Structural Heart Disease In Patients Research Articles

Role of assist device implantation and heart transplantation in the long-term outcome of patients with structural heart disease after catheter ablation of ventricular tachycardia.

IntroductionAblation of ventricular tachycardias (VTs) in patients with structural heart disease (SHD) has been associated with advanced heart failure and poor survival.Methods and resultsThis matched case-control study sought to assess the difference in survival after left ventricular assist device (LVAD) implantation and/or heart transplantation (HTX) in SHD patients undergoing VT ablation. From the initial cohort of 309 SHD patients undergoing VT ablation (187 ischemic cardiomyopathy, mean age 64 ± 12 years, ejection fraction of 34 ± 13%), 15 patients received an LVAD and nine patients HTX after VT ablation during a follow-up period of 44 ± 33 months.Long-term survival after LVAD did not differ from the matched control group (p = 0.761), although the cause of lethal events was different. All post-HTX patients survived during follow-up.ConclusionIn this matched case-control study on patients with SHD undergoing VT ablation, patients that received LVAD implantation had similar survival compared to the control group after 4‑year follow-up, while the patients with HTX had a significantly better outcome.

Catheter ablation of supraventricular tachycardia in patients with and without structural heart disease: insights from the German ablation registry

AimTo compare patient characteristics, safety and efficacy of catheter ablation of supraventricular tachycardia (SVT) in patients with and without structural heart disease (SHD) enrolled in the German ablation registry.Methods and resultsFrom January 2007 until January 2010, a total of 12,536 patients (37.2% with known SHD) were enrolled and followed for at least one year. Patients with SHD more often underwent ablation for atrial flutter (45.8% vs. 20.9%, p < 0.001), whereas patients without SHD more often underwent ablation for atrioventricular nodal reentrant tachycardia (30.2% vs. 11.8%, p < 0.001) or atrioventricular reentrant tachycardia (9.1% vs. 1.6%, p < 0.001). Atrial fibrillation catheter ablation procedures were performed in a similar proportion of patients with and without SHD (38.1% vs. 36.9%, p = 0.21).Overall, periprocedural success rate was high in both groups. Death, myocardial infarction or stroke occurred in 0.2% and 0.1% of patients with and without SHD (p = 0.066). Major non-fatal complications prior to discharge were rare and did not differ significantly between patients with and without SHD (0.5% vs. 0.4%, p = 0.34). Kaplan–Meier mortality estimate at 1 year demonstrated a significant mortality increase in patients with SHD (2.6% versus 0.7%; p < 0.001).ConclusionPatients with and without SHD undergoing SVT ablation exhibit similar success rates and low major complication rates, despite disadvantageous baseline characteristics in SHD patients. These data highlight the safety and efficacy of SVT ablation in patients with and without SHD. Nevertheless Kaplan–Meier mortality estimates at 1 year demonstrate a significant mortality increase in patients with SHD, highlighting the importance of treating the underlying condition and reliable anticoagulation if indicated.

Prevalence of heart disease in patients with mitochondrial abnormalities on skeletal muscle biopsy.

ObjectiveMitochondrial DNA mutations are associated with an increased risk of heart disease. Whether an increased prevalence of cardiovascular disease is present in patients presenting with mitochondrial abnormalities on skeletal muscle biopsy remains unknown. This study was designed to determine the prevalence of cardiac conduction disease and structural heart disease in patients presenting with mitochondrial abnormalities on skeletal muscle biopsy.MethodsThis is a retrospective cohort study of 103 patients with mitochondrial abnormalities on skeletal muscle biopsy who were referred for evaluation of muscle weakness at a single tertiary care referral center from 2012 to 2018. Of these patients, 59 (57.3%) had an electrocardiogram available and were evaluated for the presence of conduction disease. An echocardiogram was available in 43 patients (42%) who were evaluated for the presence of structural heart disease. The prevalence of cardiac disease was compared to control cohort populations (Framingham and the Atherosclerosis Risk in Communities, ARIC cohorts).ResultsMitochondrial abnormalities associated with cardiac conduction disease (defined as QRS duration ≥ 120 msec) were present in 8.9%, versus 2.0% (p < 0.001) in the Framingham population and 2.6% (p = 0.003) in the ARIC cohort. LV systolic dysfunction (LVEF ≤ 50%) was present in 11.6%, versus 3.6% (p < 0.01) in the Framingham and 3% (p < 0.01) in the ARIC populations. Left ventricular hypertrophy was present in 28.6%, versus 13.6% (p < 0.02) in the Framingham and 10.4% (p < 0.001) in the ARIC populations.InterpretationGiven the increased prevalence of cardiovascular disease, patients with mitochondrial abnormalities on skeletal muscle biopsy should undergo routine cardiac screening with physical exam, electrocardiography, and cardiac imaging.

Clinical and Electrophysiologic Characteristics of Ventricular Tachycardias from the Basal Septum in Structural Heart Disease

Background The basal septum is a common source of ventricular tachycardia (VT) in patients with structural heart disease (SHD).ObjectiveWe describe the clinical and electrophysiologic characteristics of basal septal VTs in SHD patients.MethodsData from 312 consecutive SHD patients undergoing catheter ablation of ventricular arrhythmias were reviewed.ResultsThirty-three basal-septal VTs in 31 patients (mean age 67.4{plus minus}14.2 years, left ventricular [LV] ejection fraction [EF] 42{plus minus}15%) were identified. Patients with VTs with LV basal-septal breakthrough were more likely to have ischemic cardiomyopathy and a lower LVEF; right ventricular basal-septal VT patients were more likely to have sarcoidosis or right ventricular cardiomyopathy of unknown significance, with a higher LVEF. Atrioventricular block was present in 45% and intraventricular block including persistent bi-ventricular pacing in 77%. Unipolar scar was larger than bipolar scar (area 18.8{plus minus}19.4% vs. 12.7{plus minus}14.6%, P<0.001). VTs with a right bundle branch block (BBB) morphology and S wave in V6 with positive V3/V4 polarity consistently indicated an LV basal-septal breakthrough. Inferior limb-lead discordance with a right BBB morphology and reverse pattern break in V2 were identified in LV basal infero-septal origin in 3 patients respectively. VT non-inducibility was achieved in 55% and VT recurred in 42% of patients after a single procedure, however, VT burden was significantly reduced after ablation (59 episodes pre vs. 2 episodes post, P=0.02).ConclusionBasal-septal VTs in SHD have a distinct clinical, electrocardiographic, and electrophysiologic profile depending on the breakthrough site, accompanied by a deep intramural septal substrate that limits procedural success after catheter ablation.

Frequent premature ventricular contractions. Association of burden and complexity with prognosis according to the presence of structural heart disease.

IntroductionPremature ventricular contractions (PVC) have been associated with mortality and heart failure (HF) regardless the presence of structural heart disease (SHD). The aim of this study was assessing the impact of burden and complexity of PVCs on prognosis, according to presence of SHD.Methods312 patients were retrospectively evaluated out of 1967 consecutive patients referred for 24‐hr Holter at a single hospital, with a PVC count >1% of total beats. Two groups with and without SHD. PVC burden (PVC%), presence of complex forms, incidence of all‐cause death, combined outcomes of all‐cause death and cardiovascular hospitalizations, HF death and HF hospitalizations and, sudden death (SD) or hospitalizations due to ventricular arrhythmias (VA)were assessed.ResultsPremature ventricular contraction burden was 2.7 (IQR: 1.6–6.7). SHD patients had more polymorphic PVCs, 77% versus 65%, p = .022, triplets and episodes of non‐sustained ventricular tachycardia (NSVT): 44% versus 27%, p = .002; 30% versus 12%, p < .0001. In idiopathic patients, a PVC% in the third quartile was independently associated with all‐cause mortality hazard ratio (HR) 2.288 (1.042–5.026) p = .039, but not in SHD. The complexity of the PVCs was not independently associated with outcomes in both groups. In SHD group, NSVT was associated with lower survival free from SD and VA hospitalizations, p = .028; after multivariable, there was a trend for a higher arrhythmic outcome with NSVT, HR 3.896 (0.903–16.81) p = .068.ConclusionPremature ventricular contractions in SHD showed more complex patterns. In idiopathic patients, a higher PVC count was associated with higher mortality but not is SHD patients. Complexity was not independently associated with worse prognosis.

Coronary and Structural Heart Disease Interventions During COVID-19 Pandemic: A Road Map for Clinicians and Health Care Delivery Systems

BackgroundBecause of the COVID-19 pandemic, cath labs have had to modify their workflow for elective and urgent patients. MethodsWe surveyed 16 physicians across 3 hospitals in our healthcare system to address COVID-19 related concerns in the management of interventional and structural heart disease patients, and to formulate system wide criteria for deferring cases till after the pandemic. ResultsOur survey yielded common concerns centered on the need to protect patients, cath lab staff and physicians from unnecessary exposure to COVID-19; for COVID-19 testing prior to arrival to the cath lab; for clear communication between the referring physician and the interventionalist; but there was initial uncertainty among physicians regarding the optimal management of ST elevation myocardial infarction (STEMI; percutaneous coronary intervention versus thrombolytics). Patients with stable angina and hemodynamically stable acute coronary syndromes were deemed suitable for initial medical management, except when they had large ischemic burden. Most transcatheter aortic valve implantations (TAVI) were felt appropriate for postponement except in symptomatic patients with aortic valve area <0.5 cm2 or recent hospitalization for heart failure (HF). Most percutaneous mitral valve repair (pMVR) procedures were felt appropriate for postponement except in patients with HF. All left atrial appendage closure (LAAC) and patent foramen ovale (PFO)/atrial septal defect (ASD) closure procedures were felt appropriate for postponement. ConclusionOur survey of an experienced team of clinicians yielded concise guidelines to direct the management of CAD and structural heart disease patients during the initial phases of the COVID-19 pandemic.

360-Degree Virtual Reality Consultation for the Structural Heart Disease Patient

ABSTRACT Background : Given the need to improve upon physician-patient communication, we employed a 360-degree Virtual Reality (360°VR) visualization platform for face-to-face consultations for TAVR and LAAO procedures. The platform creates patient-specific 360°VR models from volumetric scans (e.g., CT, MRI) that can be manipulated and viewed from any angle. Methods : Forty-six patients were prospectively surveyed regarding their 360°VR consultation experience for aortic valve stenosis and atrial fibrillation. For each patient, a custom 360°VR model was created from their high-resolution CT scans using Precision VR® by Surgical Theater and utilized during the 360°VR consultation. The proposed procedure was simulated in VR to show the interaction of the specific implant with the patient’s anatomy. Patient conversion rate was also evaluated. Results : Compared to prior standard (non-VR) consultations for the same medical condition, patients reported significantly higher satisfaction with the 360°VR consultation and increased understanding of their pathology and proposed procedure. Additionally, 98% of patients agreed the physician communicated well using Surgical Theater. Patients also reported that experiencing 360°VR helped improve their understanding (98%) and comfort level (93%) with the proposed procedure. Importantly, 91% of patients agreed they felt included in decisions about their treatment. Additionally, 76% rated the hospital a 9 or 10 and 81% said they would recommend this hospital. Conversion rates after 360°VR consultations were higher than those for pre-360°VR consultations (100% vs 86%, TAVR; 92% vs 68%, Watchman). Conclusion : These findings support the 360°VR technology as a powerful tool to enhance patient education, engagement and satisfaction for structural heart disease patients. Abbreviations 360°VR: 360-degree Virtual Reality; TAVR: transcatheter aortic valve replacement; LAAO: left atrial appendage occlusion; HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems; CMS: Centers for Medicare and Medicaid Services

Safety and Efficacy of Thoracoscopic Sympathectomy for Ventricular Tachycardia Control in Structural Heart Disease Patients

Introduction: The autonomous system plays an important role as a trigger of cardiac arrhythmias. Cardiac sympathetic denervation (CSD) achieved by stellate and proximal thoracic ganglia resection has been reported as an alternative approach for the management of ventricular arrhythmias (VA) in structural heart disease (SHD) patients. Methods: Patients who underwent CSD for better management of VA in SHD in a single tertiary center in Brazil were evaluated for safety and efficacy outcomes. Results: Between June 2014 and March 2020, fourteen patients (age 59{plus minus}7.5, 85% male, mean ejection fraction 30.5{plus minus}7.9%) were submitted to left or bilateral CSD. In a median follow-up time of 143 (Q1: 30; Q3: 374) days, eight patients (57,2%) presented VT recurrence. A significant reduction in the median burden of ventricular arrhythmias comparing six months before and after procedure (10 to 0; p=0.004). For the nine Chagas Disease (ChD) patients, the median burden of appropriate therapies was also reduced (11 to 0; p=0.008). There were two cases of clinically relevant pneumothorax and three cases of transient hemodynamic instability, but no direct procedure-related deaths occurred. Additionally, there was no long-term adverse events, Conclusion: CSD is safe and seems to be effective in reducing the burden of VT/VT storm in SHD patients, including Chagas disease patients. Randomized trials are needed to clarify its role in the management of these patients.

Focal Ventricular Tachycardias in Structural Heart Disease: Prevalence, Characteristics, and Clinical Outcomes After Catheter Ablation.

This study sought to summarize the procedural characteristics and outcomes of patients with structural heart disease (SHD) who have focal ventricular tachycardia (VT). Scar-mediated re-entry is the predominant mechanism of VT in SHD. Some SHD patients may have a focal VT mechanism that remains poorly described. An extended induction protocol incorporating programmed electrical stimulation, right ventricular burst pacing and isoprenaline was used to elucidate both re-entrant and focal VT mechanisms. Eighteen of 112 patients (16%) with SHD undergoing VT ablation over 2 years had a focal VT mechanism elucidated (mean age 66±13 years; ejection fraction 46±14%; nonischemic cardiomyopathy 10). Repetitive failure of termination with antitachycardia pacing (ATP) (69% of patients) or defibrillator shocks (56%) was a common feature of focal VTs. A median of 3 VTs per patient were inducible (28 focal VTs, 34 re-entrant VTs; 53% of patients had both focal and re-entrant VT mechanism). Focal VTs more commonly originated from the right ventricle (RV) than the left ventricle (LV) (67% vs. 33%, respectively). In the RV, the RV outflow tract was the most common site (33% of all focal VTs), followed by the RV moderator band (22%), apical septal RV (6%), and lateral tricuspid annulus (6%). The lateral LV (non-Purkinje) was the most common LV focal VT site (16%), followed by the papillary muscles (17%). After median follow-up of 289 days, 78% of patients remained arrhythmia-free; no patients had recurrence of focal VT at repeat procedure. In patients with recurrence, defibrillator therapies were significantly reduced from a median of 53 ATP episodes pre-ablation to 10 ATP episodes post-ablation. During follow-up, 2 patients (11%) underwent repeat VT ablation; none had recurrence of focal VT. Focal VTs are common in patients with SHD and often coexist with re-entrant forms of VT. High failure rate of defibrillator therapies was a common feature of focal VT mechanisms. Uncovering and abolishing focal VT may further improve outcomes of catheter ablation in SHD.

P5639Risk stratification for mortality using electrocardiographic markers based on 24-hour holter recordings: the JANIES-SHD study

Abstract Background Recent guidelines have stated that reduced left ventricular ejection fraction (LVEF) is the gold standard marker for identifying patients at risk for cardiac mortality. Although reduced LVEF identifies patients at an increased risk of cardiac arrest, sudden cardiac deaths (SCDs) occur considerably more often in patients with relatively preserved LVEF. Current guidelines on SCD risk stratification do not adequately cover this general population pool. Several noninvasive electrocardiographic (ECG) risk stratifiers that reflect depolarization abnormality, repolarization abnormality, and autonomic imbalance have been evaluated so far. With current therapeutic advances using new medicines or devices, an LVEF is often preserved in patients with structural heart disease (SHD). However, the usefulness of noninvasive ECG markers for risk stratification in such a patient population has not yet been elucidated. Purpose This study aimed to assess clinical indices and ECG markers based on 24-hour Holter ECG recordings for predicting cardiac mortality in patients with SHD who have left ventricular dysfunction (LVD) but relatively preserved LVEF. Methods In total, 1,829 patients were enrolled into the Japanese Multicenter Observational Prospective Study (JANIES study). In this study, we analyzed data of 719 patients (569 men, age 64±13 years) with SHD including mainly ischemic heart disease (65.8%). As ECG markers based on 24-hour Holter recordings, nonsustained ventricular tachycardia (NSVT), ventricular late potentials, and heart rate turbulence (HRT) were assessed. The primary endpoint was all-cause mortality, and the secondary endpoint was fatal arrhythmic events. Results During a mean follow-up of 21±11 months, all-cause mortality was eventually observed in 39 patients (5.4%). Among those patients, 32 patients (82%) suffered from cardiac causes such as heart failure and arrhythmia. Multivariate Cox regression analysis showed that after adjustment for age and LVEF, documented NSVT (hazard ratio=2.82, 95% confidence interval [CI]: 1.38–5.76, P=0.005) and abnormal HRT (hazard ratio=2.31, 95% CI: 1.15–4.65, P=0.02) were significantly associated with the primary endpoint. These two ECG markers also had significant predictive values with the secondary endpoint. The combined assessment documented NSVT and abnormal HRT improved predictive accuracy. Conclusion This study demonstrated that combined assessment of documented NSVT and abnormal HRT based on 24-hour Holter ECG recordings are recommended for predicting future serious events in SHD patients who have relatively preserved LVEF. Acknowledgement/Funding Grants-in-Aid (21590909, 24591074, and 15K09103 to T.I.) for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technol

Etiology and Outcomes of Syncope in Patients With Structural HeartDisease and Negative Electrophysiology Study.

This study sought to determine the cause of recurrent syncope and clinical outcomes by using the head-uptilt test (HUTT) and an insertable loop recorder (ILR) in patients with structural heart disease (SHD) and negative electrophysiology study (EPS) results. Patients with syncope and SHD with negative EPS findings have a low risk of sudden cardiac arrest. Nevertheless, the cause of recurrent syncope and the outcomes in these patients are not well characterized. This prospective study evaluated syncope patients with SHD and negative EPS results by using HUTT (with sublingual nitroglycerine [NTG] provocation as needed) and ILR. A total of 41 SHD patients (27 patients [66%] had coronary arterial disease, and 14 patients [34.15%] had dilated cardiomyopathy with mean EF of 42 ± 4.8% [range 30% to 49%]) were included. HUTT findings were positive in 25 patients (61%) in group A and negative in 16 patients (39%) in group B. An ILR was implanted in 21 of 25 group A patients (84%) and in 12 of 16 group B patients (75%), and they were followed for 15 ± 8 months. During follow-up, 17 of 21 patients (81%) in group A and 5 of 12 patients (41.7%) in group B had ILR evidence consistent with reflex syncope. One group B patient had documented atrioventricular block and underwent pacemaker implantation. There were no malignant ventricular arrhythmias or deaths on follow-up. Reflex syncope is the most common cause of syncope and accounts for approximately 60% of cases in patients with SHD, negative EPS results, left ventricular systolic dysfunction with left ventricular EF >30%, and not in heart failure.

Catheter ablation of polymorphic ventricular tachycardia/fibrillation in patients with and without structural heart disease

Catheter ablation for polymorphic ventricular tachycardia and ventricular fibrillation (PMVT/VF) may target triggering premature ventricular contractions (PVCs). Targeting ventricular scar has also been suggested, but data are limited. The purpose of this study was to characterize the electrophysiological findings and ablation outcomes for patients with PMVT/VF and structural heart disease (SHD) compared to those with idiopathic VF. Data from 32 consecutive patients (13 idiopathic VF, 19 SHD) with recurrent PMVT/VF who underwent catheter ablation were reviewed. A low-voltage area of myocardial scar was present in 15 of 19 patients with SHD. Sustained monomorphic ventricular tachycardia (SMVT) associated with scar was inducible and targeted in 8, 3 of whom had previous SMVT episodes separate from PMVT/VF episodes and 5 had no history of SMVT. Triggering PVCs were identified in 11 patients and arose from an area of endocardial scar in 6. Only scar ablation was performed in 8 patients who did not have triggering PVCs. All idiopathic VF patients underwent PVC ablation only. During a median of 540 days, 74% of SHD patients and 77% of idiopathic VF patients were free of recurrence, including 75% of those with only PVC ablation, 86% of those with scar plus PVC ablation, and 63% of those with only scar ablation. Patients with recurrent PMVT/VF and SHD often have a low-voltage scar associated with PVCs or inducible SMVT, which may also be the substrate for PMVT/VF. When present, substrate ablation targeting scar is a reasonable option for treatment of PMVT/VF even if PVCs are absent.

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease

Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation. Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n= 4), ruptured papillary muscle (n= 4), ischemic ventricular septal defect (n= 3), or severe aortic stenosis (n= 1). Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n= 11), inotrope requirement (n= 10), intraaortic balloon pump (n= 8), severe acidosis (n= 6), high-dose vasopressor requirement (n= 8), and cardiac arrest (n= 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year. ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation.

P5644Cardiac MRI for a better identification of structural heart disease in patients with ventricular arrhythmia

P5644Cardiac MRI for a better identification of structural heart disease in patients with ventricular arrhythmia

Predictors of appropriate ICD therapy in Japanese patients with structural heart diseases: A major role of prior sustained ventricular tachycardia in secondary prevention.

BackgroundImplantable cardioverter defibrillator (ICD) and cardiac resynchronization with a defibrillator (CRT‐D) are established therapies for secondary prevention of sudden cardiac death (SCD) in patients with structural heart disease (SHD), but the rates of subsequent ICD/CRT‐D therapy widely differ among patients with SHD. The aim of this study was to determine clinical factors associated with appropriate therapy for preventing SCD in patients with SHD.MethodsWe enrolled 147 patients with SHD (mean age, 59 ± 15 years; mean ejection fraction [EF], 45 ± 15%) who underwent ICD/CRT‐D implantation for secondary prevention of SCD (ischemic heart disease, n = 50; nonischemic heart disease, n = 97). ICD/CRT‐D was implanted for aborted cardiopulmonary arrest (CPA, n = 65) or sustained ventricular tachycardia (VT, n = 82).ResultsDuring a follow‐up period of 3.2 ± 3.6 years, 79 of the 147 patients had appropriate ICD/CRT‐D therapies. A Kaplan‐Meier survival curve showed that the rate of appropriate therapy was 54% at 5‐year follow‐up. Prior sustained VT, lower EF, and use of a class I antiarrhythmic drug were significantly more frequent in patients with appropriate therapy. In multivariate analysis, prior sustained VT (hazard ratio, 2.8; 95% CI, 1.60‐4.46; P = .001) was the only independent predictor for appropriate ICD/CRT‐D therapy. Kaplan‐Meier survival curves showed that rates of appropriate therapy during a 5‐year follow‐up period were 70% and 34% in patients with sustained VT and those with CPA, respectively (P = .001).ConclusionsIn SHD patients implanted with an ICD/CRT‐D, prior sustained VT as an indication of ICD/CRT‐D implantation, but not EF or an antiarrhythmic drug, predicts a high rate of appropriate therapy.

Ablation Outcomes and Predictors of Mortality Following Catheter Ablation for Ventricular Tachycardia: Data From the German Multicenter Ablation Registry.

BackgroundVentricular tachycardia (VT) causes significant morbidity and mortality. Implantable cardioverter‐defibrillator shocks terminate VT but confer a significant morbidity and mortality risk. Therefore, VT ablation is increasingly common. Patients with structural heart disease (SHD) and patients with structurally normal hearts as well as the subgroup with and without ischemic heart disease were assessed for predictors of mortality and nonfatal VT recurrence. We present the first multicenter, prospective German VT registry.Methods and ResultsIn 334 patients, 118 structurally normal hearts and 216 SHD (74.5% ischemic heart disease), referred for VT ablation in 38 centers, long‐term follow‐up was assessed for a minimum of 12 months and analyzed for factors predicting VT recurrence rates and mortality. The VTs in SHD patients were more frequently hemodynamically unstable (34.7% versus 12.7%, P<0.0001) or incessant (9.7% versus 2.7%, P<0.05). More SHD patients underwent substrate modification than patients with structurally normal hearts who had more focal ablations. Ablation failure was 9% in both groups. Two‐year mortality was higher in patients with SHD (18.7% versus 3.5%, P<0.001). Predictors of mortality include age >60 years, incessant VT, left ventricular ejection fraction ≤30%, procedural failure, and Class I and III anti‐arrhythmic drug use at discharge. Only procedural failure is a predictor of nonfatal VT recurrence.ConclusionsProcedural failure was the sole independent predictor for nonfatal VT recurrence for our study cohort. This emphasizes the importance of a successful ablation procedure in experienced hands to reduce long‐term mortality and nonfatal VT recurrence.

Incomplete Atrioventricular Septal Defect in a Patient with New Onset Atrial Fibrillation

A 60-year-old female presented with palpitations associated presyncope and increased shortness of breath on exertion (NYHA II) following a recent viral illness. Physical examination revealed heart rate 122 bpm with blood pressure 97/65 mmHg. ECG confirmed atrial fibrillation with rapid ventricular response and intermittent ventricular ectopics. Her past medical history included spontaneous pneumothorax 30 years prior, recurrent migraines and pernicious anaemia. She had two uncompleted pregnancies. Transthoracic and transoesophageal echocardiography (Fig. 1) showed incomplete atrioventricular (AV) septal defect with ostium primum atrial septal defect (ASD). There was a cleft anterior mitral valve leaflet with grade 2/4 mitral regurgitation. Coronary angiogram confirmed normal coronary arteries and significant left to right shunt. Brain MRI did not demonstrate evidence of previous cerebral emboli. The patient underwent elective repair of the AV canal defect and mitral valve repair. The cleft mitral valve leaflet was opposed to create a single leaflet and 34 mm Cosgrove annuloplasty band was placed. The ASD was closed with a bovine pericardial patch sutured along the anterior mitral valve annulus and secured to the interatrial septum. Atrial fibrillation cryoablation was performed together with left atrial appendectomy. Postoperatively, she remained pacemaker dependent and subsequently underwent dual chamber pacemaker implantation 4 days later. Late presentation congenital heart disease often occurs following the development of arrhythmia and heart failure symptoms. This case demonstrates the importance of evaluation for structural heart disease in patients with new onset atrial fibrillation.

Catheter Ablation of Ventricular Tachycardia: Moving Beyond Palliation?

Catheter ablation of ventricular tachycardia (VT) has been effective in reducing the VT burden in structural heart disease patients. Current guidelines from the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society recommend the consideration of catheter ablation in patients who have recurrent VT despite antiarrhythmic drug therapy.1 Although major trials have shown success rates of VT ablation ranging from 50% to 70%,2,3 the long-term prognosis of this patient population remains guarded: it is unknown whether successful ablation actually alters mortality outcomes.

Echocardiography Criteria for Structural Heart Disease in Patients With End-Stage Renal Disease Initiating Hemodialysis

BackgroundCardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined. ObjectivesThis study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients. MethodsWe analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654). ResultsMean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio [HR]: 1.48; confidence interval [CI]: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001). ConclusionsSHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.

GW26-e0480 The predictive value and correlation analysis on structural heart disease in patients with ventricular arrhythmias by studying of heart rate variability

GW26-e0480 The predictive value and correlation analysis on structural heart disease in patients with ventricular arrhythmias by studying of heart rate variability