Are we aiming for different metabolic targets in heart failure patients?

Introduction

Metabolic control plays an important role on major cardiovascular events (MACE) prevention. The 2019 ESC guidelines on dyslipidaemia management recommend tighter LDL-cholesterol (LDL-C) control in order to prevent cardiovascular events. However, it is not yet proven that thigh control of dyslipidaemia, glycaemic levels and body mass index (BMI) in Heart Failure (HF) patients (pts) have an impact on prognosis.

Objective

To evaluate the impact of LDL-C, HbA1c and BMI values on HF pts mortality and MACE rates.

Methods

Single centre study that included consecutive pts hospitalized for acute / decompensated chronic HF in a tertiary Hospital between January 2016 to December 2018 and followed for 12 months. The impact of LDL-C, HbA1c and BMI on mortality and MACE was assessed using Cox regression and Kaplan-Meier curve, after adjustment for age, sex, functional class and ejection fraction. A safety cut-off was established when any of these variables was deemed protective using ROC curve analysis.

Results

Two hundred twenty-four patients (71.68±13.45 years, 63.8% males) were included. Eighty-four (37.5%) pts had type 2 diabetes, 39.7% had ischemic heart disease and the median left ventricular ejection fraction was 34% (IQR 25–49.5; 60.3% HFrEF; 13.8% HFmrEF; 22.3% HFpEF). The median BMI was 25.4 kg/m2 (IQR 23.1–30.5), HbA1c, 6.4% (IQR 5.6–6.8) and LDL-C, 89.5 mg/dL (IQR 64–106); 145 (64.7%) pts were medicated with statins. The overall mortality and MACE rates during follow-up were 16.1% and 21.0%, respectively. According to the CV risk classification 39.7% pts were at very high risk and 19.6% pts at high risk. On multivariate analysis HbA1c (HR 1.5 IQR 1.1–1.9; p=0.007) and female sex (HR 9.453 IQR 2.4–37.2; p=0.001) were independent predictors of mortality, whereas LDL-C (OR 1.05 IQR 1.022–1.075; p<0.001) and BMI (OR 1.23 IQR 1.075–1.404; p=0.002) were independent protective factors. LDL-C and BMI had no effect on MACE rates, although HbA1c was an independent predictor of MACE (HR 1.27 IQR 1.03–1.57; p=0.026). For high and very high-risk pts there was still a protective trend on mortality, although non-significant, for higher levels of LDL-C (OR 1.04 IQR 0.99–1.075; P=NS). Protective LDL-C cut-off were estimated for the whole population (LDL-C 88mg/dL; AUC 0.819; sn 56.6%, sp 100%) and for the high and very-high CV risk pts (LDL-C 84mg/dL; AUC 0.815; sn 59.3%; sp 100%). A BMI safety cut-off for mortality of 25.75 kg/m2 was found (AUC 0.627; sn 61.2%; sp 58.3%).

Conclusion

This study supports the theory of the obesity and LDL-C paradox in HF. Lower LDL-C and BMI increased mortality and there is no trade-off effect on MACE rates, supporting the idea that LDL-C and BMI should not be aggressively addressed in HF pts. In our cohort a cut-off level of LDL-C below 88mg/dL is associated with higher mortality. On the other hand, diabetes should be actively treated as HbA1c predicts death and MACE in HF pts.

Funding Acknowledgement

Type of funding source: None

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Introduction

Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy.

Objective

To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting.

Methods

Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression.

Results

100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (<40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures.

The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall.

In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046).

While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF <40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI.

Conclusion

In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Analysis of hospitalization trends for ambulatory care sensitive conditions in Piauí/Brazil, 2009-18

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are hospitalizations that can be potentially preventable through care at the first level of contact for health care. In fact, the actions offered in a timely and effective manner can reduce the risk of unnecessary hospitalizations by preventing diseases, controlling acute episodes and managing chronic diseases.

Aim

Analyze the trends in hospitalizations for ACSC in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH) of the public health system (SUS), which comprised all hospitalizations of residents of Piauí, Brazil, in the period from 2009 to 2018. The explanatory variables were the hospitalizations for ACSC groups. For temporal trend analysis, the Prais-Winsten linear regression model was used in the Stata version 14 program.

Results

567,577 were recorded as ACSC, representing 35.3% of the total hospitalizations (1,608,263). Most hospitalizations for ACSC were caused by infectious gastroenteritis (33.5%). The risk of hospitalization for ACSC decreased 36.8%, showing a significant reduction in the trend of the hospitalization rate (Annual Percent Change - APC: -4.6%; 95%CI: -6.4; -2.8). There was a greater decrease in the risk of hospitalization for asthma (70.3%), hypertension (66.4%) and infectious gastroenteritis (61.8%). However, a significant increase was identified for skin infection (6.1 times) and diseases related to prenatal care and childbirth (3.2 times).

Conclusions

The reduction in hospitalizations due to ACSC is a result of the strengthening of Primary Health Care as the Brazilian health system organizer and the implementation of the Mais Médicos Program, which enabled the presence of doctors in family health teams, especially in places that had not previously been attended. It is also necessary to develop new studies to expand the discussions and debates on these findings.

Key messages

Hospitalizations reflect the living conditions of individuals, with social changes being perceived by changes in hospitalization patterns over time. The strengthening of primary care policies in Brazil was able to reduce hospitalizations for ACSC and it is necessary to further strengthen these practices to improve people's health care.

Nurses' production of meaning about National Program for Access and Quality Improvement Primary Care

Introduction

The Brazil's Family Health Strategy (ESF) is one of the initiatives for the strengthening of primary health care (PHC) in Brazil. The ESF is composed of a team of professionals, with the nurse usually adding care and administrative functions. In regard to the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), the nurses have played a prominent role, especially in the external evaluation phase.

Aim

Analyze the meanings produced by nurses about the PMAQ-AB in a state in the northeastern of Brazil.

Methods

A qualitative research was carried out with twenty-five nurses from the health macro-regions of the State of Piauí. Data were collected from four focus groups, with one group in each macro-region, containing at least six and at most seven participants. The meetings were held from September to October 2018, in which semi-structured interview script was used. For the analysis of information, the maps of association of ideas proposed by Spink and Gimenes (1994) were used.

Conclusions

Despite the difficulties and conflicts felt by nurses with the implementation of PMAQ-AB, the program was understood as an agent for transforming in the work process of family health teams. In addition, the realization of this study allowed another space for reflection to the nurses about the program, qualification and financing of PHC, which can contribute to the institutionalization of the culture of monitoring and evaluation and also the consequent strengthening of these services.

Key messages

Based on the expected impacts, we seek collaborate with reflection on the experience and generate consistent and useful information to contribute to the decision-making processes of health policies. The PMAQ-AB was considered a program that was able to induce substantial changes in work processes because it was a way to finance the workforce.

Expenditure trends in ambulatory care sensitive conditions in Piauí, Brazil, 2009 a 2018

Introduction

Hospitalizations for ambulatory care sensitive conditions (ACSC) are an indicator that assesses the effectiveness of Primary Health Care. Such hospitalizations burden the public health budget and use the resources that could subsidize other health actions.

Aim

Analyze expenditure trends in hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in Piauí, Brazil, from 2009 to 2018.

Methods

Ecological time-series study based on data from the Hospital Information System (SIH). For temporal trend analysis, a linear regression model was built using the Stata version 14 program.

Results

US$ 119,559,009.56 (Average = US$ 6,292,579.45/year) was spent on ACSC, representing 17.3% of the total hospitalizations (US$ 690,714,037.24). 2010 was the period with the highest cost (14.8%). In contrast, 2018 was the year with the lowest expenditure (5.8%). 23.7% of the costs went to hospitalizations for gastroenteritis. There was a significant decrease in total expenses with ACSC (β = -1.27; 95%CI: -1.65; -0.89; p < 0.001). There was also a reduction in expenses per individual hospitalized, while in 2009, the average expenditure was US$ 230.97/hospitalization, in 2018 it was US$ 157.30/ hospitalization, representing a significant reduction of 31.9%, (β = -12.4; 95%CI: -18.2; -6.6; p = 0.001). The “asthma” and “hypertension” groups showed the greatest cost reductions, 84.8% and 80.7%, respectively. However, an increase in spending on diseases related to prenatal and childbirth (4.1 times) and skin infection (3.9 times) was identified.

Conclusions

Part of the cost reduction is explained by the reduction of hospitalizations for ACSC. The reduced spending averages are compatible with lower hospitalizations by most expensive groups. Linked to these findings, it is observed that Brazil has faced a period of recession since 2015. To this end, additional research must be carried out to relate the expansion of health coverage with the results presented.

Key messages

The costs of hospitalizations for PHC-sensitive conditions reflect the policy of inducing health system coverage, being lower for greater coverage. The evaluation of the cost of specific groups allows the induction of PHC policies focusing on the specific care for each group with a higher cost so as not to burden the health system.

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

Introduction

 The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success.

Objectives

 To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping.

Methods

 Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage <1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis.

Results

 We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%.

Conclusions

 High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation.

Abstract Figure.

P945What is the role of late-potentials determined by signal-averaged ECG in predicting flecainide provocative test in brugada pattern?

Introduction

The sudden cardiac death risk in Brugada Syndrome (BrS) is higher in patients with spontaneous type 1 pattern. Brugada diagnosis is also established in patients with induced type 1 morphology after provocative test with intravenous administration with a sodium blocker channel. Nevertheless, this group of patients is known to be at a lower risk of SCD, and their risk stratification is still a matter of discussion.  Late potentials (LP) detected on signal-averaged ECG (SAECG) on the RVOT have been previously proposed as a predictor factor for BrS, even though data is lacking on its value.

Purpose

To evaluate the association between positive LP (LMS40> 38ms) on SAECG with modified Brugada leads and a positive flecainide test in patients with non-type 1 BrS.

Methods

Retrospective single-center study of non-type 1 BrS patients referred for the performance of a flecainide provocative test. Patients presenting with spontaneous type 1 morphology were excluded from the study. Study of LP on SAECG with modified leads for Brugada were evaluated before administration of flecainide [2mg/kg (maximum150mg), for 10minutes] with determination of filtered QRS duration (fQRS), root mean square voltage of the last 40ms of the QRS complex (RMS40) and duration of low amplitude signals <40μV of the terminal QRS complex (LMS40).

Results

126 patients (47.3 ± 14.1 years, 61.9% males) underwent study with LP SAECG and flecainide test. Among these patients, 7.9% were symptomatic and 16.7% had familiar history of BrS. Flecainide test was positive in 46.8% of patients.

In patients with a positive flecainide test, 64.4% presented LMS40 > 38ms whereas LMS40 > 38ms was present in only 46% of those with a negative flecainide test (p = 0.031). The presence of positive LMS40 was a positive predictor for a positive flecainide test, associated with a two-fold increase likelihood in the induction of a Brugada pattern (OR: 2,12; IC95% 1,025-4,392; P = 0,043).

There was no association between fQRS or RMS40 and a positive flecainide test (p = NS). fQRS > 114ms and RMS40 <20uV was present in 22% and 61% of patients with a positive flecainide test, respectively.

Conclusion

In patient with non-type 1 Brugada syndrome, LMS40 > 38ms in SAECG was a predictor for a positive flecainide test, suggesting that this finding could be helpful on the risk stratification of patients undergoing diagnostic study for Brugada syndrome.

Abstract Figure. Effect of LMS 40 in flecainide test

P1162Atrial fibrillation and Cardiac resynchronization therapy - is this combination truly bad?

Introduction

 

Cardiac resynchronization therapy (CRT) significantly reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (EF). Atrial fibrillation (AF) is a very common comorbidity in these patients, however, CRT benefit in AF patients has been controversial.

Purpose

 

To compare the prognostic impact of CRT in patients (pts) with and without AF.

Methods

Prospective, single-center study that included pts undergoing CRT implantsince 2015. Clinical and echocardiographicevaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevation ≥10% or LV end-systolic volume (ESV) reduction ≥15% were classified as responders. Patients with EF elevation ≥ 20% or ESV reduction ≥30% were classified as super-responders. All the parameters were compared between patients with and without AF.Prognostic impact of CRT was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 166 patients (31%) had AF (73.5% males, mean age 72.2 ± 10.2 years, 37.3% ischemic, LVEF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without AF), except for chronic kidney disease which was more frequent in AF pts(28% vs 17%, p = 0.012). 

The prevalence of complications and surgical revision were similar in both groups.

The CRT response rate was similar in both groups (50% in AF group vs 59.6%, p = NS) as was the super-response rate (22.4% in FA pts vs 31.5%, p = NS).

The 4-year survival rate of patients with AF was similar to non-AF (83.7% vs 84.3%). 

Conclusion

 

Despite the controversy about the efficacy of CRT in AF pts, in our population the long-term survival and CRT response rates were comparable between patients with and without AF.

Abstract Figure.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

Introduction

Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.

Purpose

To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.

Methods

A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups.

In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).

The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).

Conclusion

For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.

Abstract Figure.

Does the use of health technology assessment have an impact on the utilisation of health care resources? Evidence from two European countries

OBJECTIVES

A centralised approach to health technology assessment (HTA) may facilitate optimal use of HTA resources. A regional approach may increase the chances of local implementation of recommendations. This study aimed to compare assessment procedures in England (centralised HTA approach) with Spain (regional HTA approach) discussing key challenges and opportunities from both approaches.

METHODS

We compared technology assessments of anticancer medicines in the two jurisdictions from 2008 to 2015. To assess the implementation of HTA recommendations, we assessed trends in medicine usage using regression methods. We used IQVIA data, from 2011 to 2016, for a sample of 11 medicines. We used CatSalut data from Catalonia to assess the implementation of local recommendations.

RESULTS

In England, 66 assessments were undertaken by the National Institute for Health and Care Excellence (NICE), using a standardised methodology. In Spain, there were 79 reports undertaken by a range of bodies using a shared process and coordinated through the GENESIS collaboration; the assessment methods used varied substantially. Overall, the recommendations in the two jurisdictions were similar. Regression analyses indicate that where there is a positive recommendation by HTA bodies, the usage of the medicine responds most strongly (p < 0.001) in Catalonia (4.892), followed by England (3.120) and Spain (1.693).

CONCLUSIONS

This study suggests that medicine utilisation does respond to the positive recommendations of HTA bodies. However, if HTA capacity is organised primarily regionally, considerable effort may be required in coordination, to ensure consistent and rigorous assessments and adequate implementation of HTA findings.

Ultrasound analyses of hamstrings muscle morphology changes whit sport

Introduction Physical activities and sports can change muscle morphology. Changes caused by regular physical exercise can be assessed by ultrasound parameters such as the pennation angle, cross-sectional area, echo-intensity and muscle thickness.

Objectives This study aims to characterise and evaluate the morphological changes of the hamstring muscles through ultrasound parameters such as the pennation angle, fascicle length, cross-sectional area, echo-intensity and muscle thickness, and verify the existence of morphological changes between the dominant and non-dominant limb.

Methodology Twenty-two young female divided in two groups (control group=11; athletes group=11) were submitted to an ultrasound examination at 50% of the posterior region of the thigh, for the semimembranosus and long portion of the femoral biceps muscles in the longitudinal and in a panoramic view.

Results 22 athletes with a mean age of 22.25 years were evaluated. There were significant differences between the two groups in muscle morphology. The athletes group showed a higher value for muscle thickness, cross-sectional area, pennation angle and fascicle length and a lower value for muscle echo-intensity. This group also showed higher values for these parameters when dominant limb is compared with non-dominant.

Conclusion Physical exercise causes changes in muscle morphology and ultrasound is a good method for the musculoskeletal assessment of athlete’s performance, since it is an imaging modality that allows to carry out comparative bilateral studies for athletes performance follow up and for preventive strategies against the sedentarism.

42When to implant CRT-P or CRT-D in the elderly?

Introduction

Cardiac resynchronization therapy (CRT) in elder patients is increasingly common. However, the decision to implant a device with defibrillator in these patients is often complex and it can be limited not only by the shorter life expectancy but also by a lower relative risk of arrhythmic compare to non-arrhythmic death due to other comorbidities. Thus, wether CRT is effective in an elderly population (≥75 years old), or if a defibrillator (CRT-D versus CRT-P) influences outcomes is a pivotal concern needing additional data.

Purpose

To compare the prognostic impact of CRT-P vs CRT-D in old patients (≥ 75 years old) and its impact in the response rate to CRT.

Methods

A prospective single-center study was conducted of patients indicated for a CRT implant since 2015. Demographic and clinical criteria were evaluated. Transthoracic echocardiography was performed before CRT implant and between 6-12 months post-implant. Patients with an ejection fraction (EF) elevation ≥ 10% or a LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated using the Cox regression and Kaplan-Meier methods. The decision to implant a CRT-P or CRT-D device was made according to clinical decision. Prognostic impact of CRT-P vs CRT-D was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, follow-up duration 18.9 ± 15.8 months). Among these patients, 53.5% had &lt; 75 years old and 46.5% ≥ 75 years. Baseline clinical characteristics were similar, except for a higher prevalence of chronic kidney disease and atrial fibrillation in the elderly population. The proportion of CRT-D/CRT-P was different between these groups (p &lt; 0.001): in the elderly group, more CRT-P were implanted (67.6% vs 32.4 CRT-D) and in the younger group more CRT-D were implanted (77.9% vs 22.1% CRT-P).

The prevalence of complications due to CRT implant was similar in the two groups (4.7% vs 4.2%, p = NS) but the need for surgical revision was less frequent in the elderly group (11.0% vs 5.7%, p = 0.03). The CRT response rate was equivalent in both groups (40.1% vs 59.9%, p = NS), as was the super-response rate (33% in young vs 26.5% in old patients, p = NS).

In the elderly population, the 4-year survival rate was similar between CRT-P and CRT-D patients (75.4% vs 79.8%).

Conclusion

Patients older than 75 years old have similar benefits from the CRT as patients &lt; 75 years, with equivalent response rates to CRT. However, judging from the similar prognostic impact of CRT-P vs CRT-D in this elder population, the implant of a defibrillator should be personalized.

P1059Recurrence of AF after pulmonary vein isolation: how many times?

Introduction

Ablation of atrial fibrillation (AF) by catheter is an effective therapy, particularly in cases of refractoriness to medical therapy. Pulmonary vein isolation (PVI) has a significative long-term recurrence rate of AF, but the recurrence factors after this procedure are poorly defined.

Purpose

To characterize the causes of AF recurrence after PVI and to evaluate complementary strategies that can optimize the therapeutic efficacy.

Methods

A single centre prospective study of patients (pts) with AF submitted consecutively to PVI since September 2004. The variables responsible for the recurrence of AF, the complementary strategies of optimization of AF ablation and the occurrence of other dysrhythmias were evaluated.

Results

A population of 521 pts were submitted to PVI as a primary strategy for AF treatment - 36.1% for paroxysmal AF, 32.5% for persistent AF &lt;1 year, 14.5% persistent AF&gt; 1 year.

Eighty-three pts needed to perform 2 ablations and 10 pts performed 3 ablations. The higher the number of AF ablations, the higher the incidence of atypical atrial flutter (2% in the 1st AF ablation, 17% in the 2nd and 44% after 3 ablations).

In the pts with recurrence of AF undergoing the 2nd ablation, it was verified that most of the pulmonary veins (PV) were not isolated, with an isolation rate of only 34.1% for the right inferior PV; 29.4% for superior PV right, 29.4% lower left VP, 28.2% upper left PV. In this group, in addition to a new PVI in the pts with re-conduction of PV, 45% performed complementary ablation strategies such as: ablation of the cavo-tricuspid isthmus (52.6%); ablation of the left atrium roof line (29%); mitral isthmus ablation line (26%); applications in the scar zone (26%); posterior atrial left line (8%), atrioventricular nodal reentrant atrioventricular ablation (5%), atrial tachycardia ablation (2.6%).

In the pts submitted to the 3rd ablation, again a low PV isolation rate was confirmed: only 44.4% for the both left PV and upper right PV, and 55.6% for the right lower VP. 33.3% also performed cavo-tricuspid isthmus ablation, 22.2% lower mitral isthmus isolation and 22.2% re-isolation of gaps in the roof or intracicritricial line.

Conclusion

This prospective study demonstrates a high rate of PV re-conduction after PVI and its role in AF recurrence. Therefore, the need for a more effective and definitive IVP technique is evident.

Correlates of sedentary time in young children: A systematic review

Background: Young children appear to spend large portions of their waking time being sedentary. Understanding the correlates of sedentary time would assist in developing effective interventions among young children. The purpose of this systematic review was to summarize the current literature on the correlates of objectively measured sedentary time in young children aged 1-5.99y. Methods: This review was registered with PROSPERO (registration no. CRD42017081374) and aligned with the PRISMA Statement for systematic reviews. Five electronic databases (MEDline, CINAHL Complete, PsycINFO, SportDiscus, Scopus) were searched up to October 26, 2017 for studies investigating correlates of sedentary time measured using objective devices. A semiquantitative approach was used to synthesize data. Results: Forty-five studies were retrieved comprising 13,430 participants, and 84 correlates of sedentary time in young children were evaluated. The associations between sex, sleep habits, daily patterns (childcare vs. non-childcare hours), childcare type and sedentary time were indeterminate. Thirty-nine correlates were consistently unrelated. Forty-one potential correlates were examined in too few studies (<4) to make confident conclusions. Parental sedentary behaviour was reported 3 times and maternal sedentary behaviour was reported once. Out of these four studies, three were positively associated with child sedentary time. Conclusions: Despite reviewing 45 studies that evaluated associations for 84 correlates, this review was unable to identify any consistent correlates of sedentary time in young children. Additional research is needed in this area to provide robust evidence of the correlates of sedentary time in young children, particularly for those examined in only a small number of studies.

Behavioral effects of Bj-PRO-7a, a proline-rich oligopeptide from Bothrops jararaca venom

The heptapeptide Bj-PRO-7a, isolated and identified from Bothrops jararaca (Bj) venom, produces antihypertensive and other cardiovascular effects that are independent on angiotensin converting enzyme inhibition, possibly relying on cholinergic muscarinic receptors subtype 1 (M1R). However, whether Bj-PRO-7a acts upon the central nervous system and modifies behavior is yet to be determined. Therefore, the aims of this study were: i) to assess the effects of acute administration of Bj-PRO-7a upon behavior; ii) to reveal mechanisms involved in the effects of Bj-PRO-7a upon locomotion/exploration, anxiety, and depression-like behaviors. For this purpose, adult male Wistar (WT, wild type) and spontaneous hypertensive rats (SHR) received intraperitoneal injections of vehicle (0.9% NaCl), diazepam (2 mg/kg), imipramine (15 mg/kg), Bj-PRO-7a (71, 213 or 426 nmol/kg), pirenzepine (852 nmol/kg), α-methyl-DL-tyrosine (200 mg/kg), or chlorpromazine (2 mg/kg), and underwent elevated plus maze, open field, and forced swimming tests. The heptapeptide promoted anxiolytic and antidepressant-like effects and increased locomotion/exploration. These effects of Bj-PRO-7a seem to be dependent on M1R activation and dopaminergic receptors and rely on catecholaminergic pathways.

9 Pregnancy loss in Holstein lactating recipient cows diagnosed pregnant by pregnancy-associated glycoprotein test in blood

The objective of this study was to evaluate the pregnancy loss (PL) between Day 30 (P30) and Day 80 (P80) of pregnancy in lactating Holstein recipients that received an invivo- (flush) or invitro-produced (IVF) embryo. The recipient cows were located at Maddox Dairy in Riverdale, CA, USA, a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg. First-lactation cows were enrolled in a Presynch-Ovsynch oestrus-synchronization program and scheduled to be artificially bred for the first time at 80 days after calving or to receive an embryo 7 or 8 days after the expected heat (recipients). The data from 590 pregnancies (1045 embryo transfers) from embryos transferred between January 2018 and March 2019 was analysed. Only grade 1 embryos (from morula to hatched blastocyst stage) produced invivo or invitro from Holstein donor heifers, lactating or dry cows, were transferred fresh (invivo or invitro) or frozen-thawed (invivo), and pregnancy rates are shown in Table 1. The ruminant trophoblast produces pregnancy-associated glycoproteins (PAG) that can be detected by enzyme-linked immunoassay (ELISA) in the blood of pregnant cattle as early as 28 days after insemination. Various dairy herds in the USA have been using this test to supplement or replace the use of transrectal ultrasonography for early pregnancy diagnosis. Blood was sampled on P30 after expected heat day (23 days after embryo transfer) from the recipient cows and sent to IDEXX for the PAG Bovine Pregnancy Test, which was reconfirmed on P80 of pregnancy by transrectal ultrasonography. Pregnancy loss was considered to have occurred when a cow was pregnant on P30 but not pregnant on P80. The variable PL was analysed by binary logistic regression in the MINITAB program, and the model included effects of donor status (heifer vs. milk vs. dry) and embryo type. The total PL was 12.2% (72/590) and the details are shown in Table 1. No effect of donor status (P=0.80) was detected. However, there was effect of embryo type (P=0.004). The IVF embryos had a PL of 18.0% compared with 9.5% for the invivo-produced embryos. Further research should be performed to study heifer embryos PL, because currently more embryos are being produced from very young donor cows and sires due to intensive use of genomic testing. In conclusion, there is a higher PL in lactating dairy recipients receiving IVF fresh embryos compared with fresh or frozen invivo-produced embryos. Table 1.Embryo transfer (ET) pregnancy rates (PR, P30) in first-lactation Holstein cows (top) and pregnancy loss (PL) from Day 30 (P30) to 80 (P80) in first-lactation recipient Holstein cows (bottom) Item Heifer donor Lactating donor Dry donor Total ET P30 PR% ET P30 PR% ET P30 PR% ET P30 PR% Invivo - fresh 6 3 50.0 43 25 58.1 329 206 62.6 378 234 61.9 Invivo - frozen 75 38 50.7 221 129 58.4 296 167 56.4 IVF - fresh 123 61 49.6 91 42 46.2 157 86 54.8 371 189 50.9 Total 129 64 49.6 209 105 50.2 707 421 59.5 1045 590 56.5 P30 P80 PL% P30 P80 PL% P30 P80 PL% P30 P80 PL% Invivo - fresh 3 3 0.0 25 24 4.0 206 186 9.7 234 213 9.0 Invivo - frozen 38 35 7.9 129 115 10.9 167 150 10.2 IVF - fresh 61 48 21.3 42 35 16.7 86 72 16.3 189 155 18.0 Total 64 51 20.3 105 94 10.5 421 373 11.4 590 518 12.2

11 Invivo-derived embryo pregnancy rates at Maddox Dairy from 2008 to 2018

Maddox Dairy, located in Riverdale, CA, USA, is a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg, and they have been producing high genetic animals by embryo transfer (ET) since the early 1980s. Invivo-derived embryos from Holstein donors were transferred fresh (grade 1 or 2) or frozen (grade 1), at morula (4), early blastocyst (5), or blastocyst (6) stage, to virgin heifers (VH, natural oestrus, 13-15 months old) or lactating cows (LC, Presynch-Ovsynch, 86 days in milk, first or second lactation) 6 to 9 days after oestrus. Pregnancy diagnosis was done by transrectal ultrasonography at 32-46 days in VH and by the IDEXX PAG test at 30 days in LC. June, July, August, September, and October were called critical months (first service AI conception rate drops below 44%) and compared with the other months. The data from 32 503 ETs between January 2008 and December 2018 are summarised on Table 1. Pregnancy rates (PR) are lower for LC recipients than for VH. Embryo transfers performed 7 or 8 days after oestrus had higher PR in both types of recipients and embryos, but Day 6 and 9 oestrus are also used with fair results. The season does not seem to affect PR. There is not enough difference in the combination of stage and days from oestrus for invivo-derived embryos. These numbers do not belong to a planned experiment. Several management changes during the years were made, which make it very difficult to apply statistical methods to analyse the data correctly. They are used as a tool to make decisions in an attempt to improve future results. Table 1.Pregnancy rate (PR) of virgin heifers (top) and lactating cows (bottom)-fresh (SH) and frozen (OZ) invivo-derived embryo transfer1 Heat-months SH-ST4 SH-ST5 SH-ST6 SH-All OZ-ST4 OZ-ST5 OZ-ST6 OZ-All PR% n PR% n PR% n PR% n PR% n PR% n PR% n PR% n Heifers 6 d-CM 62 934 66 243 68 69 63 1246 56 473 58 219 62 42 57 734 6 d-OM 62 1623 67 489 69 211 64 2323 56 600 55 296 48 137 55 1033 6 d-T 62 2557 67 732 69 280 63 3569 56 1073 57 515 51 179 56 1767 7 d-CM 64 1506 68 495 67 221 65 2222 60 822 62 340 63 156 61 1318 7 d-OM 66 2723 68 1021 69 510 67 4254 57 1120 59 581 57 231 58 1932 7 d-T 66 4229 68 1516 69 731 67 6476 58 1942 60 921 60 387 59 3250 8 d-CM 65 1348 64 518 67 322 65 2188 59 595 64 258 63 108 61 961 8 d-OM 66 2166 68 886 70 510 67 3562 61 770 60 364 51 130 60 1264 8 d-T 66 3514 67 1404 69 832 66 5750 60 1365 62 622 56 238 60 2225 9 d-CM 60 109 56 43 70 20 60 172 60 5 33 6 50 4 47 15 9 d-OM 58 129 63 57 60 40 60 226 63 16 50 18 75 4 58 38 9 d-T 59 238 60 100 63 60 60 398 62 21 46 24 63 8 55 53 All-CM 64 3897 66 1299 67 632 65 5828 58 1895 61 823 63 310 60 3028 All-OM 65 6641 67 2453 69 1271 66 10 365 58 2506 58 1259 53 502 58 4267 All-T 65 10 538 67 3752 69 1903 66 16 193 58 4401 60 2082 57 812 59 7295 Lactating cows 6 d-CM 54 265 48 86 50 12 53 363 38 141 31 77 50 10 36 228 6 d-OM 49 463 52 203 45 56 50 723 46 101 48 54 59 27 48 182 6 d-T 51 728 51 289 46 68 51 1086 41 242 38 131 57 37 42 410 7 d-CM 54 755 59 274 56 103 55 1137 43 928 48 450 43 192 45 1570 7 d-OM 55 914 66 367 54 109 58 1393 46 1052 45 564 47 353 46 1969 7 d-T 55 1669 63 641 55 212 57 2530 45 1980 46 1014 46 545 45 3539 8 d-CM 63 252 68 82 76 33 65 368 48 219 56 80 42 33 50 332 8 d-OM 61 257 64 161 53 47 61 466 50 191 53 77 56 16 51 284 8 d-T 62 509 65 243 63 80 63 834 49 410 55 157 47 49 50 616 All-CM 56 1272 58 442 60 148 57 1868 44 1288 47 607 43 235 45 2130 All-OM 55 1634 62 731 51 212 56 2582 47 1344 46 695 48 396 47 2435 All-T 55 2906 60 1173 55 360 57 4450 45 2632 47 1302 46 631 46 4565 1ST=stage; CM=critical months (June, July, August, September, and October); OM=other months.

10 Pregnancy rates following artificial insemination or embryo transfer in lactating Holstein cows

Excessive heat affects the fertility of high production lactating cows, and reduced pregnancy rates (PR) are observed during summer and early fall. Embryo production programs are used to produce more calves from high genetic merit animals, but could it also increase fertility by bypassing all the negative variables affecting the embryo development before Day 7 (oocyte development, ovulation, fertilization, early embryo development)? The data from AIs and embryo transfers (ET) between June 2017 and May 2019 were analysed. June, July, August, September, and October were called critical months (first-service AI conception rate dropped below 44%). The cows were located at Maddox Dairy in Riverdale, CA, USA, a Holstein herd that milks 3500 cows with a 305-day mature-equivalent milk production of 12 800 kg. First- and second-lactation cows were enrolled in a Presynch-Ovsynch oestrus-synchronization program and scheduled for the first AI at 86 days after calving or to receive an embryo 7 or 8 days after the expected heat. The embryos were produced invivo or invitro from Holstein donors and were transferred fresh or frozen. Blood was sampled on Day 30 after expected heat day (23 days after embryo transfer), and pregnancy was detected by the IDEXX PAG Bovine Pregnancy Test. Table 1 summarises the results, where ET PR% is the number of pregnant cows divided by the number of cows that received and embryo. All the cows synchronized for AI were bred, but only cows with the presence of a corpus luteum (CL) on ET day received an embryo. The presence of a CL was not detected in 28.7% (471/1642) of the cows (32.2% in the critical months and 25.7% in the others). Unfortunately, we could not detect the presence of a CL by ultrasonography every time we transferred embryos, so the nonovulation rate might be overestimated. The cows without a CL were considered open and used to calculate the adjusted PR (AdjPR%). Embryo transfer PR is superior to that of AI, especially during the critical months. Fresh invivo embryos have the most impact. When the cows without CLs are considered open, the difference between AI and ET is still evident for fresh invivo embryos. Besides producing animals with higher genetic merit, depending on the type of embryo used, ET can increase fertility in lactating Holstein cows, especially during the critical months. The other benefit of using ET is that cows that do not ovulate are synchronized right away, which is not the case for AI cows. Table 1.AI×embryo transfer in lactating Holstein cows1 from June 2017 to May 20192 Item Critical months (June to October) Other months (November to May) All year %PR n Adj PR% n %PR n Adj PR% n %PR n Adj PR% n Artificial insemination 41.2% 896 41.2% 896 47.7% 1767 47.7% 1767 45.5% 2663 2663 Fresh invivo embryo 62.7% 373 47.5% 493 69.5% 262 55.3% 329 65.5% 635 50.6% 822 Frozen invivo embryo 59.3% 221 44.8% 292 59.4% 256 47.3% 322 59.3% 477 46.1% 614 IVF fresh embryo 47.9% 167 36.2% 221 54.0% 363 43.0% 456 52.1% 530 40.8% 677 Total embryos 58.5% 761 44.2% 1006 60.2% 881 47.9% 1107 59.4% 1642 46.1% 2113 1Lactating Holstein cows, first and second lactation, first service, Presynch-Ovsynch, 85 DIM. 2PR%=the number of pregnant cows divided by the number of cows that received and embryo; AdjPR%=adjusted pregnancy rate.

Elevated trace elements in sediments and seagrasses at CO2 seeps

Seagrasses often occur around shallow marine CO2 seeps, allowing assessment of trace metal accumulation. Here, we measured Cd, Cu, Hg, Ni, Pb and Zn levels at six CO2 seeps and six reference sites in the Mediterranean. Some seep sediments had elevated metal concentrations; an extreme example was Cd which was 43x more concentrated at a seep site than its corresponding reference site. Three seeps had metal levels that were predicted to adversely affect marine biota, namely Vulcano (for Hg), Ischia (for Cu) and Paleochori (for Cd and Ni). There were higher-than-sediment levels of Zn and Ni in Posidonia oceanica and of Zn in Cymodocea nodosa, particularly in roots. High levels of Cu were found in Ischia seep sediments, yet seagrass was abundant there, and the plants contained low levels of Cu. Differences in bioavailability and toxicity of trace elements helps explain why seagrasses can be abundant at some CO2 seeps but not at others.

Pseudo-Wellens syndrome, acute pancreatitis, and an anomalous coronary artery: a case report

Background

Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies.

Case presentation

A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features.

Conclusions

Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.

P3808iBox-CRT: Better response, less complicated, equally fast

Introduction

The optimization of the left ventricle (LV) pacing site guided by the electrical delay increases CRT response rate (RR), however it's necessary to develop technology that allows its universal use.

Purpose

The aim is automatically, and operator-independent, access the conduction delay between the right ventricular (RV) stimulus and the LV available veins in order to select the LV pacing site. It is further intended to compare the total procedure and radiation times in relation to an historical control group.

Methods

Prospective, single-center study that included patients undergoing CRT implant according to the current ESC Guidelines. All patients were submitted to a clinical, electrocardiographic and echocardiographic basal evaluation prior to CRT implantation and at 6 months of follow-up.

To evaluate conduction delays between the RV lead and the LV available veins (RV-LV delay), an external interface - intelligent Box for CRT (iBox-CRT) was used. Four measurements in at least two different tributary veins were made. The implant of all the LV leads was guided by the longest measured delay.

A positive response to CRT was defined as an improvement of >10% in left ventricle ejection fraction (LVEF) or a reduction of end-systolic volume (ESV)>15%. The results were compared to a control group (CG) of pts submitted to CRT implantation in the conventional way.

Results

60 patients were included (68.3% males, 38% ischemic, mean age 67.4±10.2 years) and submitted to CRT implant (37 CRT-P; 23 CRT-D). At basal evaluation, LVEF was 28±7%, end-diastolic volume (EDV) was 200±73ml and ESV 145±64ml. CG (n=51) had similar characteristics.

The RR was 85.7%, significantly higher compared to the CG (55.9%, p=0.003). The ESV reduced 38.2±3% in responders vs 5.7±2% in non-responders (NR) (p=0,005), EDV reduced 33.3±16% in responders vs 13.6±10% in NR (p=0.002), the mean LVEF improved 11% in responders vs −1% in NR (p=0.02).

At follow-up, the mean ESV in the study group (SG) was 89±44 ml vs 132±75ml in the CG (p=0.002) and the EDV 136±51 vs 190±78 (p=0.007).

In addition to a much better response rate, the responders in the study group had significantly higher mean LVEF at follow-up (39±11% vs 37±7%, p=0.032).

The mean intra-procedure RV-LV delay was 187±34mseg. In the responder group the baseline delay was usually higher (190±35 msec) vs NR group RV-LV delay (165±23 msec; p=NS).

Compared with CG, the automatic assessment of RV-LV delay with iBox-CRT did not increase fluoroscopy time (15±16min vs 18±16; p=NS) and shortened procedure time (65±34 vs 108±83min, p<0.005).

Conclusions

The iBox-CRT use enabled an automatic and operator independent RV-LV delays measurement, in order to implant the LV lead at the most delayed site. This technique translated into a major increase in CTR response rate, not compromising the procedure duration nor increasing the radiation exposure.

P5689First intention epicardial VT ablation: what are the results?

Introduction

Ventricular tachycardia (VT) endocardial mapping and ablation may not be sufficient in several arrhythmogenic contexts, because ventricular myocardium may comprise intricate endocardial, intramural and epicardial substract. Thus, epicardial ablation has lately become a complementary and necessary tool to approach some VTs in different types of cardiomyopathies.

Purposes

To evaluate the clinical characteristics of patient most suitable for first intention epicardial VT ablation and to describe our centre experience.

Methods

Single-centre prospective study of consecutive patients (pts) undergoing isolated first intention epicardial VT mapping and ablation since August 2015. All pts had clinical assessment, electrocardiogram (ECG), echocardiogram and cardiac magnetic resonance when feasible. Pts with a previous endocardial ablation were excluded. Epicardial subxiphoid access utilizing a tuhoy needle was performed under fluoroscopic guidance. High-density mapping was performed using CARTO® V4 and EnSite PrecisionTM systems and multipolar catheters. Radiofrequency energy was applied with an irrigated-tip catheter.

Results

First intention epicardial VT ablation was attempted in 12 pts (mean age 57.6±14.6 years, 91% male). The majority had non-ischemic dilated cardiomyopathy, of unknown aetiology in 59%, hereditary dilated cardiomyopathy in 17% ethanolic origin in 8% and post-myocarditis in 8%. Right Ventricular Arrhythmogenic Cardiomyopathy was present in 1 patient. As expected, our population presented a mean ejection fraction of 29% and 11 pts (92%) had an implantable cardioverter defibrillator - ICD (55% as primary prevention, 45% as secondary prevention). All pts had experienced symptomatic VT, with all ICD carriers receiving appropriate shocks. Only 4 pts had an available 12 lead ECG of the VT, and all of them had a QS pattern in lead aVL and a slurred initial QRS complex. The majority of patients presented low voltage areas and local abnormal ventricular activities at the epicardial surface, with the exception of 2 pts in whom ablation was not performed (one non-ischemic cardiomyopathy of ethanolic aetiology and the other of unknown origin). Mean ablation application time was 68 minutes, with an average maximum power of 39.9 watts. Mean overall procedure and fluoroscopic time was 132 and 24 minutes, respectively, with no major intraprocedural complications. During a mean follow-up of 307±328 days, 3 pts died (mean 121 days after procedure), 3 had recurrent VT episodes and ICD shocks, and 2 received heart transplant.

Conclusion

In selected pts, with non-ischemic dilated cardiomyopathy and ECG with QS pattern in aVL and slurred QRS, epicardial VT mapping and ablation may be used as first approach, preventing unnecessary endocardial mapping. This procedure demonstrated to be safe.