Evaluation of a multisensory algorithm to prevent acute decompensation of heart failure in patients implanted with a cardioverter defibrillator: rationale and design

Background

Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs [1–4]. HeartLogic is an algorithm incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing preemptive treatment of congestion to prevent acute decompensation [5–7].

Objectives

We aim to provide real-world data on the impact of pre-emptive HF management, guided by the HeartLogic index on unscheduled HF hospitalizations in a substantial cohort of patients.

Methods

The HeartLogic French Study is an investigator-initiated, prospective, multi-centre, non-randomized study. All in all, 310 patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic index calculation will be included across 10 French centers. The HeartLogic index will be monitored remotely on a weekly basis for 12 months and in case of HeartLogic index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, and unscheduled hospitalizations for ventricular or atrial arrhythmia. Blood samples will be collected for biobanking, and quality of life will be assessed. A blind and independent committee will adjudicate the events.

Conclusions

The HeartLogic French Cohort Study will provide robust real-world data on HF hospitalization in a cohort of patients managed with the HeartLogic algorithm allowing preemptive treatment of congestion.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Clinical impact of “minimal” right ventricular pacing on atrial arrhythmias: results from the prospective multi-center worldwide EMERALD study

Background/Introduction

Unnecessary right ventricular pacing (RVP), typically the result of pacing forced by the atrio-ventricular delay (AVD), can have deleterious effects such as atrial arrhythmias (AA) and heart failure (HF). Previous studies have shown that these increased risks occur when unnecessary RVP exceeds 40%, leading to the development of pacing modes to reduce the amount of unnecessary RVP and minimize these risks.

Purpose

The EMERALD (AssEssment of CoMorbiditiEs & Atrial ArRhythmiA Burden In DuaL-Chamber PaceD Patients) Study was a real-world registry designed to assess the impact of RVP burden on the risk of developing AA. The primary endpoint was the difference in incidence of persistent/permanent AA in subjects with high (>40%) and low (<40%) RVP.

Methods

EMERALD was a non-interventional, prospective, observational, multi-center registry conducted at 186 centers in 12 countries. The study enrolled subjects without a previous history of persistent or permanent AA implanted with a dual-chamber (DR) pacemaker according to ESC or ACC/AHA/HRS guidelines. Devices could be implanted as de-novo therapy, generator replacement or an upgrade in therapy. All implanted devices were approved for commercial use by local regulatory authorities. Programming was left to the investigators' discretion. Subjects were followed for at least 24 months. Persistent/permanent AA was defined as: a) >22 hours/day of AA for >7 consecutive days; b) permanent/persistent AA diagnosed during any follow-up visit; c) an AA-related ablation carried-out; d) a cardioversion performed during any follow-up visit.

Results

Eligible follow-up data were available for n=3477 subjects with a RVP value. The population was nearly evenly split between High RVP (47.7%) and Low RVP (52.3%). In the High RVP group, 11.7% fulfilled at least one criterion for persistent/permanent AA versus 9.1% in the Low RVP group (p=0.006). The primary endpoint was met. A reanalysis of the data was performed first looking at quartiles of %RVP. Based on this, the threshold of RVP was changed from 40% to 1% (High RVP>1%; Low RVP<1%). Using this new RVP threshold, 13.1% of patients in the High RVP group fulfilled at least 1 criterion for persistent/permanent AA versus 3.4% in the Low RVP group (p<0.0001).

Conclusions

The EMERALD Study confirmed the results of previous studies showing that limiting unnecessary RVP to <40% is beneficial in reducing the risk of AA in unselected DR pacemaker patients. Moreover, it showed for the first time that even small amounts of unnecessary RVP (>1%) significantly increases the risk of AAs, underlining the need to target very low RVP with efficient modes to reduce RVP.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): MicroPort CRM (Clamart, France)

Endocardial ablation of ventricular tachycardia ablation in arrhythmogenic right ventricular cardiomyopathy aiming epicardial late potential abolition

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation is frequently needed to treat ventricular tachycardia (VT) in ARVC patients. Ablation aiming non-inducibility (NI) and late potential (LP) abolition has been shown to be effective1. Simultaneous endo-epicardial mapping demonstrate epicardial involvement in most VT2. However epicardial fat and vicinity of coronary artery may prevent effective epicardial ablation.

Aims

(a) evaluate endocardial-only ablation guided by epicardial late-potential recording (EA-ELP) to achieve LP abolition (LPA) and NI; (b) measure ablation-index(AI) values allowing epicardial LP suppression by endocardial ablation, as a surrogate for transmurality.

Methods

From 2019 to 2021 the authors (XW, EG) evaluated EA-ELP in ARVC patients patient referred for ablation. Our ablation protocol was previously described3. Endo and epicardial voltage mapping of the right ventricle (RV) were performed in sinus rhythm using 0.5-1.5 mV threshlods for endocardial scar and 0.5-1 mV for the epicardial. All LP were manually tagged. Programmed ventricular stimulation (PVS) was performed till S4 from the RV apex and other sites, all inducible tolerated VT were mapped. Endocardial ablation was performed with an irrigated tip catheter positioned in front of epi-LP recorded by a multi-electrode catheter aiming to eliminate or delay epi-LP as a surrogate for transmurality. For each lesion fulfilling the «transmurality criteria», the AI values were recorded. Remap was performed to validate LPA and NI was tested. Patient follow-up (FU) rely on telemonitoring in ICD-carriers and holter/exercise test for the others.

Results

11 patients were enrolled (9M/2F, mean age 45 years), 9 for VT recurrence (3 redo) and 2 for de novo VT. The median ICD therapy before ablation was 5/patient (mean 1.7). The clinical VT originated from the RV outflow tract (RVOT) in 5 patients, peritricuspid (PT) in 2, RV free wall (RFW) in 4. Substrate were more extended in the epicardium compared to the endocardium: epi-LP and scar surfaces were 42.5 cm2/118 cm2 versus 24.5 cm2/25.5 cm2 for the endocardium. In one patient, additional epicardial lesion was necessary to achieve LPA. The mean ablation duration was 3377 s. Remap showed LPA in all patients and PVS was negative in all (not tested in one due to hemodynamic instability). One patient presented retrosternal hematoma after ablation with spontaneous favorable outcome. Endocardial AI values allowing epi-LP abolition were 595 for the inferior wall, 625 in the RVOT, 604 for PT and 639 for RFW. During a mean FU of 12 months (median 16.5 mths), only one patient had VT recurrence.

Conclusion

Based on this case-series, EA-ELP appeared as a safe and effective method to treat VT in ARVC. EA-ELP ablation allowed VT suppression in 91 % of patients after an mean FU of 12 mths. The RV endocardial AI needed to suppress epi-LP ranged was between 595-639 and could be used as surrogate for transmurality in ARVC.

Randall-type monoclonal immunoglobulin deposition disease: description of cardiac involvement

Background

Randall-type monoclonal immunoglobulin disease (MIDD) is a rare complication of a monoclonal plasma cell clone. MIDD differs from AL amyloidosis by the presence of Congo red negative non-organized immunoglobulin (Ig) deposits, most commonly light chains (LCDD) along basement membranes and sometimes heavy chains (HCDD) or light and heavy chains (LHCDD). As AL amyloidosis MIDD is a multi-systemic disease, and affects the heart. To date no study has focused on the clinical characteristics of heart disease in MIDD.

Purpose

The aim of this study was to describe the cardiologic features of patients with biopsy-proven MIDD and suspected cardiac involvement.

Methods

This multi-center, nation-wide retrospective study extracted from the database of the French reference center for AL amyloidosis and other Ig deposition diseases between 2012 to 2019. Diagnosis of cardiac involvement was assessed according to the International Society of Amyloidosis criteria for amyloid heart disease, as follows: left ventricular hypertrophy with a diastolic septum thickness ≥12mm, NTproBNP serum level ≥332 ng / L, histological evidence on cardiac or extra cardiac biopsy of typical linear non-organized Ig deposits along basement membranes. Severity was defined according to the Mayo Clinic classification for AL amyloidosis.

Results

Among 20 patients included (mean age was 70±9 years), 11 (55%) were males; 13 (65%) were LCDD, 3 (15%) HCDD and 4 (20%) LHCDD. At diagnosis, 19 (95%) had a history of hypertension, 3 (16%) had atrial fibrillation, 3 (15%) had NYHA grade 3 or 4 dyspnea. Mayo Clinic score was stage 3a in 4 patients (20%) and stage 3b in 6 patients (30%). The most frequent ECG changes were microvoltage (40%) and pseudo Q wave (40%); 64% of patients had altered sinus variability on 24-hour Holter monitoring, one patient had a high-grade conduction disorder and another had ventricular tachycardia. On echocardiography, all showed diastolic dysfunction; mean diastolic septum thickness was 13.5mm; only one patient had LVEF impairment but 38% had global longitudinal strain impairment. 10 patients had cardiac MRI, none showed contrast enhancement after gadolinium injection.

After median follow-up of 28 months, 4 patients were hospitalized for heart failure, including 2 with cardiogenic shock. Seven (35%) patients died within a median of 10 months from diagnosis. Among patients with Mayo clinic stage 3 (a or b), 67% died within a median of 8 months from the diagnosis.

Conclusions

To our knowledge, we present the first case series dedicated to the description of cardiac parameters in MIDD patients with cardiac involvement. Except for MRI appearance of cardiac infiltration, these patients showed features close to that of AL amyloid heart disease. Overall prognosis appears seemingly poor in MIDD patients with Mayo Clinic stage 3 cardiac disease.

Funding Acknowledgement

Type of funding source: None

Severe sleep apnea is associated with atrial fibrillation burden in pacemaker recipients

Background

New generation pacemaker allow the assessment day by day of sleep disordered breathing (SDB) based on impedance measurement. A recent study demonstrated that incidence of AF is higher in case of severe SA monitored by pacemaker

Purpose

The aim was to compare the atrial fibrillation (AF) burden between patients with severe and non-severe sleep apnea (SA) detected with pacemakers monitoring (SDB).

Methods

This retrospective study was carried out at our University Hospital. We included all patients with Microport CRM pacemaker implanted from 2013 to 2016 at our university hospital. Exclusion criteria were inactivation of sleep apnea monitoring (SAM), history of sleep apnea, missing data or invalid data. AF burden was assessed according to Fallback mode switch (FMS) duration. Respiratory disturbance index (RDI) was calculated as the average number of events (ventilation pause and reductions) per number of hours of monitoring. Patients with RDI<20/h were compared with patients with RDI≥20/h (considered as severe SA group).

Results

404 patients (mean age = 79.7±10 years; 52.0% men) were included. The most prevalent indication for cardiac pacing was atrioventricular block in 57%. Mean RDI was 18.9 events per hour. 234 (58%) of them had a mean RDI <20 and 170 (42%) had a mean RDI ≥20. Compared to patients with mean RDI<20, those with mean RDI ≥20 were youngers (78.6±10 years Vs 81.8±8 years; p=0.02), were more likely to be male (58.2% Vs 47.5%: p=0.035) and had more heart failure history (28.8% Vs 19.2%: p=0.03). BMI was not different between groups (26.3±5. vs 26.3±4; P=0.33). Mean follow-up was 27 months. Patients with RDI ≥20 had a mean Atrial fibrillation duration longer than patients with RDI <20 (631 min Vs 291 min respectively; p=0.014). RDI was correlated with FMS (r=0.26; p=0.0004). The stroke rate tended to be higher in the RDI ≥20 group (2.1% vs 5.4%) (p=0.12).

Conclusion

Severe SA detected by pacemaker was associated with longer AF duration. We did not find higher occurrence of stroke in the severe SA group.

Funding Acknowledgement

Type of funding source: None

Pacemakers capable of monitoring sleep-disordered breathing: impact on sleep apnea detection in real life

Background

Pacemaker recipients are at high-risk of sleep apnea (SA). New generation of pacemakers allow day by day, sleep-disordered breathing (SDB) monitoring. These devices measure variations in thoracic impedance and can detect apnea and hypopnea.

Purpose

The aim was To compare the rate of SA detection in patients implanted with and without pacemaker capable of monitoring (SDB).

Methods

This retrospective study included all consecutive patients implanted with a pacemaker between 2013 and 2016 at Poitiers university hospital. Pacemaker recipients allowing SDB monitoring (SDB monitoring group) and pacemaker recipients not allowing SDB monitoring (control group) were compared in terms of SA diagnosis, continuous positive airway pressure (CPAP) therapy initiation, newly AF discovered and stroke occurrence.

Results

Among the 1442 patients included (mean age 79 years, 39% of women, BMI = 27 kg/m2). 653 were in the SDB monitoring group and 789 in the control group. The 2 groups were not different in terms of age, body mass index, cardiovascular risk factor, cardiac function, and medication. Indication for cardiac pacing was atrioventricular block and sinus dysfunction in 56% and 23% of patients respectively. Mean follow-up was 24.7 months. 40 patients (7.5%) have been diagnosed with SA in the SDB monitoring group and 18 (2.7%) in the control group (p<0.001). CPAP therapy was initiated in 33 (5%) patients in SDB monitoring group and in 16 (2%) patients for the control group (p=0.01). The rate of newly diagnosed AF was 15% in SDB monitoring and 7% in control group (p<0.001). The incidence of stroke was 16 (2.4%) in the SDB monitoring group and 18 (3.4%) in the control group (P=0.45).

Conclusion

In real life conditions, pacemakers capable of monitoring SDB improve the diagnosis of SA and CPAP therapy rate.

Monitoring of sleep apnea after at least

Funding Acknowledgement

Type of funding source: None

[Blood pressure response to antihypertension treatment. Comparison of data obtained at the doctor's office and by ambulatory blood pressure measurement]

A comparative study of clinical and ambulatory responses to antihypertensive treatment was conducted retrospectively in 69 patients with mild to moderate arterial hypertension. The patients received different drugs, but blood pressure (BP) was measured by the same methods in each of them. (a) Clinical BP was measured with a mercury manometer some time after taking the last dose of antihypertensive drug: 24 hours in patients who took one daily dose, 12 hours in those who took two daily doses. (b) Ambulatory BP was measured with a Spacelabs SPM 5200 instrument over a minimum of 24 hours. The parameters compared were: (1) BP figures recorded. Correlation was very poor as regards both SBP (r = 0.42 before treatment, r = 0.55 after treatment) and DBP (r = 0.40 and r = 0.46 respectively). The mean BP value was lower in the ambulatory group than in the clinical group (-20/-12 mmHg), the difference being slightly less marked after treatment (-12/-6 mmHg). (2) Degree of absolute reduction of BP induced by treatment. Correlation was very poor between the two methods as regards both SBP (r = 0.46) and DBP (r = 0.49). (3) Proportion of responders and non-responders to treatment, the clinical response being defined as normalization and/or more than 10 p. 100 reduction of DBP, and the ambulatory response as a significant decrease of mean diastolic value over 24 hours. Among the 69 patients studied, there were 51 concordant cases (36 responders, 15 non-responders with the two methods) and 18 discordant cases (10 clinical responders but ambulatory non-responders, 8 clinical non-responders but ambulatory responders).(ABSTRACT TRUNCATED AT 250 WORDS)