His bundle pacing, selective and non-selective: are they equally safe and effective?

Background

Permanent His Bundle Pacing (HBP) is the most physiological form of ventricular pacing. His bundle stimulation can be selective (s-HBP) or non-selective (ns-HBP). Few comparative data in terms of safety and efficacy among the two are available in literature.

Purpose

Evaluate the safety and efficacy of s-HBP and ns-HBP stimulation and identify predictors of one or the other stimulation.

Methods

Prospective analysis of patients with HBP implanted between December 2018 and July 2021. The clinical and instrumental parameters were collected at implant and at long-term follow-up. Follow-up data were collected both at outpatient visits and by remote monitoring systems.

Results

130 patients in need for antibradyarrhythmia therapy and 26 patients with an indication for cardiac resynchronization therapy were enrolled, 134 (86%) had successful HBP (34% s-HBP and 66% ns-HBP). There were no significant clinical differences between the two populations with the exception of the presence of right bundle branch block (RBBB: 17.4% s-HBP and 34.1% ns-HBP; p = <0.05) and baseline QRS duration (116.5±27.5 ms in s-HBP and 129.9±34.7 ms in ns-HBP; p = <0.05). There were no significant predictors of ns-HBP (Figure 1). At implantation and at an average 16-month follow-up there were no significant differences in the electrical parameters between the two HBP stimulation modalities.

Twenty-one patients (15.7% of the population, 24% of s-HBP and 12.5% of ns-HBP; p=0.38) had conduction system disease progression, manifested either by a significant increase in pacing threshold (13.3% of s-HBP and 10.2% of ns-HBP recipients; p=0.64; Figure 2A) or by loss of capture (6.5% of s-HBP and 2.2% of ns-HBP recipients; p=0.69). No statically significant predictors of conduction system disease progression were found (Figure 2B). While seventeen patients who had significant threshold elevation underwent device output reprogramming, four patients, who lost capture, and a single one experiencing lead dislodgment (nS-HBP patient) required lead repositioning (8.7% of s-HBP and 4.5% of ns-HBP recipients; p=0.33). s-HBP was significantly more vulnerable to atrial oversensing that required sensitivity reprogramming (17.4% of s-HBP and 4.5% of ns-HBP recipients; p<0.05).

No significant differences in clinical endpoints (cardiovascular death, heart failure, atrial fibrillation, syncope) were observed at follow-up.

Conclusions

In patients indicated to ventricular stimulation, the potential benefit represented by HBP is burdened by a non-negligible number of complications. Though no significant differences were detected at medium-long term between s-HBP and ns-HBP stimulation, s-HBP stimulation appears to be more affected by pacing threshold increase and progression of conduction tissue disease, which resulted in an almost 2-fold (although statistically not significant) incidence of repeated surgery.

Funding Acknowledgement

Type of funding sources: None.

Is less always more? A prospective two-centre study addressing clinical outcomes in leadless versus transvenous single-chamber pacemaker recipients

Background

Transvenous (TV) pacemakers are a well established treatment of bradyarrhythmias yet their complications, namely bleeding, infection and pneumothorax, still pose challenges to modern cardiology. This applies particularly to the older patient subgroup requiring single-chamber pacing due to comorbid atrial fibrillation (AF). Furthermore, conditions such as superior venous access issues, high infectious, or bleeding risk may complicate or preclude transvenous lead implantation. While VVIR leadless (LL) pacemakers aim to tackle these shortcomings, a comparison with contemporary single-chamber TV cohorts is currently lacking thus hindering a clear definition of the scope of LL pacing in clinical practice.

Purpose

To prospectively analyse survival and complication rates in leadless versus transvenous single-chamber pacemaker recipients.

Methods

This is a prospective analysis of 344 consecutive patients who received single-chamber TV or LL pacemakers between June 2015 and May 2021 in two tertiary cardiology centres. Indications for single-chamber pacing were “slow” AF, atrio-ventricular block with comorbid AF (either permanent or accepted as “destination rhythm”) or with sinus rhythm in bedridden cognitively impaired patients. LL indications were ongoing or expected chronic haemodialysis (6.9%), superior venous access issues such as occlusion (11.1%) or need for its preservation (9.7%), active lifestyle with low amount of pacing expected (22.2%), frailty causing high bleeding and infectious risk (23.6%), as well as recent valvular endocarditis (2.8%) or implantable electronic device infection requiring extraction (5.6%).

Results

72 patients (20.9%) received LL and 272 (79.1%) TV single-chamber pacemakers. In keeping with LL indications, diabetes and ongoing haemodialysis were more prevalent in the LL population. No significant difference in overall complication rate was observed between LL and TV patients (5.6% vs. 5.1%, p=0.33) apart from haematomas, which occurred more frequently in the LL population. Only 1 haematoma in the TV group required surgical reintervention. TV recipients survival was lower with greater cardiovascular mortality, likely due to selection of significantly older patients.

Conclusions

Given the limited complication rate observed in this contemporary single-chamber TV cohort and low life expectancy of this particular population, extending LL indications to all VVIR candidates is unlikely to provide a clearcut survival advantage. Considering the higher costs of LL technology, these data prompt a careful selection of those cases where LL approach does indeed provide an advantage. In addition to the setting of vascular access issues and high bleeding or infectious risk, these may include patients with sufficient life expectancy where lead-related risks may indeed adversely affect prognosis. Based on our patient selection criteria, LL might account for approximately 20% of VVIR pacing recipients.

Funding Acknowledgement

Type of funding sources: None.

Rapid mode in novel generation visually guided laser balloon system: feasibility, safety, and impact on procedural outcomes

Funding Acknowledgements

Type of funding sources: None.

Background

Laser balloon (LB) systems are increasingly used for pulmonary vein isolation (PVI) in catheter ablation of atrial fibrillation (AF). The novel generation of the visually guided LB system includes a rapid mode (RM) feature, which potentially allows a continuous circumferential lesion for PVI. Nevertheless, data on its practicability and on its impact on procedural outcomes are lacking.

Purpose

To analyse the applicability of RM and its effect on procedural and fluoroscopic time in a cohort of patients who underwent catheter ablation of AF using a LB system.

Methods

Between September 2020 and December 2021, we prospectively included all consecutive patients who underwent PVI with LB at our centre. All the procedures were performed by the same two operators. For each pulmonary vein (PV), we firstly attempted to obtain a complete circumferential lesion at 13 W using the RM. If its application was not possible or incomplete, we performed additional single lesions at 5.5, 8.5 or 13 W to achieve complete visual PVI. Finally, we calculated the percentage of singular and total circumferential lesions made with RM for every procedure and evaluated its influence on procedural outcomes.

Results

75 patients were enrolled. We identified and successfully isolated 289 PVs, with mean procedural and fluoroscopic time of 171±51 and 38±15 min, respectively. Use of RM for more than 70% of the circumferential lesion was possible in 185 veins (64%), while we obtained complete isolation using only RM in 90 veins (31%). Reasons for interruption of RM were unfavourable anatomy, imperfect visualization of the ostium of the PV and presence of blood between the balloon and the anatomic substrate. For each vein, we observed a significantly shorter ablation (13±8 vs 23±12 min, p<0.001) and fluoroscopic time (3±3 vs 5±4 min, p<0.01) if >70% of the circumferential lesion was made through RM. Further, total procedural (157 ±52 vs 192±42 min, p<0.01), ablation (53±17 vs 88±27, p >0.001) and fluoroscopic time (30±15 vs 36.9±14 min, p 0.025) were significantly shorter if more than 70% of total circumferential lesion was achieved through rapid mode. There were five pinhole balloon ruptures during application of RM. No major complication occurred.

Conclusions

RM is a novel feature in the latest generation of LB system. In our cohort, it showed good applicability and safety, while significantly reducing procedural times. Further studies are needed to understand its possible impact on clinical outcomes.

Implantable cardioverter defibrillator in arrhythmogenic cardiomyopathy: which role for antitachycardia pacing?

Funding Acknowledgements

Type of funding sources: None.

Background

Arrhythmogenic Cardiomyopathy (ACM) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden cardiac death. Implantable cardioverter defibrillator (ICD) remains the only proven therapy to reduce mortality in ACM.

Purpose

The objective of this study was to identify characteristics of ventricular arrhythmias and treatment in patients with ACM.

Method

Retrospective analysis of the data of consecutives patients with confirmed diagnosis of ACM based on the proposed Padua Criteria, who underwent implantation of transvenous ICD from January 1992 and October 2021. The clinical data and information about appropriate and inappropriate ICD therapies were obtained from medical records with the review of the available intra-cardiac electrograms (EGMs).

Results

We enrolled 52 patients (69% males, mean age at implant 48.9 ±14.8 years), 27 (52%) were implanted for primary prevention, 25 (48%) for secondary prevention. After a median follow-up of 7.52 years [IQR: 4.37 - 12.0], 32 patients (61.5%) had 914 sustained episodes of ventricular arrhythmias (VA). 25 patients (48%) had 309 episodes of life-threatening arrhythmias (LT-VA), defined as sustained ventricular tachycardia ≥200 beats/min. In 29/32 patients (91%) ATP treated at least one episode of VA and in 14/25 (56%) at least one episode of LT-VA. Ventricular tachycardia (VT) detection was programmed at least 20 seconds, while VF detection was at least 7 seconds. Among patients with appropriate ICD activation, the first treated episode was a LT-VA in 50% of cases. Out of 914 VA episodes, 735 (80.4%) were treated with ATP and 179 (19.6%) with shocks. Considering LT-VA (cycle length 248 ± 25 ms), 201/309 (65%) and 108/309 (35%) episodes were treated with ATP and shocks, respectively. In 13 patients (25%) there was an inappropriate ICD activation, mostly caused by atrial fibrillation, while in 8 patients (15%) there was a complication needing reintervention (in 3 cases there was a loss of ventricular sensing dictating lead revision).

Conclusions

ACM patients are at risk of VA and LT-VA. The majority of VA at follow-up are monomorphic at rate <200 beats/minute, however the first treated VA episode is a LT-VA in half of cases. ATP is highly successful in terminating VT and even LT-VA, which questions the use of non-transvenous ICD in this young patient population. Nevertheless, transvenous ICDs are burdened by a relevant rate of lead complications which should be weighed in the choice of the ICD type.

Learning curve for laser balloon ablation in the treatment of atrial fibrillation: a single center experience

Funding Acknowledgements

Type of funding sources: None.

Background

Visually guided laser balloon ablation (LBA) is a promising method for pulmonary vein (PV) isolation in the treatment of atrial fibrillation (AF). To reduce procedural times, the rapid mode feature (RM), which offers an automated continuous 360° lesion for pulmonary vein isolation, was implemented in the latest version of the laser balloon system.

Purpose

We evaluated the learning curve for LBA in the treatment of AF

Method

We enrolled the first 74 patients with paroxysmal or persistent AF treated with LBA in our centre between September 2020 and December 2021. Exclusion criteria were any contraindication for the procedure. 3 different time intervals were considered (time 1 T1, time 2 T2 and time 3 T3), which included the first 25 patients, the next 25 patients and the last 24 patients, respectively. We compared fluoroscopy and procedural time and the number of pulmonary veins isolated by RM >90% (>324°) among the three group were compared.

Results

There was no difference between the three intervals in terms of age (61.2 ±9.00 vs 63.9 ±11.4 vs 58.4 ±12.9; p=n.s.), sex (68% vs 64% vs 81%; p=n.s.) and clinical characteristics. The procedural time (see picture 1) was significantly reduced from T1 to T2 (199 ±51.8 in T1 vs 159 ±38.6 in T2; p< 0.01), while there was no variation between T2 and T3 (159 ±38.6 in T2 vs 153 ±51.9 in T3; p=n.s.). We detected a reduction in fluoroscopy time between T1 and T2 (38.8 ±15.2 in T1 vs 28.8 ±10.5 in T2; p<0.01) but not further reduction was observed between T2 and T3 (28.8 ±10.5 in T2 vs 30.5 ±16.7 in T3; p =n.s.). Considering the use of (RM) feature, there was a progressive increase in the number of PVs isolated by RM >90% over time (1.0 ±0.7 PVs in T1 vs 2.0 ±1.2 PVs in T2 vs 3.3 ±0.9 in T3: p <0.01). Five pinhole balloon ruptures were observed, three in the T1 group, two in the T3 group. Temporary phrenic nerve dysfunction occurred in 1 patient in the T3 interval. No other complications were reported.

Conclusions

PV isolation by visually guided LBA is a safe procedure even during the learning curve. The system is user friendly and procedural time and fluoroscopy time reduced after a limited number of procedures.

C9 SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IN PATIENTS WITH LOW BMI: REAL–WORLD DATA FROM A EUROPEAN MULTICENTER ANALYSIS

Background

One of the current limitations of the S–ICD is the relatively large size of the generator compared to the TV (transvenous) ICD. There is little evidence whether the size of the current S–ICD generator is associated with an elevated risk of device–related complications in patients with a low body mass index (BMI).

Purpose

Aim of this study was to compare the device–related complications and long–term outcomes in a large real world cohort of S–ICD recipients in patients with a BMI <18 kg/m2 compared to patients with a BMI >18 kg/m2.

Methods

All consecutive patients meeting current guideline indications for ICD implantation and undergoing implantation of a S–ICD device (Boston Scientific, Marlborough, Massachusetts, USA) at 21 European institutions enrolled in the extended ELISIR registry were used for the current analysis. Patients were classified into two cohorts, depending on the BMI at the time of device implantations: BMI < 18 kg/m2 versus > 18 kg/m2.

Results

Out of a total of 1497 pts, 58 pts (3.9%) had a BMI < 18 kg/m2. Patients with BMI <18 kg/m2 were younger (44.6±2.4 vs 50.8±0.4; p = 0.004) and more frequently female (58.6% vs 22.3%, p < 0.001). No differences in any of the other baseline characteristic were observed. Implantation techniques resulted comparable between the groups (rates of 2–incision technique: 87.8% vs 91.9%; p = 0.256; inter–muscular placement: 89.7% vs 83.3%; p = 0.198). Of note, the mean PRAETORIAN score at implantation of patients with BMI <18 kg/m2 was significantly lower (33.8±9.1 vs 54.1±47.3; p = 0.035), although the vast majority of patients in both cohorts qualified as at low risk of conversion failure (100% vs 91.4%; p = 0.436). Over a median follow up time of 22.4 [11.6–36.8] months, both overall device–related complications (5.2% vs 7.4%) and rates of inappropriate shocks (12.0% vs 8.8%) resulted comparable between the two groups (p = 0.517 and p = 0.385, respectively). Figure 1 reports Kaplan–Meier curves showing the combined incidence of device–related complications and inappropriate shocks in the two groups (log–rank p = 0.576).

Conclusion

No differences in device–related complications and long–term outcomes after S–ICD implantation were observed in patients with BMI <18 kg/m2 compared to the remaining recipients in a large multicentered real–world analysis.

P21 AGE–RELATED DIFFERENCES AND ASSOCIATED OUTCOMES OF S–ICD: INSIGHTS FROM A LARGE, EUROPEAN, MULTICENTER REGISTRY

Background

The subcutaneous implantable cardioverter defibrillator (S–ICD) has become an alternative to transvenous ICDs (TV–ICD) in patients who do not need pacing. To date, there is little evidence directly comparing the rates of inappropriate shocks (IAS) in young vs old S–ICD recipients.

Purpose

Aim of our study was to assess differences in device–related complications and inappropriate shocks (IS) between teenagers/young adults and adult recipients of a subcutabeous implantable cardioverter defibrillator (S–ICD) device.

Methods

Two propensity–matched cohorts of teenagers + young adults (≤ 30–year–old) and adults (> 30–year–old) were retrieved from the ELISIR registry. The primary outcome was the comparison of the inappropriate shock (IAS) rate; complications, freedom from sustained ventricular arrhythmic events, overall and cardiovascular mortality were deemed secondary outcomes.

Results

A total of 1491 patients were extracted from the ELISIR project. Teenagers + young adults represented 11.0% of the entire cohort. Two propensity–matched groups of 161 patients each were used for the analysis (Figure 1); median follow–up was 23.1 [13.2–40.5] months. 15.2% patients experienced inappropriate S–ICD shocks and 9.3% device related complications were observed with no age–related differences in IAS (16.1% vs 14.3%; p = 0.642) and complication rates (9.9% vs 8.7%; p = 0.701); Figure 2 shows a survival analysis from inappropriate shocks in the teen–ager/young adult cohort (red) and in the adult cohort (blue). At univariate analysis, young age was not associated with increased rates of IAS (HR 1.204 [0.675–2.148]: p = 0.529). At multivariate analysis (Figure 3), the use of SMART pass algorithm was associated to a strong reduction in IAS (aHR 0.292 [0.161–0.525]; p < 0.001), while ARVC was associated with higher rates of IAS (aHR 2.380 [1.205–4.697]; p = 0.012).

Conclusion

In a large multicentered European registry of patients with S–ICD, 11.0% of all recipients were teenagers or young adults. The use of S–ICD in teenagers/young adults resulted safe and effective, and the rates of complications and IAS between teenagers/young adults and adults were not significantly different. The only predictor of increased IAS was a diagnosis of ARVC.

P25 SUBCUTANEOUS–ICD IN PATIENTS WITH HEART FAILURE: RESULTS FROM A MULTICENTER, EUROPEAN ANALYSIS

Background

Data on patients with heart failure (HF) with a subcutaneous implantable cardioverter defibrillator (S–ICD) are scarce.

Objective

Aim of this study was to assess clinical outcomes of the S–ICD in HF patients in a real–world analysis from the largest European retrospective S–ICD registry (ELISIR).

Methods

All consecutive patients undergoing S–ICD implantation at several European institutions were used for the current analysis. The population was classified into two groups: the HF (classified as HF with reduced and mid–range ejection fraction – HFrEF and HFmrEF) vs the no–HF cohort. The primary outcome of the study was the inappropriate shock (IS) rate across the two cohorts. As secondary outcomes, appropriate shocks, cardiovascular mortality and device–related complications during follow–up were assessed

Results

A total of 1409 patients from the ELISIR registry were included; HF patients represented 57.3% of the entire cohort (n = 701, 86.9% HFrEF; n = 106,13.1% HFmrEF). Over a median follow–up of approximately 2 years, a total of 133 inappropriate shocks were observed in the entire cohort, without significant differences among the two groups (9.2% vs 9.8%, p = 0.689). 133 complex ventricular arrhythmias were adequately recognized and treated, with similar rates of appropriate shocks (9.2% vs 9.8%, p = 0.689). Inappropriate and effective shocks–free survival has been represented in Figure 1 (Kaplan–Meier estimates). At multivariate analysis (Figure 2), age (HR = 0.974 [0.955–0.992], p = 0.005), LVEF (HR = 0.954 [0.926–0.984], p = 0.003), arrhythmogenic right ventricular cardiomyopathy – ARVC (HR = 3.364 [1.206–9.384], p = 0.020) and smart pass + (HR = 0.321 [0.184–0.560], p < 0.001) remained associated with inappropriate shocks. Moreover, a low number of patients (n = 76) experienced device–related complications, more frequently in the HF cohort (6.2% vs 3.8%, p = 0.031) with no significant differences regarding any specific outcome of interest: lead infection (1.1% vs 0.7%, p = 0.381), pocket infection (1.9% vs 0.8%, p = 0.107), pocket hematoma (3.2% vs 2.8%, p = 0.668).

Conclusion

The use of S–ICD in HF patients did not result in a higher rate of inappropriate shocks when compared to no–HF patients, even when stratifying for LVEF. Only age, LVEF, ARVC e Smart Pass algorithm were predictors of the primary outcome at multivariate analysis. Despite a lower overall rate of complications in the entire cohort, HF patients experienced device–related complications more frequently.

Optimal his bundle pacing programming in patients with permanent atrial fibrillation

Background

Interest in permanent His bundle pacing (HBP) as a means of both preventing pacing-induced cardiomyopathy and providing physiological resynchronization by normalization of His-Purkinje activation is constantly growing. Current devices are not specifically designed for HBP, which gives rise to programming challenges.

Purpose

To evaluate the critical troubleshooting HBP options in patients with permanent atrial fibrillation (AF) and variable degree of atrio-ventricular block (AVB) who receive HBP through a lead connected to the atrial port, and an additional ventricular “backup”.

Methods

Between December 2018 and March 2021, 136 consecutive patients with indication for pacing underwent HBP. Among these, 24 had permanent AF with documented symptomatic pauses. Seven of them received a dual-chamber device which was used to place a backup right ventricle (RV) lead; in this scenario, the His lead is implanted in the right atrial (RA) port, the RV lead in the RV port. Depending on the presence of an additional left ventricle (LV) lead, either a dual-chamber and a CRT device can be used.

Results

In this context, the events marked as atrial sensed (As) or paced (Ap) are indeed ventricular, so that sensing is more complex. A clinical scenario is atrial activity oversensed on the His channel (As) leading to RV dyssynchronous pacing in the ventricular safety pacing (VSP) window. A second one is intrinsic QRS undersensing causing inappropriate His pacing with possible delivery of the RV pulse depending on capture of the His pulse. The interplay of intrinsic ventricular activity (rate, signal amplitude and slew rate on both the His and the ventricular channel) and of the HV interval may be of key importance to troubleshoot As-Vp (atrial sensed – ventricular paced) [Fig. 1A] as well as Vs-Ab (ventricular sensed – atrial blanking period) sequences [Fig. 1B]. Changing sensitivity and sensing configuration may help or fail to fix these issues depending on the abovementioned aspects, making it mandatory to check that the paced AV delay is appropriately set as to avoid inappropriate RV pacing on the T wave of an undersensed intrinsic event at the His channel. DVI(R) mode programming may indeed prove safer than DDD(R) in the setting of preserved intrinsic activity or in the event of intermittent His capture loss.

Paced AV delay should be programmed slightly longer than H-V+QRS duration to avoid unnecessary RV pacing with pseudo-fusion (too short) and possibly R/T events (too long). Stability of H-V interval and of QRS duration must be verified at each device follow-up by decremental His pacing to ensure consistent sensitivity of the ventricular signal beyond stable His capture, that may be challenged by infra-hisian block.

Conclusions

Owing to the absence of HBP-specific devices, HBP shall be made safe and effective by careful troubleshooting, consisting of sensitivity setting, paced AV interval and mode programming.

Funding Acknowledgement

Type of funding sources: None. Different sensitivity settings for HBP

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Background

Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps.

Purpose

A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated.

Methods

27 consecutive patients (male 70.3%, age 61.2±8.7 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target.

Results

A total of 110 PVs were treated with LBA; in 9 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in 2 a left common ostium. MCS was used for 82 PVs (74.5%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 35 PVs (31.8%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 25 veins (22.7%). In 13 PVs (12%) MCS was used for the entire circumference. During 8508 (19.6%) seconds out of a total of 43.368 seconds, laser energy delivery occurred in the rapid mode by MCS.

No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in 3 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA.

Conclusions

In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (74.5% of total ablation extent in 19.6% of total ablation time).

Funding Acknowledgement

Type of funding sources: None.

His bundle pacing: safety, performance, and clinical outcomes in a single centre experience

Background

Permanent His bundle pacing (HBP) is a more physiological technique for cardiac stimulation and has recently emerged as an alternative for anti-bradycardia pacing and cardiac resynchronization therapy (CRT). Its main advantages over “classical” pacing are both its protective role over pacing-induced cardiomyopathy and the possibility of resynchronization by normalization of His-Purkinje activation.

Objective

To evaluate the intermediate-term outcomes of HBP in terms of safety, performance, and clinical outcomes.

Methods

Between December 2018 and July 2020, we enrolled a series of consecutive patients with indication for pacing in whom HBP was attempted. A specific lead (3830 Select Secure MRI SureScan) and sheath (C315His) were used. At follow-up clinical, safety and performance outcomes were evaluated. A significant rise in HBP pacing threshold was defined as an increase of at least 1V@1msec in the minimum voltage that could produce an effective myocardial depolarization. Remote or in-hospital device interrogation was performed by an experienced electrophysiologist.

Results

HBP was attempted in 99 patients and all implantations were performed by the same two operators. 82 procedures were successful (83%). The main reasons for HBP failure were high pacing-thresholds (n=8, 47%), infra-hisian block (n=5, 29,4%), difficult HB location (n=3, 17,6%), unsatisfactory sensing (n=1, 5,9%) or lead instability (n=1, 5,9%). During a mean follow up of 9,5±5.9 months, the overall technical and clinical complication rates were 39% and 13,3% respectively. 3 (3.6%) patients underwent His lead extraction and subsequent conventional right ventricular septum (RV) lead implantation because of lead dislodgement (n=2) or rise in pacing threshold (n=1), while 2 (2.4%) patients required His lead repositioning because of lead dislodgement (n=1) and phrenic nerve stimulation (n=1). 19 patients (23,2%) experienced a significant rise in Hisian pacing threshold and 1 of these patients also had poor sensing parameters. Oversensing was noted in 8 (9.7%) patients and in 7 of them (87.5%) it was due to both atrioventricular and ventriculoatrial crosstalk events. As regards clinical outcomes, 7 patients (8.5%) were diagnosed with new onset atrial fibrillation (AF), one of them complicated by stroke. 3 patients (3.6%) were hospitalized for acute heart failure, 1 of them after His lead dislodgement. Finally, 5 patients (6.1%) died during follow-up, but no death was related to cardiovascular events.

Conclusions

HBP is an effective technique to obtain a more physiological cardiac pacing but it is limited by a moderate rate of procedural failure and follow-up complications, mainly rising in pacing threshold and oversensing events. This is probably due to suboptimal implantation tools and lack of specific programming algorithms. New dedicated tools, increased experience and knowledge of device limitations and optimal programming are needed to improve future outcomes.

Funding Acknowledgement

Type of funding sources: None.

Third-generation laser balloon ablation: rapid mode applicability is associated with shorter time to pulmonary vein isolation

Background

The rapid mode feature implemented in the latest version of the laser balloon system (LB3, HeartLight, X3, Cardiofocus) offers an automated continuous 360° lesion for pulmonary vein isolation (PVI). However, data on its clinical applicability and the potential reduction of procedural times are not yet available.

Purpose

To explore the use of the rapid mode and its association with PV total and fluoroscopy times in our initial experience with LB3.

Methods

This analysis included consecutive patients who underwent PVI procedure with LB3. We attempted to perform a complete circular ablation line using the rapid mode at 13 W, but if needed to achieve successful isolation, rapid mode was interrupted and manual mode (5.5–8.5 W) applications were used. The percentage of rapid mode use on the 360° lesion was measured for each PV. Total and fluoroscopy times to complete PVI were also collected.

Results

A total of 110 PVs were identified in 27 LB3 procedures and successfully isolated with a mean procedural time of 85±31 min. Sixty (55%) PVs were treated by using rapid mode for more than 50% (180°) lesion and 13 (12%) of them had a pure rapid mode ablation (without necessity of manual mode applications). Right inferior PV had the highest use of rapid mode (median value 70%). The main reasons for manual applications were poor PV occlusion, imperfect ostium visualization and presence of blood. PVs with >50% rapid mode use were treated in a significantly shorter time (21.2±13.7 vs 26.8±12.4, p=0.043). Fluoroscopy time did not differ significantly (4.7±4.2 vs 5.4±4.9, p=0.48). Three pinhole balloon ruptures were observed during rapid mode energy application in the second, third and twenty-fifth procedure. No other complications occurred.

Conclusions

Few PVs could be isolated using pure rapid mode; however, its applicability for more than 50% lesion was observed more frequently and significantly reduced the time to isolation.

Funding Acknowledgement

Type of funding sources: None. Time to isolation using Rapid Mode

Slow VT treatment in a contemporary population of primary prevention ICD recipients

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable cardioverter defibrillator (ICD) is an effective therapy for sudden cardiac death (SCD). 2015 HRS/EHRA/APHRS/SOLAECE expert consensus document suggests long VT detection, above 185 bpm, as optimal ICD programming to reduce unnecessary therapies in primary prevention (PP).

Purpose

The aim of our study is to evaluate incidence, safety and efficacy of ICD treatment for VT arrhythmias below 185 bpm, in a contemporary population of PP ICD recipients with long detection intervals (LDI), morphological discrimination algorithm and antitachycardia pacing therapies (ATP) before shock.

Methods

We conducted a single centre retrospective study enrolling 236 patients implanted with a primary-prevention indication from January 2013 to June 2019. Patients were implanted with single or dual chamber single-lead transvenous ICD. All patients had standard device setting with long (at least 20 s in VT and 7 s in VF) VT/VF detection above 150 bpm and therapies starting from 171 with up to 5 ATP and multiple shocks. PainFREE-like bursts and Schaumann-like ramps ATP were always set in VT zone. Of each patient we collected a detailed report of up to five appropriate events and three inappropriate events. Arrhythmia diagnosis was confirmed from 3 independent expert physicians.  Date of the event, cycle length, type of morphology (polymorphic or monomorphic), therapies with their effect were collected.

Results

During a mean follow-up of 42 months, 47 (20 %) and 18 (8%) patients had at least one appropriate and inappropriate activation, respectively. The detailed-events analysis shows that 16 (7%) patients had 38 (30%) appropriate events with rate <188 bpm. At these rate ATP were 97% effective. 14 (38%) of inappropriate activations were caused by arrythmias with ventricular rate below 188 bpm and half of these received a shock; 30% of inappropriate shocks were due to arrhythmia with rate <188 bpm. 73% of treated events, with rate <188 bpm, were appropriate. Only 5.6% (n = 10) of ATP attempts cause arrhythmia acceleration.

Conclusions

One third of detected arrhythmias had a rate below 188 bpm and 73% were true VT. In this slow VT zone, ATP had a high success rate with low percentage of acceleration.

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps.

Purpose

A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated.

Methods

sixteen consecutive patients (male 68.7%, age 60.9 ± 7.8 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target.

Results

A total of 62 PVs were treated with LBA; in 3 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in one a left common ostium. MCS was used for 41 PVs (66.1%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 22 PVs (35.5%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 16 veins (25.8%).  In 3 PVs (4.8%) MCS was used for the entire circumference.  During 5.659 (23.6%) seconds out of a total of 23.986 seconds, laser energy delivery occurred in the rapid mode by MCS.

No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial  tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in the first 2 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA.

Conclusions

In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (66.1% of total ablation extent in 23.6% of total ablation time).

Different renal manifestations associated with very early onset pediatric inflammatory bowel disease: case report and review of literature

Background

Inflammatory bowel diseases are characterized by chronic inflammation of the gastrointestinal tract. In particular, Crohn disease and ulcerative colitis represent the two most common types of clinical manifestations. Extraintestinal manifestations of inflammatory bowel diseases represent a common complications, probably reflecting the systemic inflammation. Renal involvement is reported in 4–23% of cases. However, available data are limited to few case series and retrospective analysis, therefore the real impact of renal involvement is not well defined.

Case presentation

We report the case of a 10-years old male affected by very early onset unclassified-Inflammatory bowel diseases since he was 1-year old, presenting with a flare of inflammatory bowel diseases associated with acute kidney injury due to granulomatous interstitial nephritis. Of interest, at 7-year-old, he was treated for IgA nephropathy.

To our knowledge, no previous reports have described a relapse of renal manifestation in inflammatory bowel diseases, characterized by two different clinical and histological phenotypes.

Conclusions

The link between the onset of kidney injuries with flares of intestinal inflammation suggest that nephritis maybe considered an extra-intestinal manifestation correlated with active inflammatory bowel disease. However, if granulomatous interstitial nephritis represents a cell-mediated hypersensitivity reaction than a true extraintestinal manifestation of inflammatory bowel diseases is still not clarified. We suggest as these renal manifestations here described may be interpreted as extraintestinal disorder and also considered as systemic signal of under treatment of the intestinal disease.

Antihypertensive phytocomplexes of proven efficacy and well-established use: Mode of action and individual characterization of the active constituents

Hypertension has become the leading risk factor for worldwide cardiovascular diseases. Conventional pharmacological treatment, after both dietary and lifestyle changes, is generally proposed. In this review, we present the antihypertensive properties of phytocomplexes from thirteen plants, long ago widely employed in ethnomedicines and, in recent years, increasingly evaluated for their activity in vitro and in vivo, also in humans, in comparison with synthetic drugs acting on the same systems. Here, we focus on the demonstrated or proposed mechanisms of action of such phytocomplexes and of their constituents proven to exert cardiovascular effects. Almost seventy phytochemicals are described and scientifically sound pertinent literature, published up to now, is summarized. The review emphasizes the therapeutic potential of these natural substances in the treatment of the 'high normal blood pressure' or 'stage 1 hypertension', so-named according to the most recent European and U.S. guidelines, and as a supplementation in more advanced stages of hypertension, however needing further validation by clinical trial intensification.

P2883VT/VF treatment in a contemporary population of single chamber ICD recipients: ATP efficacVF

Aim of the study

to investigate the efficacy of ATP in consecutive, unselected ICD recipients implanted in 2014–2015.

Methods

All patients had a VT zone as 350 ms and a VF zone as 280 ms programmed, with a detection duration >20 seconds and >8 seconds respectively for VT and VF. Anti-tachycardia pacing (ATP) was available before/during charging in the VF zone, while at least 3 attempts with ATP were programmed in the VT zone. ATP efficacy was assed at the first ventricular arrhythmia episode for each patient. Overall ATP efficacy was also calculated on the burden of treated episodes.

Results

A total of 165 patients (median age 63 [48–72] years, male 79%, primary prevention 80%, ischemic 53%) implanted with a single chamber ICD were followed for a median period of 847 [666–1030] days: 44 (27%) had VT/VF episodes. Among a total of 706 VT/VF episodes, 623 were treated with ATP and/or shock. 7 patients were treated with shock as first delivered therapy (efficacy 100%), whereas 33 were treated with ATP (efficacy 55% of treated patients, 71% of episodes). The median cycle of the treated arrhythmias was 309 [280–324] ms.

Efficacy at first attempt ALL Ischemic NICM Primary Secondary Per patient (first therapy occurrence)   Shock (7/7) 100% (7/7) 100% – (6/6) 100% (1/1) 100%   ATP (18/33) 55% (13/23) 57% (5/10) 50% (13/22) 59% (5/11) 45% Per episode   Shock (14/14) 100% (14/14) 100% – (6/6) 59% (8/8) 100%   ATP (432/609) 71% (245/362) 68% (187/247) 76% (127/201) 63% (305/408) 75%

Conclusion

ATP is quite effective is a contemporary cohort of single chamber ICD recipients in a fast arrhythmia range (average 190–220 bpm) with a long detection. This observation strengthen the value of ATP in ICD selection, and should be balancen when considering an S-ICD.

P3749Discrimination between normal and abnormal electrocardiograms: agreement of seven built-in automatic diagnostic programs in a cohort of >2000 12-lead traces

Introduction

12-lead ECG is a standard evaluation for any patient admitted to a clinic but also for population screenings program and athlete periodical evaluation. Definition of a normal vs. abnormal ECG is a hard task and carefully trained physicians are needed to avoid inappropriate second level evaluations driven from a claim for ECG abnormality. Almost all current 1ECG recorders provide automatic diagnosis through built-in automatic-diagnostic computer programs (ACP). However, we have limited data comparing different ACP's in discriminating between normal and abnormal ECGs.

Aim

To assess the agreement of the main world-wide available automatic diagnostic programs implemented in current ECG recorders in discriminating between “normal” vs. “abnormal” ECGs in a large dataset of real-world ECGs.

Methods

We assessed seven ECG interpretation programs from seven different manufacturers (GE 12SL, Glasgow, MEANS, Midmark, Mortara VERITAS, Philips DXL and Schiller). We created a large set of representative ECGs converted from previously recorded digital ECGs acquired with equipment that complied with the requirements of International Electrotechnical Commission standard IEC 60601–2-51:2003 and were representative of those in hospital settings. We decided to exclude ECGs from pacemaker carriers. We used a specific device for playing back ECGs to 12-lead ECG recorders in appropriately setting to avoid interferences. Each statement from automatic diagnosis provided by each device was recorded and combined appropriately for the purpose of this analysis, identifying three group of ECGs: abnormal/substantially abnormal (ABN), normal/substantially normal (NRM) and borderline.

Results

2155 ECGs of 10s duration were analyzed by the 7 different ACPs: 513 from a pediatric population and 1642 from patients >16 years old consecutively collected mainly in hospital settings. Figure 1 evidences the prevalence of normal to abnormal grading according to each ACP in both groups of ECGs. Focusing in adult group we found that a NRM diagnosis was reported in a range of 129 (7.9%) to 478 (29.1%) among 1642 adult ECGs. On the contrary, ABN statement was reported in a range of 774 (47.1%) to 1271 (77.4%). Notably, agreement between the 7 ACPs was present in 36 ECGs (2.2%) for NRM diagnosis, while the agreement for ABN diagnosis was present in 661 (40.3%) of the ECGs. We performed a sensitivity analysis by repeating the same calculation after taking out one of the device at turn reaching a maximum of 6.5% for NRM and 41.2%% for ABN diagnosis with 6/6 agreement.

Figure 1

Conclusions

In our large cohort of almost unselected hospital ECGs the agreement on “normal” and “abnormal” among programs of different manufacturers is rather low. This should be carefully considered when using automatic ACP diagnosis as a screening or priority tool for ECG interpretation. Tailor-made review by physicians is still necessary for both clinical and research purposes.

A Single-Center 10-Year Experience with Pasireotide in Cushing's Disease: Patients' Characteristics and Outcome

Pasireotide is the first pituitary-directed drug approved for treating patients with Cushing's disease (CD). Our 10-year experience with pasireotide in CD is reported here. Twenty patients with de novo, persistent, or recurrent CD after pituitary surgery were treated with pasireotide from December 2003 to December 2014. Twelve patients were treated with pasireotide in randomized trials and 8 patients with pasireotide sc (Signifor(®); Novartis AG, Basel, Switzerland) in clinical practice. The mean treatment duration was 20.5 months (median 9 months; range, 3-72 months). Urinary free cortisol (UFC) levels mean percentage change (± SD) at last follow-up was-40.4% (± 35.1; range, 2-92%; median reduction 33.3%) with a normalization rate of 50% (10/20). Ten patients achieved sustained normalized late night salivary cortisol (LNSC) levels during treatment. LNSC normalization was associated with UFC normalization in 7/10 patients. Serum cortisol and plasma ACTH significantly decreased from baseline to last follow-up. Body weight decrease and blood pressure improvement during pasireotide treatment were independent from UFC response. Glucose profile worsening was observed in all patients except one. The frequency of diabetes mellitus increased from 40% (8/20) at baseline to 85% (17/20) at last follow-up requiring initiation of medical treatment only in 44% of patients. Pasireotide treatment was associated with sustained biochemical and clinical benefit in about 60% of CD patients. Glucose profile alteration is a frequent complication of pasireotide treatment; however, it seems to be easy to manage with diet and lifestyle intervention in almost half of the patients.

The expression of basic fibroblast growth factor (bFGF) in tumor-associated stromal cells and vessels is inversely correlated with non-small cell lung cancer progression

Tumor progression results from complex interactions between tumor and tumor-associated host tissue. Basic fibroblast growth factor (bFGF), via activation of its receptor, FGFR-1, has been postulated to be an important inducer of host stromal response and angiogenesis. To assess the putative role of tumor-associated stromal cells and vessels in tumor progression, we studied non-small cell lung cancer (NSCLC) from 84 patients, including 51 squamous cell carcinomas and 33 nonsquamous cell carcinomas, by immunohistochemical detection. bFGF and FGFR-1 immunoreactivity was observed in tumor and in tumor-associated stromal cells and vessels. The expression of bFGF and FGFR-1 in stromal cells was higher in squamous than in non-squamous cell carcinomas (respectively, P = .007 and P = .0004). We found that bFGF and FGFR-1 expression in tumor and tumor-associated stromal cells and vessels was directly correlated with host stromal response, as assessed by intratumoral extension of stroma, but not with angiogenic response, as assessed by microvessel count. Although FGFR-1 expression of tumor cells was directly correlated with T-stage (P = .03), bFGF expressions of tumor-associated stromal cells and vessels were inversely correlated with lymph node metastasis (respectively, P = .0001 and P = .0002) and advanced pathological stage (respectively, P = .03 and P = .01). These findings suggest that bFGF might mediate host stromal response in NSCLC and that the expression of bFGF in tumor-associated stromal cells and vessels might have an inhibitory role in NSCLC progression.