Worldwide survey on implantation of and outcomes for conduction system pacing with His bundle and left bundle branch area pacing leads

BACKGROUND

Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes.

METHODS

We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately.

RESULTS

The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001).

CONCLUSION

In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

Obstructive Sleep Apnoea and Cardiac Arrhythmias (OSCA) trial: a nested cohort study using injectable loop recorders and Holter monitoring in patients with obstructive sleep apnoea

INTRODUCTION

Obstructive sleep apnoea (OSA) is associated with increased cardiovascular mortality despite continuous positive airways pressure (CPAP) therapy. This excess risk may be related to increased arrhythmia risk, especially atrial fibrillation (AF). The true incidence of arrhythmia in patients with OSA is unknown. Implantable loop recorders (ILR) are powerful tools for detecting arrhythmias long-term. Cardiac autonomic function may be important in arrhythmogenesis in these patients but needs further study. We aim to identify the true incidence of arrhythmias (especially AF) using ILRs, assess cardiac autonomic function using Holter monitors in patients with OSA and explore cardiovascular outcomes.

METHODS AND ANALYSIS

A two-centre (University Hospital Coventry and St. Cross Hospital, Rugby) nested cohort study using Reveal LINQ (Medtronic, UK) ILR to identify precise arrhythmia (atrial/ventricular) incidence in patients with moderate-severe OSA. 200 patients will be randomised 1:1 to standard care alone or standard care+ILR (+Holter monitor at baseline and 12 months). The primary objective is to compare arrhythmia detection over 3 years between the two groups. Cardiac autonomic function will be assessed in the ILR-arm at baseline and 12 months post CPAP. Secondary objectives will explore the mechanisms linking OSA and arrhythmia using cardiac autonomic function parameters based on Holter recordings and circulating biomarkers (high sensitivity Troponin-T, N-terminal pro B-type natriuretic peptide, matrix metalloproteinase-9, fibroblast growth factor 23, high sensitivity C-reactive protein, interleukin-6 and tumour necrosis factor-α) before and after CPAP initiation in the ILR-arm.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Authority after examination by the Solihull Research and Ethics Committee. The main ethical considerations was the minimally invasive nature of ILR insertion outside of usual care. Patient advisory groups were consulted with a positive outcome for this type of research. We plan on publishing papers in peer-reviewed journals based on the primary objective and any interesting findings from secondary objectives. We will endeavour to publish all relevant data.

TRIAL REGISTRATION NUMBER

NCT03866148.

High-intensity interval training in cardiac rehabilitation (HIIT or MISS UK): A multi-centre randomised controlled trial

BACKGROUND

There is a lack of international consensus regarding the prescription of high-intensity interval exercise training (HIIT) for people with coronary artery disease (CAD) attending cardiac rehabilitation (CR).

AIM

To assess the clinical effectiveness and safety of low-volume HIIT compared with moderate intensity steady-state (MISS) exercise training for people with CAD.

METHODS

We conducted a multi-centre RCT, recruiting 382 patients from 6 outpatient CR centres. Participants were randomised to twice-weekly HIIT (n = 187) or MISS (n = 195) for 8 weeks. HIIT consisted of 10 × 1-minute intervals of vigorous exercise (>85% maximum capacity) interspersed with 1-minute periods of recovery. MISS was 20-40 minutes of moderate intensity continuous exercise (60-80% maximum capacity). The primary outcome was the change in cardiorespiratory fitness (peak oxygen uptake, VO2 peak) at 8-week follow-up. Secondary outcomes included cardiovascular disease risk markers, cardiac structure and function, adverse events, and health-related quality of life.

RESULTS

At 8 weeks, VO2  peak improved more with HIIT (2.37 mL.kg-1.min-1; SD, 3.11) compared with MISS (1.32 mL.kg-1.min-1; SD, 2.66). After adjusting for age, sex and study site, the difference between arms was 1.04 mL.kg-1.min-1 (95% CI, 0.38 to 1.69; p = 0.002). Only 1 serious adverse event was possibly related to HIIT.

CONCLUSIONS

In stable CAD, low-volume HIIT improved cardiorespiratory fitness more than MISS by a clinically meaningful margin. Low-volume HIIT is a safe, well tolerated, and clinically effective intervention that produces short-term improvement in cardiorespiratory fitness. It should be considered by all CR programmes as an adjunct or alternative to MISS.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02784873. https://clinicaltrials.gov/ct2/show/NCT02784873.

Population estimates of obstructive and non-obstructive hypertrophic cardiomyopathy in the UK and Germany

Background

While numerous publications have estimated the prevalence of diagnosed hypertrophic cardiomyopathy (HCM), none have quantified the real-world proportion of obstructive and non-obstructive HCM using nationally representative data sources in any European countries.

Purpose

To estimate the prevalence of diagnosed HCM and its subtypes in the UK and Germany.

Methods

Patients with HCM were identified in the UK from 01 Apr 2009 to 30 Oct 2020 and Germany from 2011 to 2019. UK patients with HCM were identified using electronic health records from the Clinical Practice Research Datalink (CPRD) primary care data linked with Hospital Episode Statistics (HES) secondary care data using ICD-10 (I42.1, I42.2), Read, Medcode, SNOMED, and OPCS codes. German patients with HCM were identified using a nationally representative administrative claims data pool (WIG2 Benchmark database) from several German Statutory Health Insurance (SHI)-insurances using ICD-10 and OPS codes. Obstructive HCM was identified as any obstructive HCM diagnosis, any HCM diagnosis with septal reduction therapy, and any HCM diagnosis and left ventricular outflow tract obstruction (LVOTO; not in German claims data). Non-obstructive HCM was any non-obstructive or unspecified HCM diagnosis without evidence of any obstructive HCM. Annual prevalence was calculated for each year in the respective study periods and average annual prevalence across the study period.

Results

The average annual prevalence rate of HCM was 4.15/10,000 in the UK and 8.61/10,000 in Germany, while the average annual prevalence rate of obstructive HCM was 2.84/10,000 in the UK and 4.18/10,000 in Germany (Table). The proportion of HCM that was obstructive HCM was 68% in the UK and 49% in Germany. The prevalence rates of diagnosed HCM and obstructive HCM tended to increase over time (Figure).

Conclusion

The prevalence of HCM, obstructive HCM and the proportion of HCM that is obstructive varied between the UK and Germany. The prevalence of HCM was generally consistent with previously published estimates. Although there are limitations with coding in administrative data, it is important to differentiate obstructive HCM from non-obstructive HCM given their unique treatments and disease progression and management, especially since at least 49–68% of HCM is obstructive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol Myers-Squibb

Impact of sodium-glucose co-transporter inhibitors on cardiac autonomic function and mortality: no time to die

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to improve cardiovascular outcomes not only in patients with diabetes but also in those with heart failure, irrespective of diabetic status. However, the mechanisms underlying the cardioprotective effects of these newer anti-diabetic drugs remain to be fully elucidated. One exciting avenue that has been recently explored in both preclinical and clinical studies is the modulation of the cardiovascular autonomic nervous system. A reduction in sympathetic nervous system activity by SGLT2 inhibitors may potentially translate into a reduction in arrhythmic risk and sudden arrhythmic death, which may explain, at least partly, the cardioprotection shown in the cardiovascular outcome trials with different SGLT2 inhibitors. Although some of the data from the preclinical and clinical studies are promising, overall the findings can be contradictory. This highlights the need for more studies to address gaps in our knowledge of these novel drugs. The present review offers an in depth overview of the existing literature regarding the role of SGLT2 inhibitors in modulating cardiovascular autonomic function as one of the possible pathways of their cardioprotective effects.

Cardiovascular Biomarkers: Lessons of the Past and Prospects for the Future

Cardiovascular diseases (CVDs) are a major healthcare burden on the population worldwide. Early detection of this disease is important in prevention and treatment to minimise morbidity and mortality. Biomarkers are a critical tool to either diagnose, screen, or provide prognostic information for pathological conditions. This review discusses the historical cardiac biomarkers used to detect these conditions, discussing their application and their limitations. Identification of new biomarkers have since replaced these and are now in use in routine clinical practice, but still do not detect all disease. Future cardiac biomarkers are showing promise in early studies, but further studies are required to show their value in improving detection of CVD above the current biomarkers. Additionally, the analytical platforms that would allow them to be adopted in healthcare are yet to be established. There is also the need to identify whether these biomarkers can be used for diagnostic, prognostic, or screening purposes, which will impact their implementation in routine clinical practice.

Initial experience of temperature-controlled irrigated radiofrequency ablation for ischaemic cardiomyopathy ventricular tachycardia ablation

BACKGROUND

The DiamondTemp ablation (DTA) catheter system delivers high power, open-irrigated, temperature-controlled radiofrequency (RF) ablation. This novel ablation system has not been previously used for ventricular tachycardia (VT) ablation.

OBJECTIVE

Feasibility of using the DTA catheter system for VT ablation in ischaemic cardiomyopathy (ICM) patients.

METHOD

Ten ICM patients with optimal anti-arrhythmic drug therapy and implantable cardiac defibrillators (ICD) were recruited. VT inducibility testing was performed at the end of the procedure. ICD data for device detected VT episodes and device treated VT episodes were collected for 6-months pre- and post-ablation.

RESULTS

Substrate analysis demonstrated reductions in the borderzone area of 4.4 cm² (p = 0.026) and late potential area of 3.5 cm² (p = 0.0449) post-ablation, with reductions in the mean bipolar and unipolar voltages of the ablation target areas (0.14 mV (p = 0.0007); 0.59 mV (p = 0.0072) respectively). Complete procedural success was achieved in 9 procedures. Post-ablation VT inducibility testing was not performed in 1 procedure due to a steam pop complication resulting in pericardial tamponade requiring drainage. Mean follow-up of 214 ± 33 days revealed an 88% reduction in total VT episodes (n = 266 median 16 [IQR 3-57] to n = 33 median 0; p = 0.0164) and 77% reduction in ICD therapies (n = 128 median 5 [IQR 2-15] to n = 30 median 0; p = 0.0181).

CONCLUSION

The DTA system resulted in adequate lesion characteristics with effective substrate modification, acute procedural success and improved outcomes at intermediate-term follow-up. Randomised controlled trials are required to compare the performance of the DTA system against conventional ablation catheters.

Rationale and study design of the MINERVA study: Multicentre Investigation of Novel Electrocardiogram Risk markers in Ventricular Arrhythmia prediction-UK multicentre collaboration

INTRODUCTION

The purpose of this study is to assess the ability of two new ECG markers (Regional Repolarisation Instability Index (R2I2) and Peak Electrical Restitution Slope) to predict sudden cardiac death (SCD) or ventricular arrhythmia (VA) events in patients with ischaemic cardiomyopathy undergoing implantation of an implantable cardioverter defibrillator for primary prevention indication.

METHODS AND ANALYSIS

Multicentre Investigation of Novel Electrocardiogram Risk markers in Ventricular Arrhythmia prediction is a prospective, open label, single blinded, multicentre observational study to establish the efficacy of two ECG biomarkers in predicting VA risk. 440 participants with ischaemic cardiomyopathy undergoing routine first time implantable cardioverter-defibrillator (ICD) implantation for primary prevention indication are currently being recruited. An electrophysiological (EP) study is performed using a non-invasive programmed electrical stimulation protocol via the implanted device. All participants will undergo the EP study hence no randomisation is required. Participants will be followed up over a minimum of 18 months and up to 3 years. The first patient was recruited in August 2016 and the study will be completed at the final participant follow-up visit. The primary endpoint is ventricular fibrillation or sustained ventricular tachycardia >200 beats/min as recorded by the ICD. The secondary endpoint is SCD. Analysis of the ECG data obtained during the EP study will be performed by the core lab where blinding of patient health status and endpoints will be maintained.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Research Ethics Committees Northern Ireland (reference no. 16/NI/0069). The results will inform the design of a definitive Randomised Controlled Trial (RCT). Dissemination will include peer reviewed journal articles reporting the qualitative and quantitative results, as well as presentations at conferences and lay summaries.

TRIAL REGISTRATION NUMBER

NCT03022487.

COVID-19 and arrhythmia: An overview

Arrhythmias in COVID-19 patients are associated with hypoxia, myocardial ischemia, cytokines, inflammation, electrolyte abnormalities, pro-arrhythmic or QT-prolonging medications, and underlying heart conditions such as severe congestive heart failure, inherited arrhythmia syndromes, or congenital heart conditions. In the pediatric population, multisystem inflammatory syndrome can lead to cardiac injury and arrhythmias. In addition, arrhythmias and cardiac arrests are most prevalent in the critically ill intensive care unit COVID-19 patient population. This review presents an overview of the association between COVID-19 and arrhythmias by detailing possible pathophysiological mechanisms, existing knowledge of pro-arrhythmic factors, and results from studies in adult and pediatric COVID-19 populations, and the clinical implications.

Safety and feasibility of trans-venous cardiac device extraction using conscious sedation alone-Implications for the post-COVID-19 era

BACKGROUND

Transvenous lead extraction (TLE) for implantable cardiac-devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID-19, longer recovery-times and increased procedural-costs. We report the feasibility/safety of TLE using conscious-sedation alone with immediate GA/cardiac-surgery back-up if needed.

METHODS

Retrospective case-series of consecutive TLEs performed using conscious-sedation alone between March 2016 and December 2019. All were performed in the electrophysiology-laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking-stylets/cutting-sheaths, including mechanical-sheaths. Baseline patient-characteristics, procedural-details and TLE outcomes (including procedure-related complications/death) were recorded.

RESULTS

A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual-chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy-defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead-dwell times were 11.0 ± 8.8/8.3 (0.3-37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse-generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure-time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean-dose: 33 ± 8 ml 1% lidocaine), IV drug-doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead-extraction was achieved in 110 (85%) leads, partial lead-extraction (<4 cm-fragment remaining) in 5 (4%) leads. Sedation-related hypotension requiring IV fluids occurred in 2 (managed without adverse-consequences) and hypoxia requiring additional airway-management in none. No procedural deaths occurred, one patient required emergency cardiac surgery for localized ventricular perforation, nine had minor complications (transient hypotension/bradycardia/pericardial effusion not requiring intervention).

CONCLUSION

TLE undertaken using LA/conscious-sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolization of COVID-19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.

Real-world evaluation of followup strategies after ICD therapies in patients with VT (REFINE-VT)

Implantable cardiac defibrillators (ICDs) can prevent sudden cardiac death, but the risk of recurrent ventricular arrhythmia (VA) and ICD shocks persist. Strategies to minimise such risks include medication optimisation, device programming and ventricular tachycardia (VT) ablation. Whether the choice of these interventions at follow-up are influenced by factors such as the type of arrhythmia or ICD therapy remains unclear. To investigate this, we evaluated ICD follow-up strategies in a real-world population with primary and secondary prevention ICDs. REFINE-VT (Real-world Evaluation of Follow-up strategies after Implantable cardiac-defibrillator therapies in patients with Ventricular Tachycardia) is an observational study of 514 ICD recipients recruited between 2018 and 2019. We found that 77 patients (15%) suffered significant VA and/or ICD therapies, of whom 26% experienced a second event; 31% received no intervention. We observed an inconsistent approach to the choice of strategies across different types of arrhythmias and ICD therapies. Odds of intervening were significantly higher if ICD shock was detected compared with anti-tachycardia pacing (odds ratio [OR] 8.4, 95% confidence interval [CI] 1.7 to 39.6, p=0.007). Even in patients with two events, the rate of escalation of antiarrhythmics or referral for VT ablation were as low as patients with single events. This is the first contemporary study evaluating how strategies that reduce the risk of recurrent ICD events are executed in a real-world population. Significant inconsistencies in the choice of interventions exist, supporting the need for a multi-disciplinary approach to provide evidence-based care to this population.

Safety and outcome of nurse-led syncope clinics and implantable loop recorder implants

BACKGROUND

Implantable loop recorders (ILRs) are effective in achieving symptom-rhythm correlation. Data on the diagnostic yield of ILRs, on nurse-led syncope clinics, and on nurse-led ILR implants are limited.

OBJECTIVE

We evaluated the safety and efficacy of our nurse-led syncope clinic and nurse-led ILR implants.

METHODS

A retrospective study of all consecutive patients undergoing nurse-led ILR implantations was performed between April 2016 and April 2018. Patients were referred from both nurse-led and physician-led clinics. Data were collected on baseline demographic characteristics, referral source, symptom-rhythm correlation, ILR findings, and subsequent changes to management. All ILRs were enrolled into remote monitoring with automatic arrhythmia detection, and all immediate (≤24 hours) ILR implant complications were recorded. Comparisons were made between nurse-led and physician-led clinics and subsequent outcomes.

RESULTS

A total of 432 patients with an ILR were identified: 164 (38%) from nurse-led and 268 (62%) from physician-led clinics; 200 (46%) were women (mean age 66.5 ± 18.2 years; mean follow-up duration 28.9 ± 9.5 months). Primary ILR indications were syncope (n = 251 [58%]), presyncope (n = 33 [7%]), palpitation (n = 39 [9%]), cryptogenic stroke (n = 78 [18%]), and other reasons (n = 31 [7%]). No immediate ILR implant complications occurred. Overall, 156 patients (36%) had a change in management as a direct result of ILR findings, with no overall differences between nurse-led and physician-led clinics (35% vs 36%; P = .7). More patients had newly diagnosed atrial fibrillation in physician-led clinics (15% vs 7%; P = .01), and more patients had pacemaker implants for bradycardia in nurse-led clinics (23% vs 13%; P < .01).

CONCLUSION

Nurse-led ILR implantation was safe and effective. Nurse-led syncope clinics achieved good symptom-rhythm correlation with resultant significant changes to management in comparison to physician-led clinics. Larger prospective studies are needed to evaluate their longer-term impact.

Real-world evaluation of follow up strategies after implantable cardiac-defibrillator therapies in patients with ventricular tachycardia (REFINE-VT)

Introduction

Implantable cardiac-defibrillators (ICD) can prevent sudden cardiac death but the risk of recurrent ventricular arrhythmia (VA) and ICD therapies persists. Established strategies to minimize such risks include medication optimization, device reprogramming or ventricular tachycardia (VT) catheter ablation (CA). However, the timing and choice of these strategies at ICD follow-up may not be as consistent in the real-world as the regulated conditions of clinical trials. Furthermore, whether these decisions at follow-up are influenced by the type of arrhythmia, ICD therapy or patient characteristics remain unclear.

Purpose

We evaluated ICD follow-up strategies in patients with ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM) to refine the outpatient management of these complex patients and ultimately improve overall patient outcome.

Methods

REFINE-VT is a retrospective study of 514 patients with ICD/CRT-D who attended ICD follow-up between June 2018 to September 2019 at the University Hospital Coventry & Warwickshire (UHCW) tertiary cardiology department. All follow-ups were face-to-face. Patients were divided into 2 groups according to the absence or presence of sustained VA (e.g. &gt;30 seconds of VT and/or appropriate ICD therapy), described as “negative event” and “positive event” groups respectively. The type of strategy employed in response to a positive event were categorized into 4 groups: (1) Medication change only (2) Device programming +/− medication (3) Referral for VT CA (4) No intervention

Results

514 consecutive patients with ICD (52%) or CRT-D (48%) were analysed. Overall mean age was 67±14 years with 79% male patients. ICM was diagnosed in 329 (64%) patient and NICM in 185 (36%). 437 (85%) patients had no significant VA and/or ICD therapy referred to as the negative group. A total of 77 patients (15%) suffered VA and/or ICD therapies, of whom 22 patients (26%) experienced a second event. 31% (n=24) of this positive event group received no preventative strategy (Table 1). We observed an inconsistent approach to the choice of strategies across different types of arrhythmias and ICD therapies. E.g. the odds of intervening were significantly higher if ICD shock was detected compared to anti-tachycardia pacing (OR 8.4, 95% CI 1.7–39.6, p=0.007). Even in patients with two events, the rate of referral for VT ablation and escalation of antiarrhythmics were similarly as low as patients with a single event (Table 2).

Conclusion

This is the first contemporary study that has evaluated how strategies that reduce the risk of recurrent ICD events are executed in a real-world population. We have demonstrated that the decision to intervene and choices of strategy remain inconsistent and partially biased by the type of arrhythmia and ICD therapy at follow-up. This supports the need for an evidence-driven multi-disciplinary VT clinic to refine and standardize our approach to this heterogeneous population.

Funding Acknowledgement

Type of funding sources: None.

Treatment outcomes in patients with drug-resistant TB-HIV co-infection treated with bedaquiline and linezolid

BACKGROUND: Bedaquiline (BDQ) has not been extensively studied among patients co-infected with HIV drug-resistant tuberculosis (DR-TB). We compared treatment outcomes in DR-TB patients treated with BDQ- and linezolid (LZD) containing regimens to historic controls treated with second-line injectable-containing regimens.METHODS: Retrospective cohort study of consecutive DR-TB patients initiated on BDQ- and LZD-containing regimens at a TB referral hospital in KwaZulu-Natal, South Africa. Participants were prospectively followed through 24 months for treatment outcome and adverse events. Outcomes were compared to a historic control cohort of DR-TB HIV patients enrolled at the same facility prior to BDQ introduction.RESULTS: Adult DR-TB patients initiating BDQ between January 2014 and November 2015 were enrolled (n = 151). The majority of patients were female (52%), HIV co-infected (77%) and on antiretroviral therapy (100%). End of treatment outcomes included cure (63%), TB culture conversion (83%), completion (0.7%), loss to follow-up (15%), treatment failure (5%), and death (17%). Compared to historic controls (n = 105), patients treated with BDQ experienced significantly higher TB culture conversion and cure, with significantly lower mortality. Adverse effects were common (92%), and most frequently attributed to LZD (24.1%). QT segment prolongation was common but without clinical sequelae.CONCLUSION: Treatment with BDQ- and LZD-containing regimens was associated with improved treatment outcomes and survival in DR-TB HIV patients.

Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature

POTS is under diagnosed with an estimated prevalence of 0.2%. North American and Australian researchers, as well as patient groups have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base.

AIM

To map the POTS evidence base.

METHODS

Two reviewers systematically searched 12 databases until July 1st 2019 using the search term "Postural Tachycardia Syndrome" (n = 7280) and categorised the literature. Inclusion criteria included all adult published literature with no language restrictions. 779 papers are analysed and mapped.

RESULTS

Seven themes were identified: symptomology and quality of life 16.8% (n = 132), biomedical topics 16.5% (n = 130), co-morbidities 10.3% (n = 81), non-pharmacological management 9.8% (n = 77), aetiologies 6.9% (n = 53), pharmacological management 6.7% (n = 53), and clinical management 6.6% (n = 52). There 45 subthemes. Quality appraisal of the research studies (n = 233) evaluated design, sample size, outcome measures, data analysis and research biases. 74.8% (n = 175) were observational designs and 25.2% (n = 59) were experimental designs (16 using a randomised controlled design, 11 of which had a sample size greater than 21). 47.4% (n = 111) of studies only measured duration of effect for <1 day. 11.5% (n = 27) of studies reported outcomes using an unvalidated subjective measurement tool.

CONCLUSION

The volume of adult POTS literature is small and the validity and reliability of the research lacks rigour. The evidence map methodology provides POTS researchers with a benchmark for research thus far. This paper adds an in-depth research appraisal to the broad calls for action, highlighting the pressing need for multicentre, good quality research in POTS, to support guidelines and consensus development in the future.

Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation

Background

Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia (VT) ablation. State-of-the-art multipolar mapping catheters have enhanced mapping capabilities. The purpose of this study was to investigate whether long-term outcomes were improved with the use of a HD Grid mapping catheter combining complementary mapping strategies in patients with structural heart disease VT.

Methods

Consecutive patients underwent VT ablation assigned to either HD Grid, Pentaray, Duodeca, or point-by-point (PbyP) RF mapping catheters. Clinical endpoints included recurrent anti-tachycardia pacing (ATP), appropriate shock, asymptomatic non-sustained VT, or all-cause death.

Results

Seventy-three procedures were performed (33 HD Grid, 22 Pentaray, 12 Duodeca, and 6 PbyP) with no significant difference in baseline characteristics. Substrate mapping was performed in 97% of cases. Activation maps were generated in 82% of HD Grid cases (Pentaray 64%; Duodeca 92%; PbyP 33% (p = 0.025)) with similar trends in entrainment and pace mapping. Elimination of all VTs occurred in 79% of HD Grid cases (Pentaray 55%; Duodeca 83%; PbyP 33% (p = 0.04)). With a mean follow-up of 372 ± 234 days, freedom from recurrent ATP and shock was 97% and 100% respectively in the HD Grid group (Pentaray 64%, 82%; Duodeca 58%, 83%; PbyP 33%, 33% (log rank p = 0.0042, p = 0.0002)).

Conclusions

This study highlights a step-wise improvement in survival free from ICD therapies as the density of mapping capability increases. By using a high-density mapping catheter and combining complementary mapping strategies in a strict procedural workflow, long-term clinical outcomes are improved.

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support

OBJECTIVES

Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study.

MEASUREMENTS

Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used.

RESULTS

The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia.

CONCLUSION

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

Case report: Managing profound circulatory collapse post-atrial fibrillation ablation: a methodical approach

Background

Circulatory collapse during/post-pulmonary vein (PV) isolation by cryo-balloon ablation is a Cardiology emergency that has multiple potential causes and requires a methodical investigative approach. Some of the complications that can arise include cardiac tamponade, bleeding/vascular injury, anaphylaxis, Addisonian crisis, acute pulmonary embolism, acute PV stenosis, oesophageal injury, and vagal reaction.

Case summary

Here, we present a case of a 76-year-old lady who developed profound circulatory collapse during an elective pulmonary vein isolation by cryo-balloon ablation for symptomatic paroxysmal atrial fibrillation (AF). Cardiac tamponade, bleeding/vascular injury, and other less common causes were excluded. She only responded transiently to fluid resuscitation and developed intermittent bradyarrhythmias and hypotension which responded to isoprenaline. She was discharged home at Day 3 post-AF ablation after remaining well and continued to do so at follow-up.

Discussion

Circulatory collapse during/post-PV cryo-balloon ablation is a Cardiology emergency that has multiple potential causes. The ganglionate plexi form part of the cardiac intrinsic autonomic nervous system (ANS) and are located close to the left atrial–PV junctions. The presence of vagal response has been observed to be a marker of ANS modulation although its significance on the long-term outcome post-ablation has yet to be elucidated. The true cause of our patient’s profound circulatory collapse is uncertain but a vital learning point in this case is the systematic exclusion of common and potentially life-threatening complications following AF ablation. A persistent vagal reaction secondary to PV cryo-balloon ablation can usually be managed with supportive medical therapy as demonstrated in our case.

MAGNETO cardiography parameters to predict future Sudden Cardiac Death (MAGNETO-SCD) or ventricular events from implantable cardioverter defibrillators: study protocol, design and rationale

INTRODUCTION

Predicting sudden cardiac death (SCD) is challenging as current risk predictors have significant limitations. Evaluating magnetocardiogram (MCG) parameters could be of great value and we plan to assess the capability of a new mobile unshielded MCG device in predicting SCD and ventricular arrhythmias (VA) in patients undergoing implantable cardioverter defibrillator (ICD) implantation.

METHODS AND ANALYSIS

A prospective multicentre (University Hospitals Coventry and Warwickshire (UHCW) National Health Service (NHS) Trust/University Hospital North Midlands NHS Trust, UK) observational study evaluating the VitalScan MCG (Creavo Medical Technologies, UK) to predict future VA risk; 270 patients meeting criteria for primary or secondary prevention ICDs (ischaemic or non-ischaemic aetiology) are being recruited. The first patient was recruited September 2019 and the study will be completed at final participant follow-up. The primary endpoint is appropriate ICD therapy for VA, secondary endpoint is SCD. Previous trials using MCG identified late QRS signals/QRS fragmentation as potential indicators of SCD in small samples using large shielded expensive MCG devices that were difficult to use clinically. It is hoped the MAGNETO-SCD trial will show this new MCG device can provide real world risk stratification for SCD/VA risk. The trial has recruited 25 patients (13 with secondary prevention indication) from a single site (UHCW) with recruitment starting at the second site in March 2020.

ETHICS AND DISSEMINATION

Research Ethics Committee, Yorkshire and Humber Sheffield Research Ethics Committee UK (Ref: 19/YH/0143) and Health Research Authority (IRAS reference 254466, EDGE ID: 123146) approval received on 17/07/2019. The Medicines and Healthcare products Regulatory Agency approval received 11/07/2019. Results will be disseminated via a peer-reviewed publication and presentation at international conferences.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov Registry (NCT04352816) and EU Clinical Trials Registry (EudraCT2019-002994-78).

The Impact of a Nurse-Led Syncope Clinic: Experience from a single UK tertiary center

Background

Syncope is a leading cause of hospital admission and is associated with significant morbidity and mortality. Our Syncope Clinic commenced in 2014 and we sought to evaluate its impact on outcomes (1‐yr mortality and syncope re‐hospitalization) in patients discharged following syncope admission.

Methods

A single‐center study of all consecutive patients discharged with syncope (ICD‐10 R55) between April 2012 and 2017. Patient demographics, comorbidities, hospital stay, syncope re‐hospitalization, and mortality at one‐year were collected. Those subsequently referred and seen in Syncope Clinic were compared with those who were not and predictors of poor outcome were evaluated.

Results

In total 2950 patients were discharged from hospital with syncope (median age: 73years, 51% male) with 1220 (41%) discharged same‐day; after commencement of Syncope Clinic 231were subsequently reviewed here. Overall mortality was 11%, which was lower in the Syncope Clinic group (3% vs 12%, P < .001). Temporal analysis revealed reduced re‐hospitalization following commencement of Syncope Clinic (2% vs 6%, P = .027). Independent predictors of mortality were increasing age (HR 1.03, 95% CI 1.03‐1.04), AF (HR 1.6, 95% CI 1.2‐2.1), HF (HR 2.2, 95% CI 1.6‐3.0), COPD (HR 1.9, 95% CI 1.4‐2.7), and CHADS₂ score ≥ 1 (HR 1.45, 95% CI 1,12‐1.87). Syncope Clinic attendance was associated with reduced mortality (HR 0.3, 95% CI 0.1‐0.6).

Conclusions

Syncope patients discharged from hospital had reduced 1yr mortality if seen in subsequent Syncope Clinic. Independent predictors of mortality were COPD, HF, AF, and CHADS₂ ≥1. Prospective randomized trials of Syncope Clinics are warranted.

'I felt like a human being' – An exploratory, multi-method study of refugee involvement in the development of mental health intervention research

The purpose of this study was to pilot and methodologically appraise innovative patient and public involvement (PPI) evaluation tools and to describe a case study of refugee involvement in the development of mental health intervention research. 'Refugee Advisors' were involved in the development of a randomised controlled trial protocol evaluating a brief group intervention for refugee children experiencing symptoms of post-traumatic stress in Sweden. During an 8-hour research meeting, observation and questionnaire data were collected using the Active Involvement of Users in Research Observation Schedule and Questionnaire, followed by a focus group discussion. The multi-method approach demonstrated good feasibility. There were clear examples of how the advisors influenced research development e.g. recruitment strategy, cultural brokerage among study group participants, outcome measure validation. The advisors described a perceived impact on the research, equality and acceptance, and knowledge gain. A sense of appreciation and empowerment was also interpreted. However, potential issues relating to the relevance of contributions and use of an interpreter were identified.

Safety and cost-effectiveness of same-day complex left atrial ablation

Background

Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.

Method

Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.

Results

A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.

Conclusions

Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

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We have previously reported same-day standard catheter ablation is safe, feasible and cost-effective. Data on same-day complex left-atrial ablation are limited.

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Our multi-centre cohort study of 967 consecutive elective complex left-atrial ablation procedures between January 2011 and December 2019 revealed same-day ablations using conscious sedation were safe and associated with very few complications and could have significant benefits to patients and cost-savings for healthcare providers worldwide.

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Same-day complex left-atrial ablation procedures can be performed safely without the need for overnight-stay. This has major implications for both patients and healthcare providers, especially given the current financial challenges and Covid-19 pandemic.

Effectiveness of a school-based intervention for adolescents and teachers to promote mental health among refugee and migrant adolescents

Refugee youth have often experienced trauma during relocation and continue to face adversity in their host country in the form of acculturation stress, residence insecurity, social isolation, and experiences of discrimination. These experiences are associated with a significant risk of developing mental health problems such as post-traumatic stress disorder (PTSD). This cluster randomised trial aims to evaluate the effectiveness of a school-based intervention that provides a manualized, trauma-focussed programme called Teaching Recovery Techniques (TRT) to target refugee and migrant youth and an In-Service Teacher Training (INSETT) programme to teachers. The study will consider the impact of the intervention on the mental health of adolescent refugees and their guardians who participate in the TRT programme. It will also consider the intervention's impact on the interrelationships between teachers and parents and teachers' cultural competence, as well as the social support and school belonging experienced by adolescents who do not participate in TRT but whose teachers receive INSETT training. Further details on TRT and INSETT, trial design and preliminary findings will be presented at the workshop.

Meaningful patient and public involvement to advance healthcare equity, quality and accessibility

Background

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. It can lead to a richer understanding of public health research topics, improve data quality and analysis, increase trust in and dissemination of research findings, and ultimately achieve health services that are useful, useable and desirable. However, this all relies on PPI being conducted in a meaningful, respectful and inclusive way. Guidance is available on how to conduct, report and evaluate PPI activities. However, evaluative data are often brief, narrative descriptions, which reflects the lack of robust tools specifically developed to assess PPI. The purpose of this study was to develop and pilot tools to objectively assess PPI in the context of research project meetings.

Methods

PPI and group dynamics literature was used to guide the construction of an observation protocol and questionnaire. The research tools were piloted within a randomised trial of a community intervention for refugee children reporting symptoms of posttraumatic stress.

Results

The Active Involvement of Users in Research Observation Schedule is a semi-structured observation protocol, which consists of 12 observable behaviours relating to the interpersonal relations between researchers and PPI advisors; the nature of advisor contributions; and how the advisors guide research development. Each category consists of positive and negative behaviours. There is an accompanying paper-based assessment form that allows attendees to independently and anonymously grade the meeting on a list of items that correspond to those on the observation pro-forma. Preliminary inter-rater reliability for the observation protocol is good (ICC=0.833; 95% CI: 0.569-0.947).

Conclusions

Although the research tools require further refinement and validation, the methodological approach offers a promising, rigorous way to evaluate PPI.

Key messages

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. The Active Involvement of Users in Research Observation Schedule and Questionnaire offer a promising, rigorous way to evaluate PPI and promote meaningful involvement to advance public health research.

Body composition in heart failure and the impact of cardiac resynchronisation therapy: a proof-of-concept study

Aims

Body composition (BC) is known to alter in heart failure. Cardiac resynchronisation therapy (CRT) improves left ventricular geometry but the impact on BC is unknown. Our aim was to evaluate BC in these patients before and after CRT implantation.

Methods

Prospective proof-of-concept pilot study of heart failure patients undergoing CRT between September 2014 and December 2015. Assessments performed pre-CRT and post-CRT (6 weeks and 6 months) were: BC parameters (using air-displacement plethysmography), New York Heart Failure classification for assessing symptom severity, echocardiography to assess left ventricular geometry, electrocardiography, Minnesota Heart Failure Questionnaire and N-terminal probrain natriuretic peptide (NT-pro-BNP). Repeated measures analysis of variance was performed to assess relative change over time and potential correlations.

Results

Twenty-five patients were recruited; mean-age (±SD) was 73.4±10.0 years, 23 males, 18 CRT defibrillators (remainder CRT pacemakers), 16 had ischaemic aetiology, 6 diabetics, 17 with left bundle-branch morphology on ECG and 10 had atrial fibrillation. Significant inverse correlations were observed in the first 6 weeks following CRT between fat mass and left ventricular end-diastolic volume (r=−0.69, p<0.01) and NT-pro-BNP and fat mass (r=0.41, p=0.05). No significant differences were noted over 6 months. There was an observed trend towards reduced fat mass in the first 6 weeks post-CRT implant driven by non-responders. There was no significant difference between responders and non-responders in BC over 6 months.

Conclusion

This is the first study to observe interplay between BC and cardiac geometry/function following CRT; a trend in overall fat mass reduction was noted following CRT and merits further study.

Long-term follow-up of normal and structural heart ventricular tachycardia catheter ablation: real-world experience from a UK tertiary centre

Background

Ventricular tachycardia (VT) is associated with increased morbidity and mortality. There is growing evidence for the effectiveness of catheter ablation in improving outcomes in patients with recurrent VT. Consequently the threshold for referral for VT ablation has fallen over recent years, resulting in increased number of procedures.

Objective

To evaluate the effectiveness and safety of VT ablation in a real-world tertiary centre setting.

Methods

This is a prospective analysis of all VT ablation cases performed at University Hospital Coventry. Follow-up data were obtained from review of electronic medical records and patient interview. The primary endpoint for normal heart VT was death, cardiovascular hospitalisation and VT recurrence, and for structural heart VT was arrhythmic death, VT storm (>3 episodes within 24 hours) or appropriate shock.

Results

Forty-seven patients underwent 53 procedures from January 2012 to January 2018. The mean age ±SD was 57±15 years, 68% were male, 81% were Caucasian and 66% were elective cases. The aetiology of VT included normal heart (49%), ischaemic cardiomyopathy (ICM, 36%), dilated cardiomyopathy (9%), hypertrophic cardiomyopathy (4%) and valvular heart disease (2%). Procedural success occurred in 83%, with six major complications. After a median follow-up of 231 days (lower quartile 133, upper quartile 631), the primary outcome occurred in 28% of patients. There were two non-arrhythmic deaths (4%). At a median follow-up of 193 days (129–468), the primary outcome occurred in 19% of patients with ICM, while VT storm/appropriate shocks occurred in three patients (17%).

Conclusions

Our real-world registry confirms that VT ablation is safe, and is associated with high acute procedural success and long-term outcomes comparable with randomised controlled studies.

P2837Day-case complex left atrial ablation is safe and cost-effective: experience from a UK tertiary centre

Background

Day-case standard catheter ablation is becoming routine. However, patients having complex left atrial ablation for atrial fibrillation (AF) or left atrial tachycardia (LAT) often stay overnight. We have been performing day-case complex left atrial ablation since 2015.

Purpose

To evaluate the safety, efficacy and cost-effectiveness of day-case complex left atrial ablation compared with those who stayed overnight.

Methods

A retrospective analysis of all consecutive complex left atrial ablations performed in a UK tertiary cardiac centre between 2010–2018. Data were collected on baseline parameters, procedure details including mapping technique, ablation strategy, immediate efficacy, and acute complications.

Results

A total of 830 complex left atrial catheter ablations were performed; mean age±SD=60±12 years, 63% male. The majority were AF ablation (n=804, 96.9%), with the rest being LAT/left-atrial flutter. Of the AF cases, 545 were paroxysmal (≤7 days), 212 persistent (>7 days) and 47 long-standing (>1yr); 98% of cases were elective. Pulmonary vein isolation was performed in all; additional LA lines were done in 163, CTI ablation in 129 and CFAEs in 33. 3D-mapping (Carto/Precision)=44.7% (with contact sensing=38.0%), PVAC=18.7%, PVI cryo-balloon=36.6%. Of the cohort 331 (39.9%) were done as day-case. Acute success= 94.9%, acute complications=4.58% (femoral site complications, n=12; pericardial effusion, n=19 (9 needing drain); stroke/cerebral embolus, n=3; phrenic nerve palsy, n=5; first degree heart block, n=1). Comparison of day-case vs non day-case revealed no significant difference in number of complications (Table 1). An overnight stay at out hospital costs £350. During the period of study our institution saved £115.850 (∼140,000 euros).

Day-case vs non day-case ablation Parameters Day-case (n=331) Non day-case (n=499) p-value Mean age ± SD (years) 61.2±11.6 59.1±11.9 0.009 Males (n, %) 205 (61.9%) 321 (64.3%) 0.484 Normal heart (n, %) 243 (73.4%) 383 (76.8%) 0.276 Paroxysmal AF (n, %) 218 (65.9%) 327 (65.5%) 0.928 Fluoroscopy time (mins) 23.8±13.9 27.0±14.5 0.001 Procedure time (mins) 150±89.6 163±68.2 0.025 % with 3D-mapping 30.8% 56.9% <0.001 Acute complications (n, %) 12 (3.63%) 26 (5.21%) 0.285

Conclusions

Day-case complex left atrial cardiac ablation is safe and effective. It is associated with good clinical outcomes and leads to significant cost savings as an overnight stay is not needed.

3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases

Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilized in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3DE-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.

P6561Diagnostic yield of implantable loop recorders: a comparison of arrhythmia nurse specialists versus clinicians

Background

Implantable loop recorders (ILR) are recommended in guidelines to determine symptom-rhythm correlation. Arrhythmia Nurse Specialists (ANS) play a critical role in the assessment of such patients. Their effectiveness at risk stratification for ILR implantation is unknown. The ESC 2018 Syncope guidelines recommend more research in this field.

Aim

To evaluate the diagnostic yield of consecutive ILR implants at a tertiary centre over a 2year period and compare ANS versus Clinicians.

Methods

A retrospective study of all patients undergoing ILR implant between April 2016 and April 2018. Data collected included baseline patient demographics, referral source and management changes made by ILR findings.

Results

305 patients had an ILR; median age was 71yrs (interquartile range 52–81), 55% male. Median follow-up time was 15months. Referrals were from general cardiology (GC) = 98 (32%), electrophysiology (EP) = 105 (34%), and ANS-led syncope clinic = 102 (34%). Indications for ILR implant were syncope = 203 (65.9%), palpitation = 21 (6.9%), pre-syncope = 16 (5.2%), cryptogenic stroke = 35 (11.5%) and others 7 (8.9%) (falls, channelopathies). Of the entire cohort, 102 (34.0%) experienced arrhythmias recorded on the ILR that resulted in a change of management. This included: pacemaker implant = 49 (16.1%), complex-device implant = 7 (2.3%), AF=28 (9.2%), SVT=14 (4.6%), VT=1 (0.3%). Of those with a syncope indication (n=203), findings on ILR altered management in 73patients (36.0%) over a median follow-up of 18months; a pacing indication in this syncope group was present in 44 (21.9%) patients (median time to diagnosis: 2.7 months) with 24 receiving a pacemaker indication within 3 months of ILR insertion. ANS had a higher pacemaker implant rate. Overall, an ILR resulted in a diagnostic yield of 34.1% (n=104). Specialist nurse referral resulted in an overall greater trend towards change of management in 38.2% of patients compared with GC (32.7%) and EP (31.0%) (p=0.593 nurse vs. consultant).

Conclusion

The overall diagnostic yield of ILR insertion was 34% in our study. ANS had a trend towards a greater diagnostic yield compared with clinicians, and significantly more pacemaker indications. Our data suggests that ANS patient selection for ILR insertion are at least comparable to clinicians.

Characterisation of circulating biomarkers before and after cardiac resynchronisation therapy and their role in predicting CRT response: the COVERT-HF study

Aims

Cardiac resynchronisation therapy (CRT) is effective treatment for selected patients with heart failure (HF) but has ~30% non-response rate. We evaluated whether specific biomarkers can predict outcome.

Methods

A prospective single-centre pilot study of consecutive unselected patients undergoing CRT for HF between November 2013 and December 2015 evaluating cardiac extracellular matrix biomarkers and micro-ribonucleic acid (miRNA) expression before and after CRT assessing ability to predict functional response and survival. Each underwent three assessments (pre-implant, 6  weeks and 6  months postimplant) including: New York Heart Association (NYHA) class, echocardiography, electrocardiography, 6  min walk test (6MWT), Minnesota Living with Heart Failure Questionnaire (MLHFQ) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP). Plasma markers of cardiac fibrosis assessed were: N-terminal pro-peptides of collagen I and III, collagen I C-terminal telopeptides (CTx) and matrix metalloproteinases (MMP-2 and MMP-9) as well as a panel of miRNAs (miRNA-21, miRNA-30d, miRNA-122, miRNA-133a, miRNA-210 and miRNA-486).

Results

A total of 52 patients were recruited; mean age (±SD) was 72.4±9.4 years; male=43 (82.7%), ischaemic aetiology=30 (57.7%), mean QRS duration=166.4±23.5  ms, left bundle branch block (LBBB) morphology = 39 (75.0%), mean NYHA=2.7±0.6, 6MWT=238.8±130.6  m, MLHFQ=46.4±21.3  and left ventricular ejection fraction (LVEF)=24.3%±8.0%. Mean follow-up=1.7±0.3  and 5.8±0.7 months. There were 27 (55.1%) functional responders (3 no definable 6-month response; 2 missed assessments and 1 long-term lead displacement). No marker predicted response, however, CTx and LBBB trended most towards predicting functional response.

Conclusion

No specific biomarkers reached significance for predicting functional response to CRT. CTx showed a trend towards predicting response and warrants further study.

Trial registration number

NCT02541773.

Extracellular cardiac matrix biomarkers in patients with reduced ejection fraction heart failure as predictors of response to cardiac resynchronisation therapy: a systematic review

OBJECTIVE

Cardiac resynchronisation therapy (CRT) is an effective therapy for selected patients with heart failure (HF); however, a significant non-response rate exists. We examined current evidence on extracellular cardiac matrix (ECM) biomarkers in predicting response following CRT.

METHODS

Complete literature review of PubMed, Ovid SP MEDLINE, Cochrane Library and TRIP, reference lists, international cardiology conferences and ongoing studies between December 1999 and December 2015 conducted according to prospectively registered study selection and analysis criteria (PROSPERO:CRD42016025864) was performed. All observational and randomised control trials (RCT) were included if they tested prespecified ECM biomarkers' ability to predict CRT response. Risk of bias assessment and data extraction determined pooling of included studies was not feasible due to heterogeneity of the selected studies.

RESULTS

A total of 217 studies were screened; six (five prospective cohort and one RCT substudy) were included in analysis with 415 participants in total. Study sizes varied (n=55-260), cohort characteristics contrasted (male: 67.8%-83.6%, ischaemic aetiology: 40.2%-70.3%) and CRT response definitions differed (three clinical/functional, three echocardiographic). Consistent observation in all ECM biomarker behaviour before and after CRT implantation was not observed between studies. Lower type I and type III collagen synthesis biomarkers (N-terminal propeptides of type I and III procollagens) expression demonstrated replicated ability to predict reverse left ventricular remodelling.

CONCLUSION

Collagen synthesis biomarkers offer the most potential as ECM biomarkers for predicting CRT response. Heterogeneity between these studies was large and limited the ability to pool and compare results numerically. Use of different response definitions was one of the biggest challenges.

Cardiac resynchronization therapy and its role in the management of heart failure

The prevalence of heart failure is increasing and it is associated with significant mortality and morbidity. Optimal medical therapy improves outcome, but heart failure continues to have a substantial impact on both the individual patient and wider society. Over the last two decades, cardiac resynchronization therapy has revolutionized the treatment of selected patients who have heart failure. Cardiac resynchronization therapy significantly reduces mortality and hospitalization through reverse cardiac remodelling. This review informs non-specialists about cardiac resynchronization therapy and for which patients it should be considered.

The changing face of cardiovascular disease 2000-2012: An analysis of the world health organisation global health estimates data

The pattern and global burden of disease has evolved considerably over the last two decades, from primarily communicable, maternal, and perinatal causes to non-communicable disease (NCD). Cardiovascular disease (CVD) has become the single most important and largest cause of NCD deaths worldwide at over 50%. The World Health Organisation (WHO) estimates that 17.6 million people died of CVD worldwide in 2012. Proportionally, this accounts for an estimated 31.43% of global mortality, with ischaemic heart disease (IHD) accounting for approximately 7.4 million deaths, 13.2% of the total. IHD was also the greatest single cause of death in 2000, accounting for an estimated 6.0 million deaths. The global burden of CVD falls, principally, on the low and middle-income (LMI) countries, accounting for over 80% of CVD deaths. Individual populations face differing challenges and each population has unique health burdens, however, CVD remains one of the greatest health challenges both nationally and worldwide.

Long-Term Follow-Up of Isolated Epicardial Left Ventricular Lead Implant Using a Minithoracotomy Approach for Cardiac Resynchronization Therapy

BACKGROUND

Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach.

AIM

To evaluate the success of this approach at long-term follow-up.

METHODS

Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response).

RESULTS

Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward <24 hours. Median hospital stay was 3.4 ± 1.9 days. The overall complication rate was 17.5% (n = 7): 15.0% (n = 6) short term and 2.5% (n = 1) long term; these included three (7.5%) LV noncapture events all treated with reprogramming. There were two (5.0%) wound infections requiring oral antibiotics and two (5.0%) device infections requiring intravenous antibiotics (one had device resiting, the other developed septic shock requiring intensive care admission). Assessment of clinical response was possible in 34 (81.0%) at follow-up: 21 (61.8%) were responders and 13 (28.2%) nonresponders with no significant differences between these groups; no clinical predictors of response were identified.

CONCLUSION

Isolated epicardial LV lead implant using minithoracotomy is relatively safe and effective at successful LV pacing. Response rate and postoperative recovery at long-term follow-up are reasonable in these high-risk patients.

Safety and Cost-Effectiveness of Same-Day Cardiac Resynchronization Therapy and Implantable Cardioverter Defibrillator Implantation

Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD) implantation improve morbidity and mortality in selected patients. Many centers still admit patients overnight. We evaluated the safety, feasibility, and cost savings of same-day CRT/ICD device implantation by performing a retrospective study of all consecutive elective CRT/ICD implants at a tertiary center from January 2009 to April 2013. All emergency and/or inpatient cases were excluded. Data were collected on baseline demographics, implantation indication, procedure details, complications (categorized as immediate [≤24 hours], short term [24 hours to 6 weeks], medium term [6 weeks to 4 months], and long term [>4 months]), and mortality (30 day and 1 year). Comparisons were made between those having planned same-day versus overnight stay procedures. A cost analysis was performed to evaluate cost savings of the same-day policy. A total of 491 devices were implanted during this period: 267 were elective (54 planned overnight, 213 planned same-day) of which 229 were CRT pacemakers or CRT defibrillators and 38 ICDs. There were 26 total overall complications (9.7%) with no significant differences between planned same-day versus planned overnight stay cohorts (9.4% vs 11.1%, p = 0.8) and specifically no differences in immediate, short-, medium-, and long-term complications at follow-up. The 30-day and 1-year mortality rates did not differ between the two groups. An overnight stay at our hospital costs $450 (£300); our cost saving during this period was $91,800 (£61,200). Same-day CRT/ICD implantation is safe, feasible, and associated with significant cost savings. It provides significant advantages for patients and health care providers, especially given the current financial climate.