Requiring Pacemaker Implantation Research Articles

Management of pregnancy and delivery in women with transposition of the great arteries after atrial switch operation: A 16-year single-center experience.

This study aimed to summarize cases of successful pregnancy and delivery in patients with transposition of the great arteries (TGA) after atrial switch operation (ASO), to provide management, clinical experience, and maternal and fetal outcomes. During a 16-year period (2004-2019), we experienced 30 pregnancies in 15 patients after ASO at our institution. We retrospectively reviewed the medical records of the patients. In 30 pregnancies, there were 21 (70%) live births, five (17%) miscarriages, and four (13%) artificial abortions. There were no maternal or neonatal deaths. Cardiac complications occurred in nine (43%) patients: deterioration of right ventricular (RV) function in one, symptomatic heart failure (HF) in three, supraventricular tachyarrhythmia requiring electrical cardioversion in two, sick sinus syndrome that required pacemaker implantation in two, and hemoptysis in one. Obstetric complications occurred in five (24%). Neonatal complications were premature births (delivery at <37 weeks of gestation) in 15 (71%), and birthweight <2500 g in 18 (86%). The mode of delivery consisted of vaginal delivery (VD) in five (24%), and cesarean section (CS) in 16 (76%). A high incidence of preterm CS and cardiac complications including deterioration of RV function was observed in patients who had undergone ASO for TGA.

235 Ventricular arrhythmias and cardiac autonomic function in patients with severe aortic valve stenosis before and after transcatheter aortic valve implantation

Abstract Aims Transcatheter aortic valve implantation (TAVI) has become a first-line treatment for most patients with severe aortic stenosis (AS) at intermediate/high surgical risk, resulting in significant improvement of clinical outcome. However, whether ventricular arrhythmias (VAs) or cardiac autonomic dysfunction influence outcome and whether TAVI has any effects on VAs and cardiac autonomic function is unknown. Thus, this study was aimed to investigate: I1) whether VAs and autonomic dysfunction [as assessed by heart rate variability (HRV)] are associated with clinical outcome and (2) the effects of TAVI on VAs and HRV, in patients with severe AS. Methods and results We studied 71 consecutive patients with severe aortic stenosis, admitted to our department of Cardiovascular Medicine to undergo TAVI. Patients with previous cardiac surgery, percutaneous coronary revascularization, acute coronary syndrome, and other significant heart valve disease or relevant comorbidities were excluded. The day before TAVI all patients underwent transthoracic Doppler echocardiography (TTDE), including global longitudinal strain (GLS) assessment, and 24-h ECG Holter monitoring (HM), to assess VA burden and HRV. A clinical follow-up was performed at 6 months from discharge. Furthermore, TTDE and 24-h HM were performed at follow-up in 38 (54.5%) and 29 (40.8%) patients, respectively. The primary endpoint was the occurrence of major clinical events (MACE), that include death, hospitalization for cardiac causes, pacemaker implantation, myocardial infarction, or stroke. Of 71 patients (48 female, mean age 80.5 ± 6.5 years) enrolled in the study, a 6-month clinical follow-up could be performed in 54 (76%). MACE occurred in 21 patients (38.9%), 8 of whom (14.8%) had hospitalization for heart failure, 13 (24%) required pacemaker implantation, and 3 had stroke (5.6%). Compared to baseline, at follow-up the mean aortic valve gradient (50.6 ± 11.4 vs. 8.38 ± 3.23 mmHg, P &amp;lt; 0.001), left ventricle (LV) mass index (131.4 ± 38.9 vs. 112.9 ± 28.3 g, P = 0.007), pulmonary artery systolic pressure (37.3 ± 5.8 vs. 30.2 ± 9.8 mmHg; P &amp;lt; 0.001), and the ratio of Doppler transmitral early filling velocity to tissue-Doppler early diastolic mitral annular velocity (E/e′) (16 ± 5.3 vs. 13.2 ± 4.7 P &amp;lt; 0.001) were significantly reduced. In contrast no changes were observed in VAs. The number of premature ventricular complexes (PVCs) at HM was indeed 1062 ± 3833 vs. 1206 ± 3322 at follow-up and baseline, respectively (P = 0.11). Furthermore, PVCs &amp;gt;10 per hour were detected in a higher number of patients at 6-month follow-up, compared to baseline (23.8% vs. 45.2%; P = 0.022). No significant differences were detected in most time-domain and frequency-domain HRV parameters. Unexpectedly, SDNNi (62.8 ± 19.1 vs. 41.9 ± 16.5; P = 0.008), RMSSD (54.6 ± 36.6 vs. 30.1 ± 17.9; P = 0.024) and VLF (56.4 ± 49.6 vs. 29 ± 12.7; P = 0.028) were found to be significantly higher at follow-up compared to baseline. Conclusions Our data show that, in patients with severe AS, TAVI does not seem to have significant effects on VA burden, despite echocardiographic and clinical improvement. Similarly, our data failed to show significant improvement of sympatho-vagal balance at follow-up compared to baseline in these patients.

810 Incidence and determinants of permanent pacemaker implantation after transcatheter aortic valve replacement

Abstract Aims conduction disturbances requiring pacemaker implantation (PPM) are among the most common complications in patients undergoing transcatheter aortic valve replacement (TAVR). Introduction in clinical practice of a new generation of TAVR devices is contributing to a significant reduction in procedural complications. However, limited data is available regarding PPM implantation after TAVR with the latest available devices. Accordingly, in this analysis we aimed to investigate the incidence and risk factors for new permanent pacemaker implantation after TAVR according to the type and diameter of valve implanted. Methods Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407, 38 (9.3%) were excluded because they already presented a PPM/ICD, received only balloon angioplasty or for procedural unsuccess. The independent association between baseline clinical and procedural variables and the occurrence of PPM implantation was investigated with cross-sectional logistic regression analysis. Results Out of 368 TAVR procedures included in the final analysis, 89 (24.2%) required in-hospital PPM implantation. No differences were observed for age and common cardiovascular risk factors between groups. Among procedural variables, patients requiring PPM had lower left ventricular ejection fraction (LVEF) and experienced a longer intensive care unit stay. Valve types used were Corevalve n = 98 (26.6%) (first-generation devices), Evolute R, n = 191 (51.9%), Evolute Pro, n = 3 (1.1%), Portico n = 2 (0.5 %), or Sapien 3, n = 73 (19.8%) (second-generation devices). Clinical and procedural correlates of PPM implantation were depicted in Figure. Of note, compared to the first generation of self-expandable devices, the second generation is associated with a lower risk of PPM implantation, albeit non-significant for the subgroup of second generation self-expandable devices. Finally, valve diameter was also an independent predictor of PPM implantation Conclusions PPM was required in 24.2% of patients who underwent TAVR with first- and second-generation balloon or self-expandable valves. For instance, in our population, second-generation TAVR devices were associated with a lower risk of PPM implantation compared to the previous generation. However, further investigations are warranted to assess the impact of new implantation techniques and valve technology on such an important outcome.

808 Frequency and impact of atherothrombotic status in patients undergoing transcatheter aortic valve replacement

Abstract Aims Many efforts have been made in the last decade to minimize the risk of bleeding in patients undergoing transcatheter aortic valve replacement (TAVR), such as a less intensive antithrombotic therapy and technical improvement in devices implantation. Conversely, evidence on high atherothrombotic status (HATR) is still lacking in patients undergoing TAVR. Accordingly, in this analysis, we aimed to evaluate frequency and impact of atherothrombotic status in patients undergoing transcatheter aortic valve replacement. Methods Patients who underwent TAVR at our Institution from September 2008 to November 2020 were included in this analysis. Out of 407 patients, 6 (1.5%) were excluded as they underwent only balloon angioplasty or for procedural unsuccess. HATR status includes patients with prior percutaneous coronary intervention/coronary artery bypass graft, prior stroke/transient ischaemic attack (TIA), or with a diagnosis of diabetes. Continuous variables following normal distribution were compared with the student’s t-test and categorical data were analysed with the chi-square test. A Cox regression model was used to evaluate the association between HART status and all-cause mortality at one 1-year follow-up. Results Compared to patients with low atherothrombotic status (LATR) (n = 238; 59.4%), HART patients (n = 163; 40.6%) were older, more likely female and with a higher prevalence of common cardiovascular risk factors including chronic kidney disease, smoke, and hyperlipidaemia. Between LATR and HATR groups, no differences have been observed, in terms of procedural time, type of devices used (Balloon vs. self-expandable device), or hospitalization length. Compared to LART, HART patients were more likely to be discharged on statin (63.7% vs. 83%, P &amp;lt; 000.1), on dual antiplatelet therapy (50.4% vs.58.9%, P = 0.03), or on oral anticoagulant if required (27.7% vs. 29.5%, P = 0.03). Furthermore, no differences have been observed in terms of in-hospital adverse events, including death, severe bleeding, any conduction disturbances requiring pacemaker implantation, access complications, myocardial infarction, or stroke/TIA. For instance, HART was not a predictor of mortality at 1 year follow-up, even after adjustment for baseline characteristics. Conclusion In our population, no differences in procedural and in-hospital adverse events have been observed according to the atherothrombotic profile. HATR patients were more likely to be discharged with more intensive antithrombotic and hypolipidaemic strategies, despite the coexistent high prevalence of bleeding determinants. However, ATR status does not impact 1-year mortality even after adjustment for baseline characteristics.

Incidence of and risk factors for pacemaker implantation after the modified Cryo-Maze procedure for atrial fibrillation

ObjectivesThe Maze procedure is a well-established treatment for atrial fibrillation. However, it is sometimes associated with bradycardia requiring pacemaker implantation. We assessed the rates of in-hospital and late-onset pacemaker implantation after the modified Cryo-Maze procedure and explored the risk factors for pacemaker implantation. MethodsThis study enrolled a series of 751 patients who underwent the modified Cryo-Maze procedure at our institution between 2001 and 2020. Multivariable Fine-Gray regression was used to analyze the risk factors for late-onset pacemaker implantation. ResultsTwelve patients (1.6%) underwent in-hospital pacemaker implantation, and 55 patients (7.3%) underwent late-onset pacemaker implantation during a median follow-up of 4.5 years (interquartile range, 1.4-10.0). The most common primary indication for pacemaker implantation was sick sinus syndrome (56 patients [7.5%]), followed by complete atrioventricular block (11 patients [1.5%]). The cumulative incidence of late-onset pacemaker implantation with death as a competing risk was 2.8% at 1 year, 7.7% at 5 years, and 10.8% at 10 years. Risk factors for late-onset pacemaker implantation included a longer preoperative atrial fibrillation duration (hazard ratio, 1.14; P < .001) and an older age (hazard ratio, 1.05; P = .001). The mortality, cumulative incidence of cerebrovascular accidents, and rate of atrial fibrillation recurrence were not significantly different between patients with and without pacemaker implantation. ConclusionsLonger preoperative atrial fibrillation duration and older age are risk factors for late-onset pacemaker implantation after the modified Cryo-Maze procedure. However, the incidence of pacemaker implantation is not associated with increased morbidity or atrial fibrillation recurrence.

C8. An Extremely Rare Case: Cardiac Contusion Presenting with an Atrioventricular Block, An Unfortunate Fall

Abstract Background Blunt cardiac injury (BCI), also referred to cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose in the absence of clear diagnostic criteria. The clinical manifestation ranges from none to fatal arrhythmias to cardiac wall rupture seen on post-mortem examination. Cardiac biomarkers and electrocardiograms are usually helpful in identifying cardiac trauma but are not necessarily abnormal in all cases. Case Illustration A 55-year-old male with no history of cardiac disease was brought to the emergency department after a motor vehicle collision resulted in chest wall injury. The patient was found to have left clavicle fracture, left costae II-VII fractures, and hematothorax followed by chest tube insertion. The patient had multiple episodes of complete heart block with junctional escape rhythm alternate with high degree 2:1 AV conduction, and sometimes became a normal sinus rhythm. A temporary pacemaker was inserted. After the patient underwent the ORIF procedure, cardiac rhythm revealed normal sinus rhythm and temporary pacemaker is removed. Discussion High-degree AV block has been reported in human studies following BCI, secondary to necrosis, inflammation, or fibrotic changes in the subendocardial tissue. 50% of patients reviewed in the literature had a recurrence or permanent complete heart block requiring pacemaker implantation and complete heart block secondary to BCI which was associated with a 20% mortality in the post-traumatic period. Our patient developed a fatal heart block in the early period which could have easily been missed.

C8. An Extremely Rare Case: Cardiac Contusion Presenting with an Atrioventricular Block, An Unfortunate Fall

Abstract Background Blunt cardiac injury (BCI), also referred to cardiac contusion, is a known cause of myocardial injury. It is often challenging to diagnose in the absence of clear diagnostic criteria. The clinical manifestation ranges from none to fatal arrhythmias to cardiac wall rupture seen on post-mortem examination. Cardiac biomarkers and electrocardiograms are usually helpful in identifying cardiac trauma but are not necessarily abnormal in all cases. Case Illustration A 55-year-old male with no history of cardiac disease was brought to the emergency department after a motor vehicle collision resulted in chest wall injury. The patient was found to have left clavicle fracture, left costae II-VII fractures, and hematothorax followed by chest tube insertion. The patient had multiple episodes of complete heart block with junctional escape rhythm alternate with high degree 2:1 AV conduction, and sometimes became a normal sinus rhythm. A temporary pacemaker was inserted. After the patient underwent the ORIF procedure, cardiac rhythm revealed normal sinus rhythm and temporary pacemaker is removed. Discussion High-degree AV block has been reported in human studies following BCI, secondary to necrosis, inflammation, or fibrotic changes in the subendocardial tissue. 50% of patients reviewed in the literature had a recurrence or permanent complete heart block requiring pacemaker implantation and complete heart block secondary to BCI which was associated with a 20% mortality in the post-traumatic period. Our patient developed a fatal heart block in the early period which could have easily been missed.

Abstract 10951: Clinical Outcome of Maze Procedure for Atrial Fibrillation Combined with Mitral Valve Disease and Tricuspid Regurgitation

Introduction: The surgical strategy for atrial fibrillation (AF) combined with mitral valve (MV) disease are still controversial whether biatrial or left atrial maze procedure should be performed concomitantly. Hypothesis: Our retrospective study aimed to evaluate the long-term results of two kinds of maze procedure combined with MV surgery and identify the factors involved in AF recurrence. Methods: We enrolled 88 patients from January 2010 to December 2020 who underwent MV surgery with maze procedure concomitantly. The patients were divided into two groups; biatrial maze, group F: n=42 and left atrial maze, group L: n=46). Primary endpoint was AF recurrence and we also evaluated early and late complication and preoperative and operative factors related to AF recurrence. The average follow-up term was 2.8 years. Results: Preoperative factors of long-standing AF and TR grade were significantly higher in group F than group L (P=0.004, 0.02, respecively). Consequently, tricuspid annuloplasty (TAP) was performed significantly frequent in group F than group L (P=0.002). We encountered 2 hospital deaths (4.4%) due to postoperative cerebral hemorrhage and AMI in group L. There was 1 case (2.2%) required pacemaker implantation (PMI) during hospitalization in group L and 3 cases (7.1%) requiring PMI in Group F in late-period. The AF recurrence rates at 1 and 5-year follow-ups between Group F and Group L were not significantly different (24.4% and 28.4% vs. 22.9% and 32.4%, P =0.79). However, the AF recurrence rate in group L with TAP is significant high than those of the other groups (group F 24.4% and 28.4%, group L with TAP 44.3% and 56.7%, and group L without TAP 7.7% and 14.3% at 1 and 5 years, respectively p =0.005). Subject with group L with TAP were associated with a high risk of AF recurrence, with an adjusted OR of 2.4 (95% CI: 1.31-4.45, P =0.005). Conclusions: Our study demonstrated that both concomitant maze procedure was effective for preventing AF recurrence. However, it is also revealed that left atrial maze with TAP significantly increased AF recurrence. It was suggested that preoperative right atrial load was involved in primary occurrence of AF and left atrial maze alone might not control AF recurrence in such situation.

Prognostic impact of percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement

Abstract Background Despite the continuous developments of transcatheter aortic valve implantation (TAVI), around 15% of the patients (P) who undergo this procedure require permanent pacemaker (PM). Right ventricular pacing (RVP), particularly with a cumulative percentage of ventricular pacing (CVp) above 40%, has been associated with detrimental effects on ventricular function and an increased risk of cardiovascular events in non-TAVI patients. Aim To evaluate the long-term prognostic significance of RVP, regarding overall mortality and the combined endpoint of overall mortality/heart failure hospitalization in P requiring a PM after TAVI. Methods We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. CVp was determined from stored PM data. P with previous PM were excluded. Post-TAVI PM implantation was defined as a device implantation during hospital stay or during the first month after discharge. Results 474P, 57% male, mean age 81.7±6.5 years with a mean left ventricular ejection fraction of 51.5±14.6% were analysed. Mean follow-up was 18.7 months. Mean STS score and mean Euroscore II were, respectively, 6.89% and 5.76%. Mean gradient was 51.67 mmHg and mean aortic valve area 0.71 cm2. After TAVI, 104P (21.9%) required PM implantation, with a mean CVp of 65.3±43.4%. Post-TAVI PM was not associated with a worse outcome - overall mortality: HR 1.13, 95% CI 0.72 – 1.78, p=0.57; combined mortality/heart failure hospitalization: HR 1.22, 95% CI 0.87 – 1.70, p=0.24. The follow-up Kaplan-Meier curves according to the need for PM post-TAVI were similar: log rank p=0.24. A CVp cut-off of 40% was not associated with any of the study endpoints - overall mortality: HR 1.72, 95% CI 0.38–7.86, p=0.48; combined mortality/heart failure hospitalization: HR 1.32, 95% CI 0.45–3.91, p=0.61. Also, a CVp cut-off of 40% did not provide an accurate risk stratification as survival free of events was similar between these P and those below this cut-off (log rank p=0.11) and in comparison, with P without PM (log rank p=0.65). Conclusions In P submitted to TAVI with a self-expanding valve, the need for PM implantation is common, but not associated with increased risk of total mortality or heart failure hospitalization during a 18 months follow-up period. A CVp cut-off of 40% showed poor discriminative ability regarding long-term events in this population. Funding Acknowledgement Type of funding sources: None.

Clinical outcomes of pacemaker implantations before and after cancer diagnosis

Abstract Background Cardiotoxicity caused by anticancer treatment affects cardiac conduction. Clinical outcomes of pacemaker patients with newly diagnosed cancer are insufficiently understood. Purpose The aim was to investigate the effect of anticancer therapy on pacemaker properties. Methods All patients with pacemaker and confirmed cancer diagnosis treated with chemotherapy at our tertiary university hospital were included in this study. The pacemaker database (containing pacemaker related information) was matched with hospital-wide electronic health records (containing cancer types, comorbidities and echo data). Survival data were retrieved from the Statistics Austria Federal Institute. Clinical and pacemaker data of patients with previously diagnosed cancer requiring pacemaker implantation (Group A) were compared to patients with pre-existing pacemaker followed by cancer diagnosis (Group B). Results Out of 972 included patients, 295 patients (30.3%) had the pacemaker implantation after their first cancer diagnosis (Group A), and 677 patients (69.7%) had already a pacemaker before their first cancer diagnosis (Group B). Cancer types are displayed in Figure 1. The following cancer types were associated with increased likelihood for pacemaker implantation after cancer diagnosis (Group A): kidney cancer (OR 2.07, 95% CI 1.12 to 3.83, P=0.02), lymphomas (OR 2.27, 95% CI 1.21 to 4.26, P=0.01), and eye cancer (OR 9.29, 95% CI 1.03 to 83.50, P=0.047). Patients in Group A were older at pacemaker implantation (76.0 years [IQR 68.0–82.2] vs. 72.1 years [IQR 64.3–78.0], P&amp;lt;0.001), and single-chamber pacemakers were less frequent (21.8% vs. 32.1%, P=0.001). Pacemaker implantation due to bradycardic atrial fibrillation was less frequent in Group A (15.6% vs. 21.8%, P=0.03), but implantation due to an “unspecified” indication was increased (20.6% vs. 12.7%, P=0.002). Patients in Group A had lower pacing threshold at baseline but had a stronger increase in pacing threshold during the follow-up as indicated in Table 1. No differences regarding left or right ventricular function, left or right end-diastolic diameter, or mitral or tricuspid regurgitation were detected between the groups. Patients in Group A had smaller left atria (59.7±10.7mm vs. 63.9±24.0mm, P=0.02) and smaller right atria (57.9±10.4mm vs. 61.2±11.8mm, P=0.001). Patients with cancer diagnosis requiring pacemaker had worse 10-year survival (31.2% vs. 51.1%, log-rank P&amp;lt;0.001) as shown in Figure 1. Conclusion Kidney cancer, lymphoma, and cancer of the eye were associated with increased probability of pacemaker implantation after cancer diagnosis. The significant increase in pacing threshold in patients undergoing chemotherapy could be associated with chemotherapy-induced cardiotoxicity. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 Future and Emerging Technologies Programme Figure 1. Cancer types and survivalTable 1. Baseline characteristics

Previous pacemaker therapy was not associated with the risk of clinical events in patients with atrial fibrillation: the Fushimi AF Registry

Abstract Background Patients with atrial fibrillation (AF) occasionally require pacemaker implantation. Meanwhile, patients with implanted pacemaker are occasionally found to have subclinical AF and develop clinical AF. However, little is known about the clinical outcomes of AF patients with implanted pacemaker. Purpose We aimed to investigate the clinical outcomes in AF patients undergoing previous pacemaker therapy. Methods The Fushimi AF Registry is a community-based prospective survey of the AF patients in a city of Japan. Follow-up data including prescription status were available for 4,447 patients. After exclusion of patients with implantable cardioverter defibrillator and cardiac resynchronization therapy, we investigated 293 AF patients with pacemaker implantation at baseline. We performed propensity score-matching analysis to assess the impact of pacemaker therapy in AF patients. Results Of a total cohort, patients with pacemaker were more often female (51.2% vs. 39.7%; p&amp;lt;0.01) and older (78.0 vs. 73.3 years of age; p&amp;lt;0.01). Patients with pacemaker were more likely to have pre-existing heart failure (33.1% vs. 26.6%; p&amp;lt;0.01), valvular heart disease (22.9% vs. 16.8%; p&amp;lt;0.01), chronic kidney disease (48.8% vs. 34.7%; p&amp;lt;0.01), and history of performing direct current cardioversion (7.2% vs. 3.1%; p&amp;lt;0.01), compared with patients without pacemaker. Mean CHA2DS2-VASc score was higher in patients with pacemaker (3.80 vs. 3.34; p&amp;lt;0.01). Patients with pacemaker were more often prescribed oral anticoagulants (62.1% vs. 55.2%; p=0.02), verapamil (13.3% vs. 9.4%; p=0.03), and loop diuretics (30.7% vs. 21.8%; p&amp;lt;0.01). Using propensity score-matching, 291 patients with pacemaker and 291 without pacemaker were matched and baseline characteristics were comparable. The median follow-up period was 1,819 days. All-cause death occurred in 91 patients with pacemaker (6.0 /100 person-years) and 79 patients without pacemaker (5.9 /100 person-years), with a hazard ratio (HR) for patients with pacemaker of 1.01 (95% confidence interval [CI], 0.75 to 1.37; p=0.93). Furthermore, HR of cardiac death for patients with pacemaker was 1.00 (95% CI, 0.23 to 4.32; p=0.99), that of stroke or systemic embolism was 0.69 (95% CI, 0.44 to 1.07; p=0.10) and that of hospitalization for heart failure was 0.94 (95% CI, 0.65 to 1.37; p=0.76). Conclusion We identified that patients undergoing previous pacemaker therapy were not associated with the incidence of various adverse clinical events in Japanese AF patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, Takeda Pharmaceutical, and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development.

Early Conduction Disorders After Aortic Valve Replacement With the Sutureless Perceval Prosthesis

BackgroundThis study was conducted to determine the incidence of postoperative conduction disorders and need for pacemaker (PM) implantation after aortic valve replacement (AVR) with the Perceval prosthesis (Livanova, Saluggia, Italy). MethodsFrom January 2007 to December 2017, 908 patients underwent AVR with Perceval S in 5 participating centers. Study end points focused on electrocardiographic changes after AVR and the incidence of new PM implantation in 801 patients after exclusion of patients with previous PM (n = 48) or patients undergoing tricuspid (n = 28) and/or atrial fibrillation ablation (n = 31) surgery. Logistic regression analysis was performed to determine risk factors for PM need. ResultsMean age was 79.7 ± 5.2 years, and 476 (59.4%) were women. Median logistic European System for Cardiac Operative Risk Evaluation (2011 revision) score was 4.1% (interquartile range, 2.6%-6.0%). Isolated AVR was performed in 441 patients (55.1%). Associated procedures were coronary artery bypass grafting in 309 (38.6%) and mitral valve surgery in 51 (6.4%). Overall 30-day mortality was 3.9% and was 2.8% for isolated AVR. Electrocardiographic changes included a significant increase of left bundle branch block from 7.4% to 23.7% (P < .001) and development of complete atrioventricular block requiring PM implantation in 9.5%. Multivariable analysis revealed independent of a learning period (odds ratio [OR], 1.91; 95% confidence limits (CL), 1.16-3.13; P = .011), preexisting right-bundle branch block (OR, 2.77; 95% CL, 1.40-5.48; P = .003), intraoperative prosthesis repositioning (OR, 6.70; 95% CL, 1.89-24.40; P = .003), and size extra large (OR, 6.81; 95% CL, 1.55-29.96; P = .011) as significant predictors of PM implantation. ConclusionsIn a challenging elderly population, use of the Perceval S for AVR provides low operative mortality but at the risk of an increased PM implantation rate. Besides preexisting right bundle branch block, the significant effect of size extra large, an increased valve size/body surface area ratio, and need for intraoperative repositioning on PM rate are underscoring the reappraisal of the annular sizing policy.

Retrograde penetration pacing into the conduction system as an alternative approach of his-bundle pacing

BackgroundThe optimal right ventricular (RV) pacing site during pacemaker implantation is still unclear due to left ventricular (LV) dyssynchrony by traditional RV pacing. His-bundle (HIS) pacing has achieved narrow QRS and maintained LV synchrony but high failure rate. RV septal pacing occasionally has QRS waveform with wide and narrow component in the early and late phase, respectively, and maintains LV synchrony, reflecting the normal conduction system. We aimed to define this QRS waveform as retrograde penetration pacing into the conduction system (RPP-CS) and compared its effect on LV synchrony as an alternative approach of HIS pacing. Methods and ResultsWe enrolled 42 patients with atrio ventricular block (AVB) or bradycardia atrial fibrillation (AF) requiring pacemaker implantation (RPP-CS, n = 27; no RPP-CS, n = 15). Baseline characteristics were similar between the groups. RPP-CS was observed in 96% and 26% of the RV septum and apex area, respectively. RPP-CS had a significantly shorter QRS width (p < 0.001). The frequency of maintaining LV synchrony was significantly higher in RPP-CS (67% vs. 20%, p = 0.003). The QRS interval's optimal cut-off value during RPP-CS was 132 ms for prediction of LV synchrony (sensitivity 83%, specificity 89%, positive predictive value 94%, and negative predictive value 73%). During RPP-CS, shorter QRS intervals (QRS ≤ 132 ms) had better postoperative LV ejection fraction than longer intervals (p < 0.001). ConclusionsRPP-CS, especially with short QRS intervals (≤132 ms), had a high frequency of LV synchrony, maintained postoperative cardiac function, and may be an adequate first-line RV pacing site strategy for AVB or bradycardia AF as an alternative approach of HIS pacing.

Cardioneuroablation for Treatment of Atrioventricular Block.

[Figure: see text].

Epidemiologic Burden of Hospitalization Among Adult Filipinos for Cardiac Arrhythmias Requiring Permanent Pacemaker Implantation

BACKGROUND: Symptomatic bradycardia, commonly attributed to sinus node dysfunction/ sick sinus syndrome, or atrioventricular (AV) blocks or conduction disorders from chronic fascicular blocks, is treated by implantation of a permanent pacemaker. Despite it being a class 1 recommendation, there is a perception based on informal surveys that permanent pacemaker implantation (PPI) is underutilized. The Philippines showed slow growth in the volume of implantation from 1049 in 2015 to 1225 in 2016. The Philippine pacemaker data after 2016 are incomplete and unreliable because of the lack of a national registry. It is the aim of this study to ascertain the prevalence of cardiac arrhythmias requiring PPI and the volume of its utilization in the Philippines. OBJECTIVES: The aims of this study were to (1) to determine the prevalence of hospitalization claims in 2017 and 2018 for cardiac arrhythmias requiring PPI, (2) to determine the regional distribution of arrhythmias requiring PPI, (3) to determine the regional distribution of hospitalization claims for PPI, (4) to determine the number of hospitalization claims for specific cases requiring PPI and the corresponding mortality rate, (5) to determine the number of hospitalization claims for PPI and the corresponding mortality rate, and (6) to describe the demographic profile of patients with indications and with claims for PPI, as well as the duration of hospitalization and type of facilities where the hospital claims were filed. METHODS: This is a descriptive study of Filipino patients 19 years or older, admitted for cardiac arrhythmias requiring PPI in the Philippine Health Insurance Corporation (PhilHealth)–accredited hospitals in 2017 and 2018. The data for disease prevalence were gathered from the database of PhilHealth using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) of the World Health Organization. The procedures that the patients underwent were determined using the latest PhilHealth Relative Value Scale (RVS) codes. Other variables gathered were the demographic data, diagnosis, region, duration of hospital stay, type of facility on admission, and the status on discharge. Qualitative data were tabulated and presented as frequency and percent distribution. Quantitative data were reported as median with corresponding quartiles (Q1 and Q3). RESULTS: Based on the 2017 and 2018 database of PhilHealth, out of the nationwide total medical admissions, there were 958 total claims for arrhythmias requiring pacemaker implantation in 2017 and 1144 total claims in 2018. The prevalence in both years was similar (0.04%). There were 549 and 683 total claims for PPI, in 2017 and 2018, respectively, and preponderantly done in the National Capital Region. Sick sinus syndrome/tachycardia–bradycardia syndrome had the greatest number of total claims for both years. More than half of the patients who had PPI were females. The median age was similar (67 and 68 years old for both years and 73 and 75 years old in 2017 and 2018, based on ICD-10 and RVS codes, respectively). The duration of hospitalization was a median of 4 days (ICD-10 codes) and 5 to 6 days (RVS codes). Most of the hospital claims for cardiac arrhythmias (76%–79%) requiring PPI were filed in private facilities. Mortality among those diagnosed was 3.6% for complete atrioventricular block and 0.3% for sick sinus syndrome but was low among those who underwent PPI (0.8%–2.2%).. CONCLUSION: The prevalence of hospitalization claims for arrhythmias requiring PPI was 0.04%, both in 2017 and 2018. There is a big gap between the number of cases requiring a permanent pacemaker and the number that underwent the procedure. Hospitalization claims, based on ICD-10 codes and RVS codes, were centralized in the National Capital Region and private hospitals. The mortality rate among those who had the procedure was low. KEYWORDS: arrhythmia, permanent pacemaker insertion or implantation, prevalence, hospitalization, PhilHealth

Smartwatch detected high-degree atrioventricular block requiring pacemaker implantation after transcatheter aortic valve replacement during COVID-19.

Abstract We report the case of a 63-year-old woman who received remote health monitoring through the smartwatch after transcatheter aortic valve replacement. She began to dizzy on the third day after discharge and was found advanced atrioventricular block. Subsequent evaluation revealed a high-degree atrioventricular block, treated with permanent pacemaker implantation.

Clinically Significant High-Grade AV Block as a Reversible Cause for Acute Kidney Injury in Hospitalized Patients-A Propensity Score Matched Cohort.

Background. High-grade AV block (HGAVB) is a life-threatening condition. Acute kidney injury (AKI) which is usually caused by renal hypo-perfusion is associated with adverse outcomes. We aimed to investigate the association between AKI and HGAVB. Methods. This is a retrospective cohort comparing the incidence of AKI among patients with HGAVB requiring pacemaker implantation compared with propensity score matched controls. Primary outcome was the incidence of AKI at admission. Secondary outcomes were change in creatinine levels, AKI during stay, recovery from AKI, mortality and major adverse kidney events (MAKE). Results. In total, 80 HGAVB patients were compared to 400 controls. HGAVB patients had a higher proportion of admission AKI compared to controls (36.2% versus 21.1%, RR = 1.71 [1.21–2.41], p = 0.004). Creatinine changes from baseline to admission and to maximum during hospitalization, were also higher in HGAVB (p = 0.042 and p = 0.033). Recovery from AKI was more frequent among HGAVB patients (55.2% vs. 25.9%, RR = 2.13 [1.31–3.47], p = 0.004) with hospitalization time, MAKE and crude mortality similar (p > 0.158). Conclusions. AKI occurs in about one third of patients admitted with HGAVB, more frequent compared to controls. Patients with AKI accompanying HGAVB were likelier to recover from AKI. Further studies to explore this relationship could aid in clinical decision making for HGAVB patients.

Long-term impact of transient atrioventricular block during atrioventricular nodal re-entrant tachycardia ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Ablation of atrioventricular nodal re-entrant tachycardia (AVNRT) is an extremely safe procedure, being complete atrioventricular (AV) block the most feared complication. Transient AV or ventriculoatrial (VA) block during ablation is considered a risk marker of immediate AV permanent block. Purpose To study whether TB (transient block) during AVNRT ablation is associated with a higher risk of AV permanent block and pacemaker implantation during long term follow-up. Methods Retrospective analysis of all patients who underwent ablation for AVNRT in our center and had a minimum five years follow-up. Patients carrying a cardiac pacing device were excluded. Data was extracted from electronic medical records and follow-up was performed by telephone contact. TB was defined as AV or VA loss of conduction of at least 1 beat during energy delivery. Results We included 689 patients who underwent AVNRT ablation from March 1995 to December 2015: mean age 52.6 ± 18.6 years; 240 (34.8%) male; 677 radiofrequency and 12 cryotherapy ablations. TB was observed in 106 (15,4%) patients. Baseline characteristics are described in Table 1. Within the TB group, 44 (41.5%) patients presented with AV block, 60 (56.6%) with VA block, and 2 patients presented with both. TB concerned more than one beat in 65 (61.9%) cases and persisted after cessation of energy delivery in 15 (14.2%) cases. Two patients did not recover AV conduction, requiring pacemaker implantation before discharge. During a median 12.5 years follow-up (IQR 9.5-16.6), 3 of the remaining 104 TB patients required pacemaker implantation due to AV block. All 3 had presented AV TB and had undergone radiofrequency ablation; they were not significantly older (67.0 ± 9.3 vs 48.8 ± 19.8, p = 0.12) but presented longer basal PR (237.0 ± 115.2 vs 152.6 ± 26.5, p &amp;lt; 0.001) and HV (57.3 ± 6.7 vs 44.2 ± 7.6, p = 0.004) intervals. When compared to the non-TB group, there were no differences in pacemaker implantation due to AV block during follow-up (7 (1.2%) p = 0.19). However, median time to pacemaker implantation was shorter in TB patients than in non-TB: 0.7 [0.1-1.4] vs 13.7 [5.2-22.0], p = 0.02. Conclusion Long term incidence of permanent AV block did not differ between TB and non-TB groups, however AV block occurred significantly earlier in TB patients. Non-TB group(n = 583) TB group(n = 106) p Age (mean ± SD) 53.2 ± 18.3 49.3 ± 19.8 0.05 PR (mean ± SD) 153.0 ± 28.4 155.0 ± 33.8 0.54 AH (mean ± SD) 83.3 ± 23.6 82.1 ± 22.2 0.64 HV (mean ± SD) 44.4 ± 7.8 44.6 ± 7.9 0.76

Syncope: call for the missed diagnosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas. Purpose To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope. Methods Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation. Results In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications. Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department. Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance). Conclusions Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Catheter ablation for atrial arrhythmias in adults with congenital heart disease: recurrence rates and predictors of acute procedural success

Abstract Funding Acknowledgements Type of funding sources: None. Background Heart rhythm disorders are an important cause of morbidity and emergency hospitalisation in patients with adult congenital heart disease (ACHD), and this is due to a combination of surgical scar, residual haemodynamic lesions, and cardiac chamber dilatation. The most effective available treatment is catheter ablation, although this can be extremely challenging owing to abnormal anatomy and problems accessing intra cardiac sites critical to the arrhythmia mechanism. However, outcomes of catheter ablation and analysis of factors which may predict recurrence of arrhythmia remain poorly defined. Purpose To define the cohort of ACHD patients undergoing catheter ablation for atrial arrhythmia in a large tertiary centre, characterise outcomes, and determine factors associated with arrhythmia recurrence. Methods Retrospective study of all catheter ablations for atrial arrhythmias in ACHD patients between April 13, 2016 and December 16, 2019 at our institution. Patients were identified using a field search through a centralised database; and pre-specified clinical and procedural data of interest, and time from ablation to recurrence were determined from the computerised electronic record. Binary logistical regression and cox regression analysis were used to determine potential predictors of acute procedural success and arrhythmia recurrence respectively. Results Among 90 patients (mean age 43 ± 15 years) who underwent catheter ablation for atrial arrhythmia, 39 (43%) were treated for macro-reentrant atrial tachycardia, 19 (21%) for focal atrial tachycardia, 9 (10%) for multifocal atrial tachycardia, 10 (10%) for atrial fibrillation, 7 (8%) for atrioventricular nodal reentrant tachycardia, and 6 (7%) for atrioventricular reentrant tachycardia. 35 (39%) of patients had "severe" complexity ACHD as per the Bethesda classification. 35 (39%) experienced recurrent arrhythmia with a median time to recurrence of 120 days. Age, gender, body mass index, complexity of congenital heart disease, and previous surgical repair were not identified as being significantly associated with recurrence, however univariate cox regression analysis showed a significantly longer time to recurrence in cases utilising electroanatomical mapping and demonstrating non-inducibility of arrhythmia in the lab post ablation (p &amp;lt; 0.001). There was 1 case of post-ablation bradycardia requiring pacemaker implantation, but no other complications. Conclusion Catheter ablation for atrial arrhythmia in ACHD patients is safe and effective, with a majority of patients achieving multiple arrhythmia-free months. Non-inducibility of arrhythmia post procedure and use of electroanatomical mapping are predictors of freedom from recurrence of atrial arrhythmia, suggesting effective characterisation and ablation of the arrhythmia mechanism is more important than the underlying substrate. These findings may aid management decisions for recurrent arrhythmia in ACHD patients.