neutral effect on global biventricular function.

Incidencia y predicción de hospitalización por insuficiencia cardiaca en pacientes con fibrilación auricular: escala REFLEJA

Introduction and objectivesHospitalization for heart failure (HHF) is common in patients with atrial fibrillation (AF) and is associated with increased mortality. The aims of this study were to determine the incidence of HHF, identify the clinical predictors of its occurrence, and develop a new risk scale. MethodsThe incidence of HHF was estimated using data from the prospective single-center REFLEJA registry of outpatients with AF (October 2017-October 2018). A multivariate Cox regression model was calculated to detect HHF predictors, and a nomogram was created for individual risk assessment. ResultsOf the 1499 patients included (mean age 73.8±11.1 years, 48.1% women), 127 had HHF (incidence rate of 8.51 per 100 persons/y) and 319 died (rate of death from any cause of 21.1 per 100 persons/y) after a 3-year follow-up. The independent predictors of HHF were age, diabetes, chronic kidney disease, pulmonary hypertension, previous pacemaker implantation, baseline use of diuretics, and moderate-severe aortic regurgitation. The c-statistic for predicting the event was 0.762 (95%CI after boostrapping resampling, 0.753-0.791). The cumulative incidences of the main outcome for the risk scale quartiles were 1.613 (Q1), 3.815 (Q2), 8.378 (Q3), and 20.436 (Q4) cases per 100 persons/y (P <.001). ConclusionsHHF was common in this AF cohort. The combination of certain clinical characteristics can identify patients with a very high risk of HHF.

Sex differences and survival after TAVI for severe aortic stenosis

Abstract Background There is still controversy about survival rates and clinical response of women versus men who undergo transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (SAS). Purpose Assess mortality and heart failure (HF) symptoms following TAVI for SAS, according to sex. Methods A retrospective analysis of a single-center database including all TAVI performed in 2011-2019 was performed. Clinical, echocardiographic, and blood-analysis data were determined, and all-cause mortality over the five years after the procedure was compared based on sex. A reduction of at least one New York Heart Association (NYHA) class after TAVI was the secondary endpoint. Results Of the 488 cases analyzed, 252 (51.6%) were women. They were older (84 vs. 80 years-old, p&amp;lt;0.001), had a lower body surface area, and had a higher estimated surgical risk, as determined by EuroSCORE II (4.5 vs. 3.8, p=0.011) and STS-mortality (4.46 vs. 3.44, p&amp;lt;0.001). However, they had a lower prevalence of diabetes mellitus, coronary artery disease, and peripheral artery disease, a lower estimated creatinine clearance, and a lower frequency of previous pacemaker implantation. Women had more frequently a phenotype of high gradient severe aortic stenosis, with lower functional aortic valve areas. While there was no difference in TAVI design, smaller valves were implanted in women. Median follow-up was 46 months and there was a 40% mortality rate over the five years after treatment, with no statistically significant differences according to sex in both univariate and multivariate analysis, after adjusting for estimated surgical risk. EuroSCORE II had a statistically significant association with the primary endpoint (hazard ratio 1.03 (1.01-1.05), p=0.004). Despite having a similar NYHA class before TAVI, women experienced a lower frequency of functional class improvement (61% vs. 72%, p=0.034). Conclusions Although women had a higher estimated surgical risk, no differences were found regarding survival after TAVI for SAS. However, improvement in HF symptoms was less frequent in this subset.Table 1Figure 1

Remote monitoring of cardiac implantable devices in children: characteristics and outcome in a retrospective single centre contemporary study. TelePaedia study

Abstract Introduction Remote monitoring (RM) has revolutionized implantable cardiac device care in adults. It has demonstrated its safety on hard criteria, a reduction in the number of hospitalizations and emergency room visits, early detection of events and a reduction in inappropriate therapies. However, while pediatric population is becoming emerging, particularly considering congenital heart diseases, there is no contemporary study. Objective The aim of our study was to characterize in our cohort of RM patients the population of children (below 18 yo) implanted with a pacemaker or an ICD and under RM for more than 1 year. Method The data collection was carried out retrospectively within the cohort of RM patients at our university hospital. The outcome combined occurrence of ventricular (VT)/supraventricular (SVT) arrhythmias, appropriate or inappropriate therapies, lead dysfunction/fracture and ERI. Results The study population included 34 patients (17F/17M) with a mean age of 9.4+/-5.8 years (range 0-18 yo) and a mean remote follow-up of 4.6+/-3.9 years (range 1-13 y). The indications for pacing were postoperative atrioventricular block (AVB, n = 9) for operated congenital heart disease or hypertrophic cardiomyopathy (n=1), congenital AVB (n= 5), muscular dystrophy (n = 1) and genetic sinus node dysfunction (n = 1). Indications for an ICD were resuscitated sudden death in hypertrophic cardiomyopathy (n = 4), LQTS (n = 5), CPVT (n = 2), arrhythmogenic right ventricular dysplasia (n = 2), Brugada syndrome (n = 1) and congenital heart disease (n = 2). Pacing devices (n = 17) were mostly implanted with epicardial leads and abdominal box (n = 12). ICDs (n = 18) were implanted in primary (n = 4) or in secondary prevention with epicardial (n = 2)/ endovascular (n=9) /subcutaneous (n = 2) leads depending on children weight and anatomy. One 12 yo-boy had an S-ICD in addition to a previous pacemaker. There were a total of 13 patients with device-triggered alerts: VT in 8 including appropriate therapies in 6 and inappropriate shocks in 2, supraventricular tachycardia in 2, RV lead dysfunction in 2, RV lead fracture in 1 and no alert for ERI. All alerts were treated within 24h. Conclusion This is the first report of cardiac device remote monitoring in a pediatric population. In our population 13/34 patients experienced alerts necessitating intervention over a mean 4.6 year-follow-up. Remote monitoring through device-triggered alerts allowed efficient treatment of an arrhythmic event or a lead dysfunction. This is a preliminary study suggesting the need for further studies on a larger population. Remote monitoring should be considered in all eligible-device children and should be considered as standard of care.

Abstract 17982: Impact of Obstructive Sleep Apnea on Bradyarrhythmia Hospitalizations: Analysis of the National Inpatient Sample 2016-2020

Background: Obstructive sleep apnea (OSA) has been associated with many forms of heart rhythm disorders, including bradycardia and cardiac conduction delay. Here, we aimed to investigate the relationship between OSA and bradyarrhythmias. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 to 2020. 1,685,704 hospitalizations with a primary diagnosis of bradyarrhythmias (including sinus node dysfunction, atrioventricular block and cardiac conduction disorder with 1:1 AV conduction) were identified and stratified based on the presence of OSA using ICD-10 codes. Multivariate regression analysis was used to adjust for confounders and analyze the variables. Results: Out of the 1,685,704 hospitalizations with bradyarrhythmias, 204,307 (%12.1) had OSA. In-hospital mortality in patients with OSA was significantly lower (3.51% vs 5.64%; p&lt;0.001). When adjusted to patient demographics, comorbidities, and hospital characteristics, independent risk factors for inpatient mortality included congestive heart failure (aOR 1.22, 95% CI 1.17 - 1.27, p-value&lt;0.001), atrial fibrillation (aOR 1.14, 95% CI 1.10 - 1.18, p-value &lt;0.001); however conditions associated with a lower risk for inpatient mortality included previous CABG (aOR 0.91, 95% CI 0.85 - 0.97, p-value 0.004) and previous pacemaker (aOR 0.61, 95% CI 0.58 - 0.65, p-value &lt;0.001). Mean length of stay (LOS) and mean hospital charges (HC) were also lower in the presence of obstructive sleep apnea compared to those without (5.28 vs 6.01 days, p-value 0.002 &amp; $90,549 vs $103,450, p-value &lt; 0.001 respectively). Conclusion: Amongst hospitalizations with a primary diagnosis of bradyarrhythmias, patients with OSA had better outcomes in terms of in-hospital mortality, length of stay and total mean hospitalization charges. This likely suggests that OSA-related bradyarrhythmias are a more benign and modifiable when compared to non-OSA-related bradyarrhythmias.

Implantation depth of balloon-expandable transcatheter heart valves and risks for permanent pacemaker implantation and midterm adverse events.

Permanent pacemaker implantation (PPI) remains a relevant complication after transcatheter aortic valve implantation (TAVI) and its impact on outcome remains controversial. This study aimed to analyze the effects of implantation depth on PPI at 30 days and assess its impact on outcome with the balloon-expandable Sapien 3 (S3) prosthesis. Between 2014 and 2018, 849 patients without previous pacemaker undergoing transfemoral TAVI with the S3 were included. Prosthesis implantation depth was measured and divided into Quintiles. An ordinal logistic regression was used to assess its association with PPI, while a multivariate logistic regression was performed to identify predictors of PPI. Survival analyses were performed with the Kaplan-Meier method and a multivariable Cox regression was performed to ascertain the impact of PPI on mortality. Overall, incidence of PPI at 30 days was 9.7%. Implantation depth decreased consistently from a median of 6.7 mm [5.55-8.00] in 2014 to 2.7 mm [2.30-3.50] in 2018 (p < 0.001). When considering Quintiles of implantation depth, incidence of PPI was significantly higher in upper Quintiles and risk for PPI was significantly lower for the 1. Quintile compared to the 5. Quintile (OR: 0.34, 95% CI: [0.16-0.73]; p = 0.003). In the adjusted multivariable logistic regression implantation depth persisted ad independent predictor of PPI at 30 days. Patients requiring PPI at 30 days displayed significantly higher mortality at 4 years compared to patients without PPI (49.5% vs. 40.0%; log-rank = 0.022). In a multivariate analysis, increased logistic EuroScore, diabetes mellitus, and history of atrial fibrillation, were independent predictors of all-cause mortality at 2 years. Higher prosthesis implantation relative to the virtual aortic annulus was significantly associated with reduced risk for PPI at 30 days. Patients with PPI at 30 days exhibited higher mortality during follow-up, however, only logistic EuroScore, diabetes mellitus, and history of atrial fibrillation were identified as independent predictors of mortality at 2 years.

Fate of concomitant tricuspid regurgitation in patients undergoing coronary artery bypass grafting

ObjectiveOwing to a lack of supportive data, tricuspid regurgitation (TR) is usually not addressed in patients undergoing coronary artery bypass grafting (CABG). Here we evaluated changes in TR degrees over time and its impact on survival in patients undergoing CABG. MethodsWe reviewed the data of 9726 patients who underwent isolated CABG between January 2000 and January 2021. According to preoperative TR severity, patients were stratified into nonsignificant (none to trivial, mild) and significant (moderate to severe) TR groups. We excluded patients who had undergone previous tricuspid valve surgery, pacemaker placement, and concomitant valve or ablative surgery. Propensity score matching and Cox proportional hazards models were used to identify associations between TR grade and the primary outcome of all-cause mortality. The secondary outcome was change in TR severity on the last echocardiogram. ResultsAfter propensity score matching, 380 patients in each group were identified. At baseline, 359 patients had moderate TR (94.5%) and 21 (5.5%) had severe TR. On the last follow-up echocardiogram, TR had improved in 40.5% of the patients in the significant TR group. Kaplan–Meier survival curves showed significantly lower survival in patients with significant preoperative TR compared to those with nonsignificant TR (P < .001). After adjusting for other confounders, survival was no worse in the patients with significant TR group (hazard ratio, 1.05; 95% confidence interval, 0.80-1.38; P = .70). ConclusionsSignificant preoperative TR improved in 40.5% of patients after isolated CABG. After adjusting for other factors, significant TR did not affect long-term survival.

Conduction Disturbance After Transcatheter Aortic Valve Implantation With Self- or Balloon-Expandable Valve According to the Implantation Depth

Membranous septum (MS) length, in conjunction with implantation depth (ID), is known as a determinant of conduction disturbance (CD) after transcatheter aortic valve implantation (TAVI). However, its impact might be dissimilar among valve types because each valve has a different platform. This study sought to investigate the different impacts of ID and MS length on the new-onset CD between ACURATE neo and SAPIEN 3. This study included patients without a previous permanent pacemaker implantation who underwent TAVI with ACURATE neo and SAPIEN 3 and divided them into 2 groups based on the ID according to MS length (deep and shallow implantation group). Deep implantation was defined as transcatheter heart valve implantation deeper than MS length. The primary endpoint was new-onset CD (new permanent pacemaker implantation or new-onset complete left bundle branch block). A total of 688 patients (deep implantation: n=373, shallow implantation: n=315) were identified as a study cohort. New-onset CD developed more frequently in the deep implantation group (16.6% vs 7.0%; p=0.0001). Deep implantation was revealed as a predictor of new-onset CD. Moreover, deep implantation was significantly associated with new-onset CD after SAPIEN 3 implantation but not after ACURATE neo. Among patients with MS shorter than 2mm, ACURATE neo was superior in terms of avoiding new-onset CD. In conclusion, the deep implantation was associated with new-onset CD after TAVI with SAPIEN 3 but not with ACURATE neo. These results may impact device selection in patients with a preexisting high risk of CD.

Incremental value of right atrial strain analysis to predict atrial fibrillation recurrence after electrical cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is the most frequent cardiac arrhythmia, associated with elevated risks of cardiovascular events and death. The assessment of left atrial (LA) mechanics has been reported to refine AF risk prediction, however it does not completely predict AF relapse. The potential added role of right atrial (RA) function in this setting is unknown. Purpose This study sought to evaluate the added value of RA longitudinal reservoir strain (RARS), on top of LA longitudinal reservoir strain (LARS) analysis, for the prediction of AF recurrence after electrical cardioversion (ECV). Methods We retrospectively studied 132 consecutive adult patients (men 55%, 72±10 years) with persistent AF undergoing ECV in hospital setting. Exclusion criteria were: pregnancy, previous cardiac surgery, pacemaker or implantable cardioverter defibrillator, severe valvular regurgitation/stenosis, ventricular systolic dysfunction, poor apical acoustic window, unsuccessful ECV, early recurrent AF and lack of follow-up. LA and RA size and function were analyzed by conventional 2D and speckle-tracking echocardiography before ECV. The endpoint was AF recurrence. Results After a total follow-up of 12 months, 63 patients (48%) showed AF recurrence. Both LA and RA reservoir strain were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LARS 10±6 vs 13±7%, RARS 14±10 vs 20±9 %, respectively, p&amp;lt;0.001 for both). By receiving operating curve (ROC) analysis, the best cut-offs associated to AF recurrence after ECV were 15% for RARS [AUC 0.77 (95%CI 0.69–0.84), p&amp;lt;0.0001] and 10% for LARS [AUC 0.69 (95%IC 0.60–0.77), p&amp;lt;0.0001]. Kaplan-Meier curves showed that patients with both LARS≤10% and RARS ≤15% had a significant risk for AF recurrences (log-rank, p&amp;lt;0.001) (Figure 1). However, at multivariable Cox regression, RARS [HR 3.26, 95%CI (1.73–6.13), p&amp;lt; 0.001] was the only parameter independently associated with the AF recurrence. RARS provided incremental prognostic value over LARS, LA and RA volumes concerning the prediction of AF relapse after ECV (Figure 2). Conclusions RARS was independently associated with AF recurrence after ECV and provided an incremental prognostic value over LARS. This study highlights the importance of assessing the functional remodeling of both RA and LA in patients with persistent AF. Figure 1. Atrial fibrillation recurrence freedom according to left and right atrial reservoir longitudinal strain. Kaplan-Meier plots of patients grouped according to the threshold levels of left (left panel) and right (right panel) values of reservoir longitudinal strain identified by the Receiver Operating Curve analyses.

Impact of pacing mode and different echocardiographic parameters on cardiac output (PADIAC).

The extent of the hemodynamic benefit from AV-synchronous pacing in patients with sinus rhythm and AV block is not completely understood. Thus, we systematically investigated the association of an array of echocardiographic and epidemiological parameters with the change in cardiac output depending on the stimulation mode (AV-synchronous or AV-asynchronous pacing). Patients in sinus rhythm after previous dual chamber pacemaker implantation underwent a thorough basic echocardiographic assessment of diastolic and systolic left ventricular function, and atrial function (26 echo parameters, including novel speckle tracking strain measurements). Then, stroke volume was measured with AV-synchronous (DDD) and AV-asynchronous (VVI) pacing. Each patient represented their own control, and the sequence of stroke volume measurements was randomized. In this prospective single-center study (NCT04068233, registration August 22nd 2019), we recruited 40 individuals. The stroke volume was higher in all patients when applying AV-synchronous DDD pacing [median increase 12.8 ml (16.9%), P < 0.001]. No echo parameter under investigation was associated with the extent of stroke volume increase in a linear regression model. Of all epidemiological variables, a history of acute myocardial infarction (AMI) was associated with an attenuated stroke volume gain in a univariate and a multivariate regression model that adjusted for confounders. A- and S-wave velocities were reduced in the AMI group. In our cohort of patients, each subject benefited from AV-synchronous DDD pacing. No single echo parameter could predict the amount of stroke volume increase. The beneficial effect of AV-synchronous pacing on stroke volume was attenuated after prior acute myocardial infarction.ClinicalTrials.gov identifier (NCT number): NCT04068233.

Permanent pacemaker implantation and left bundle branch block with self-expanding valves - a SCOPE 2 subanalysis.

No detailed data on left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) exist from randomised clinical trials comparing the ACURATE neo and CoreValve Evolut devices. Our aim was to assess the incidence and impact of new LBBB and PPI with self-expanding prostheses from a powered randomised comparison. From the SCOPE 2 trial, 648 patients with no previous pacemaker were analysed for PPI at 30 days, and 426 patients without previous LBBB were adopted for analysis of LBBB at 30 days. Results: At 30 days, 16.5% of patients required PPI; rates were higher in CoreValve Evolut compared to ACURATE neo recipients (21.0% vs 12.3%; p=0.004). Previous right bundle branch block (odds ratio [OR] 6.11, 95% confidence interval [CI]: 3.19-11.73; p<0.001) was associated with an increased risk of PPI at 30 days, whereas the use of the ACURATE neo (OR 0.50, 95% CI: 0.31-0.81; p=0.005) was associated with a decreased risk. One-year mortality was similar in patients with and without new PPI. A total of 9.4% of patients developed persistent LBBB at 30 days, with higher incidences in CoreValve Evolut recipients (13.4% vs 5.5%; p=0.007). New LBBB at 30 days was associated with lower ejection fraction at 1 year (65.7%±11.0 vs 69.1%±7.6; p=0.041). New LBBB and PPI rates were lower in ACURATE neo compared to CoreValve Evolut recipients. The ACURATE neo valve was associated with a lower risk of PPI at 30 days. No effect on 1-year mortality was determined for PPI at 30 days, while LBBB at 30 days was associated with reduced ejection fraction at 1 year.

The impact of extra-valvular cardiac damage on mid-term clinical outcome following transcatheter aortic valve replacement in patients with severe aortic stenosis.

To quantify extra-valvular cardiac damage associated with severe aortic valve stenosis (AS), a novel staging model was proposed. This study aimed to validate this model in patients undergoing transcatheter aortic valve replacement (TAVR) as well as to assess its prognostic impact. Based on echocardiographic findings, the following stages were applied: isolated AS (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary hypertension or tricuspid regurgitation (stage 3), or right ventricular dysfunction (stage 4). The primary endpoint was 2-year all-cause mortality. The distribution across stages was 0.8% at stage 0, 7.5% at stage 1, 63.3% at stage 2, 18.3% at stage 3, and 10.1% at stage 4. All-cause mortality increased at all stages 1-4 (12.1%, 18.2%, 26.6%, and 28.2%; p = 0.023). In the multivariate model, the stage of cardiac damage, age, New York Heart Association (NYHA) class III/IV, peripheral artery disease, and previous pacemaker were independent predictors of the primary endpoint. Patients treated for severe AS show a high prevalence of extra-valvular cardiac damage. An increase in stage is associated with higher 2-year all-cause mortality. The application of this staging model may add value to current treatment algorithms.