Atrial high-rate episodes in patients with devices without a history of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial high-rate episodes (AHREs) recorded with cardiac implantable electronic devices (CIEDs) have been associated with the development of clinical atrial fibrillation (AF) and increase in stroke, and death risk.

Purpose

We sought to perform a systematic review with a meta-analysis to evaluate the prevalence of AHREs detected by CIEDs, their association with stroke risk, development of clinical AF, and mortality among patients without a documented history of AF.

Methods

We searched several databases, ClinicalTrials.gov, references of reviews, and meeting abstract books without any language restrictions up to 9 September 2020. We studied patients with CIEDs in whom AHREs were detected. Exclusion criteria were an AF history. Our primary outcome was the risk of ischemic stroke in patients with AHREs.

Results

We deemed eligible eight studies for the meta-analysis enrolling a total of 4322 patients with CIED and without a documented AF history. Evidence of moderate certainty suggests that patients with documented AHREs were 4.45 times (95% CI 2.87–6.91) more likely to develop clinical AF. Evidence of low confidence suggests that AHREs were associated with a 1.90-fold increased stroke risk (95% CI 1.19–3.05).

Conclusion

The present systematic review and meta-analysis demonstrated that among patients without a documented history of AF, the detection of AHREs by CIEDs was associated with significant increased risk of clinical AF and stroke.

Multipoint left ventricular pacing effects on hemodynamic parameters and functional status: HUMVEE single-arm clinical trial

Objectives

The aim of this study was to assess the capacity of optimized multipoint pacing (MPP) over optimized cardiac resynchronization therapy (CRT), in terms of clinical, functional, and echocardiographic parameters among dyssynchronous heart failure patients.

Methods

Eighty patients (Caucasian, 77.5% male, 68.4±10.1 years, 53.8% ischemic cardiomyopathy) sequentially received optimized CRT and optimized MPP over 6 and 12-month periods, in a single-arm clinical trial. Clinical, laboratory and echocardiographic assessment was conducted at baseline and following completion of each step.

Results

Significant additive effects of optimized MPP over optimized CRT were noted regarding 6-minute walking distance (baseline/optCRT/optMPP: 293±120m vs 367±94m vs 405±129m, p<0.001), NYHA class (2.36 vs 2.19 vs 1.45, p<0.001), VTIlvot (14.25±3.2cm vs 16.2±4cm vs 17.5±3.4cm, p<0.001), stroke volume (48±13.5ml vs 55±15ml vs 59±15ml, p<0.001), LVEF (29%±7.1% vs 33%±7.3% vs 37%±7.7%, p<0.001), maximal left atrial volume (77.2±34.2ml vs 74.2±39.5ml vs 67.7±32ml, p=0.02), pulmonary artery systolic pressure (35.9mmHg vs 33.5mmHg vs 31mmHg, p<0.001), and right ventricular strain (−8.3%±6.9% vs −8.8%±6.6% vs −11.8%±6.1%, p=0.022). Regarding VAC SW and CP as percentages of maximal, there was significant difference detected compared to baseline for both CRT and MPP. Additive effects persisted only if suitable MPP dipoles were present. Exploratory analysis revealed that ischemic cardiomyopathy continued to exhibit significant differences favoring MPP, whereas nonischemic cardiomyopathy had similar findings regarding total left atrial strain and quality of life.

Conclusions

Optimized MPP showed significant improvements on hemodynamic parameters and ventricular function, in heart failure patients over optimized CRT. The beneficial effect was more prominent in men and in those with rather reduced LVEF, consistent with findings suggesting a beneficial trend in VAC and CP with the more homogenous depolarization offered by optimized MPP

Funding Acknowledgement

Type of funding sources: None.

Permanent pacemaker implantation in unexplained syncope patients with electrophysiology study-proven atrioventricular node disease

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy

Purpose

Aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study-proven atrioventricular node disease.

Methods

This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. 135 patients received the ABP, while 101 denied.

Results

The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ±  29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), 6 of 135 (4.4%) in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p < 0.001).

Conclusion

Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined atrioventricular node disease, identifies a subset of patients who will benefit from permanent pacing.

Noninvasive risk factors for the prediction of inducibility on programmed ventricular stimulation in post-MI patients with ejection fraction over 40% at SCD risk, insights from the PRESERVE EF study

Funding Acknowledgements

Type of funding sources: None.

Background

Sudden cardiac arrest (SCA) in post myocardial infarction (post-MI) patients with a relatively preserved left ventricular systolic function (LVEF≥40%) has an annual incidence of 1%, in the absence of adequate risk stratification methods and guideline recommendations for primary prevention. In the PRESERVE-EF study we used a two-step SCA risk stratification approach to detect patients at risk for major arrhythmic events. Seven noninvasive risk factors (NIRFs) were extracted from ambulatory electrocardiography (AECG). Patients with at least one NIRF present were referred for invasive programmed ventricular stimulation (PVS). Inducible patients received an ICD.

Purpose

To assess the performance of NIRFs extracted from 24hr AECG, based on the PRESERVE EF criteria, in predicting inducibility.

Methods

The PRESERVE EF study enrolled 575 patients. Two hundred and four of them had at least one NIRF and an indication for PVS, but 52 of them declined. Finally, 41 out of 152 patients who underwent PVS were inducible. For the present analysis data from these 152 patients (mean age 60 ± 10years, LVEF 49 ± 6%, 89% males) were analyzed. Chi-square test, univariate logistic regression and areas under ROC curves were calculated for the PVS inducibility endpoint.

Results

Age, male gender and LVEF for the PVS inducible patients group (n = 41) and the noninducible patients group (n = 111) were, respectively: 61 ± 9years vs 59 ± 10years (p = 0.310), 98% vs 86% (p = 0.048), 45 ± 4% vs 51 ± 7% (p < 0.001). Among NIRFs examined, LVEF ≤ 50%, nsVT≥1/24hour and presence of LPs on SAECG presented high and significant Odds Ratios (ORs) for a positive PVS study end point. A simple risk score based on cutoff points of LVEF ≤ 50%, NSVTepisode≥1/24hour and presence of LPs missed only 1 out of the 41 inducible patients and yielded: OR 14.146 (p = 0.01) with a high sensitivity 98% but low specificity 26% for a positive PVS (AUC = 0.65).

Conclusion

Cut off points of LVEF ≤ 50%, nsVTepisode≥1/24hour and presence of LPs were important predictors of inducibility. A simple risk score based on these predictors achieves high sensitivity but low specificity.  The final decision for an ICD implantation should be based on a positive PVS, which is irreplaceable in risk stratification.

P4529Atrioventricular optimization in cardiac resynchronization therapy with quadripolarleads, improves energy handling and quality of life in heart failure patients: HUMVEE Trial

Background

Cardiac resynchronization therapy (CRT) is a well-established technique for symptomatic heart failure (HF) patients, producing significant clinical benefits. Recent studies have revealed the potential role of multipoint pacing (MPP) in improving response and clinical outcomes. The aim of Heart failUre study of Multisite pacing effects on VEntriculoartErial coupling (HUMVEE) trial was to evaluate the association between MPP of the left ventricle vs those of standard biventricular pacing (BVP) on: a) ventriculoarterial coupling (VAC) and energy efficiency of the failing heart, b) diastolic function, c) quality of life, and d) NT-proBNP levels.

Methods

HUMVEE is a single-center, prospective (13 months) trial (clinicaltrials.gov identifier NCT03189368), of 54 NYHA III patients (69±9 years; 79% men; 50% dilated cardiomyopathy), under optimal tolerated medical therapy, with standard BVP indication, having being implanted with a CRT system able to deliver both modes of pacing. Creatinine and NT-proBNP levels and echocardiographic measurements (VAC calculation, strain rate, diastolic function assessment), as well as 6-min-walking-test and quality of life (MLHF questionnaire) were measured at baseline, 6 months post BVP optimization (right before MPP activation) and at the end of follow-up (6 months post MPP optimization). Cardiac power (CP) was calculated according the equation: CP=Cardiac Output x Mean Aortic Pressure/451.

Results

Both CRT and MPP improved 6-min-walk (differences at baseline/6 mo/end of FU: 277±27 vs. 345±27 vs 363±27 m, p=0.07); left ventricular ejection fraction (24,2% vs 30,6%vs, 32%, p=0.05); end -diastolic diameters of left ventricle (65±1,4 vs. 63±1.7 vs. 61±1.1, p=0.03); end-systolic volume (150±15 vs. 140±10 vs. 131±13, p=0.08); stroke volume (41.6±9 vs. 53.6±14 vs. 62±9, p=0.0001 for MPP); left atrial volume (76±5 vs. 74±10 vs 61±6, p=0.001 for MPP), E/Emv (14±5 vs. 12±4 vs. 11±3, p=0.05 for MPP); NtproBNP (2782±1000 vs. 2080±2500 vs. 2000±1000, p=0.05 for MPP). VAC was reduced from 1.14±0.27 to 1.1±0.17 (p=0.1) while CP increased from 564.2±142 to 768±103 (p=0.009). Quality of life score (the lower the better) improved from 23.75±17 at baseline to 17.25±10 at end of FU (p=0.05).

Conclusions

MPP is a new, promising pacing modality with the potential to improve HF patients' outcome, offering additive effects on myocardial energy balance, cardiac power, systolic and diastolic ventricular function and aortoventricular coupling, especially in ischemic patients. HUMVEE trial illustrates those clinical, imaging and biochemical divergences of MPP from standard BVP that reflect significant improvement in quality of life in patients with advanced HF and cardiac dysychronization.