Abstract Objectives This study assessed trends in transesophageal echocardiography (TEE) use, rate of left atrial appendage (LAA) thrombus detection, and incidence of periprocedural cerebrovascular ...accident (CVA) since transitioning to a strategy of uninterrupted warfarin or briefly interrupted novel oral anticoagulant therapy in 2010. Background TEE is routinely performed before ablation for atrial fibrillation (AF) to ensure absence of LAA thrombus. Methods Patients with AF ablation presenting between January 2010 and September 2015 at Johns Hopkins Hospital were enrolled in an AF ablation registry; TEE and ablation outcomes were retrospectively analyzed. Presence of LAA thrombus, dense spontaneous echo contrast (SEC), or patent foramen ovale (PFO) were recorded. CVA incidence from procedure onset to 30 days post-procedure was evaluated using electronic medical record review. Results Pre-procedure TEE was performed in 646 of 1,224 AF ablation cases (52.8%). There was a decline in pre-procedure TEE use from 86% in 2010 to 42% in 2015 (p < 0.001). CVA incidence was 4/1,224 (0.33%) cases, and did not change during the study period. TEE findings included LAA thrombus (n = 6; 0.93%), PFO (n = 23; 3.6%), and dense spontaneous echo contrast (n = 99; 15.3%). Both SEC and LAA thrombus were associated with persistent AF, higher CHA2 DS2 VASC score, increased LA size, reduced LAA flow velocity, and decreased left ventricular ejection fraction. PFO was not associated with prior AF ablation, and SEC was not associated with increased CVA incidence. Conclusions CVA is a rare complication of AF ablation in patients with minimally interrupted anticoagulation. Pre-ablation TEE may be reasonably avoided in patients without high-risk features.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Implantable cardioverter-defibrillator (ICD) implantation is contraindicated in those with <1-year life expectancy.
The aim of this study was to develop a risk prediction score for 1-year mortality ...in patients with primary prevention ICDs and to determine the incremental improvement in discrimination when serum-based biomarkers are added to traditional clinical variables.
We analyzed data from the Prospective Observational Study of Implantable Cardioverter-Defibrillators, a large prospective observational study of patients undergoing primary prevention ICD implantation who were extensively phenotyped for clinical and serum-based biomarkers. We identified variables predicting 1-year mortality and synthesized them into a comprehensive risk scoring construct using backward selection.
Of 1189 patients deemed by their treating physicians as having a reasonable 1-year life expectancy, 62 (5.2%) patients died within 1 year of ICD implantation. The risk score, composed of 6 clinical factors (age ≥75 years, New York Heart Association class III/IV, atrial fibrillation, estimated glomerular filtration rate <30 mL/min/1.73 m(2), diabetes, and use of diuretics), had good discrimination (area under the curve 0.77) for 1-year mortality. Addition of 3 biomarkers (tumor necrosis factor α receptor II, pro-brain natriuretic peptide, and cardiac troponin T) further improved model discrimination to 0.82. Patients with 0-1, 2-3, 4-6, or 7-9 risk factors had 1-year mortality rates of 0.8%, 2.7%, 16.1%, and 46.2%, respectively.
Individuals with more comorbidities and elevation of specific serum biomarkers were at increased risk of all-cause mortality despite being deemed as having a reasonable 1-year life expectancy. A simple risk score composed of readily available clinical data and serum biomarkers may better identify patients at high risk of early mortality and improve patient selection and counseling for primary prevention ICD therapy.
Cardiac resynchronization therapy (CRT) reduces morbidity and mortality among individuals with dyssynchronous systolic heart failure (HF). However, patient outcomes vary, with some at higher risk ...than others for HF progression and death.
To develop a risk prediction score incorporating variables associated with mortality, left ventricular assist device (LVAD) implant, or heart transplant in recipients of a primary prevention cardiac resynchronization therapy-defibrillator (CRT-D).
We followed 305 CRT-D patients from the Prospective Observational Study of Implantable Cardioverter-Defibrillators for the composite outcome of all-cause mortality, LVAD implant, or heart transplant soon after device implantation. Serum biomarkers and electrocardiographic and clinical variables were collected at implant. Multivariable analysis using the Cox proportional hazards model with stepwise selection method was used to fit the final model.
Among 305 patients, 53 experienced the composite endpoint. In multivariable analysis, 5 independent predictors ("HF-CRT") were identified: high-sensitivity C-reactive protein >9.42 ng/L (HR = 2.5 1.4, 4.5), New York Heart Association functional class III/IV (HR = 2.3 1.2, 4.5), creatinine >1.2 mg/dL (HR = 2.7 1.4, 5.1), red blood cell count <4.3 × 10(6)/μL (HR = 2.4 1.3, 4.7), and cardiac troponin T >28 ng/L (HR = 2.7 1.4, 5.2). One point was attributed to each predictor and 3 score categories were identified. Patients with scores 0-1, 2-3, and 4-5 had a 3-year cumulative event-free survival of 96.8%, 79.7%, and 35.2%, respectively (log-rank, P < .001).
A simple score combining clinical and readily available biomarker data can risk-stratify CRT patients for HF progression and death. These findings may help identify patients who are in need of closer monitoring or early application of more aggressive circulatory support.
Multivariable Cox proportional hazards models were used to calculate the hazard ratios (HRs) associated with the different types of ICD therapy modeled as time-dependent covariates. Compared with ...patients who did not receive any ICD therapy, those who received appropriate ICD therapy only were more likely to be male, have higher body mass index, have lower use of beta-blockers, and have an ICD rather than a cardiac resynchronization therapy-defibrillator device.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Infection remains a feared complication after cardiac device implantation. Whether early postprocedural leukocytosis, a recognized marker of infection, is an indicator of impending infection is ...unclear and was the focus of this study. A retrospective chart review of consecutive patients who underwent implantable cardioverter defibrillator or pacemaker implantation was performed. The association between change in white blood cell (WBC) count and development of infection after device implantation was assessed. Infection was defined as pocket or lead infection or as bacteremia or sepsis <60 days after implantation. Pre- and postprocedural WBC counts were obtained within 48 hours of the procedure. Significant leukocytosis was defined as a ≥50% increase in WBC count; 1,245 device implantations met inclusion criteria. Device-related infections occurred in 8 cases (0.6%). A modest 17.6 ± 30.2% increase in WBC count was observed for the entire cohort. Cases resulting in infection demonstrated minimal change in WBC count (mean +5.5 ± 26.5%). No infections occurred in patients with ≥50% increases in WBC count or postprocedural WBC counts >15,000/μl. Subjects with significant leukocytosis were younger (mean age 61.9 ± 16.5 vs 65.6 ± 15.1 years, p <0.01), had longer procedure times (mean 198 ± 97 vs 170 ± 77 minutes, p <0.001), and received biventricular implantable cardioverter-defibrillators (25% vs 13.9%, p <0.001). In conclusion, after device implantation, a ≥50% increase in WBC count occurred in about 10% to 15% of patients. Age, race, type of device, and procedure time influenced the development of significant leukocytosis. Elevation in WBC count after cardiac device implantation was not associated with an increased risk for early infection.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Methodological difficulties associated with QT measurements prompt the search for new electrocardiographic markers of repolarization heterogeneity.
We hypothesized that beat-to-beat 3-dimensional ...vectorcardiogram variability predicts ventricular arrhythmia (VA) in patients with structural heart disease, left ventricular systolic dysfunction, and implanted implantable cardioverter-defibrillators (ICDs).
Baseline orthogonal electrocardiograms were recorded in 414 patients with structural heart disease (mean age 59.4 ± 12.0; 280 white 68% and 134 black 32%) at rest before implantation of ICD for primary prevention of sudden cardiac death. R and T peaks of 30 consecutive sinus beats were plotted in 3 dimensions to form an R peaks cloud and a T peaks cloud. The volume of the peaks cloud was calculated as the volume within the convex hull. Patients were followed up for at least 6 months; sustained VA with appropriate ICD therapies served as an end point.
During a mean follow-up time of 18.4 ± 12.5 months, 61 of the 414 patients (14.73% or 9.6% per person-year of follow-up) experienced sustained VA with appropriate ICD therapies: 41 of them were white and 20 were black. In the multivariate Cox model that included inducibility of VA and use of beta-blockers, the highest tertile of T/R peaks cloud volume ratio significantly predicted VA (hazard ratio 1.68, 95% confidence interval 1.01 to 2.80; P = .046) in all patients. T peaks cloud volume and T/R peaks cloud volume ratio were significantly smaller in black subjects (median 0.09 interquartile range 0.04 to 0.15 vs. median 0.11 interquartile range 0.06 to 0.22, P = .002).
A relatively large T peaks cloud volume is associated with increased risk of VA in patients with structural heart disease and systolic dysfunction.
Each of the main approaches to catheter ablation of atrial fibrillation (AF, segmental and circumferential) is associated with limited efficacy in patients with permanent AF. The objective is to ...report outcomes of circumferential ablation with pulmonary vein (PV) isolation, determined using a circular mapping catheter, in patients with permanent AF and determine relations between the duration of permanent AF and efficacy. The patient population was composed of 41 consecutive patients (34 men; age 58 ± 11 years) with permanent AF who underwent radiofrequency catheter ablation through circumferential ablation with PV isolation. They were in permanent AF for 2.3 ± 3.6 years, and 3.4 ± 2.2 cardioversion procedures and 1.9 ± 0.8 class I/III antiarrhythmic drugs had failed. After a follow-up of 11 ± 2 months, the single-procedure success rate was 36% (n = 15) with an additional 12% (n = 5) showing improvement. With repeat procedures in 19%, the success rate was 54% (n = 22) with an additional 12% (n = 5) showing improvement. All patients who underwent repeat ablations had recovered PV conduction. Single-procedure success was higher in patients who were in permanent AF for ≤1 year compared with those in permanent AF for >1 year (50% vs 20%, respectively, p = 0.05). A major complication occurred in 4 patients (8%), including 3 patients with vascular complications and 1 with stroke. In conclusion, study results suggest that circumferential ablation with PV isolation has moderate efficacy in patients with permanent AF. Efficacy is limited in those in continuous AF for >12 months.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Implantable cardioverter-defibrillators (ICDs) reduce the risk of death in patients with left ventricular dysfunction. Little is known regarding the benefit of this therapy in African Americans ...(AAs).
The purpose of this study was to determine the association between AA race and outcomes in a cohort of primary prevention ICD patients.
We conducted a prospective cohort study of patients with systolic heart failure who underwent ICD implantation for primary prevention of sudden cardiac death. The primary end-point was appropriate ICD shock defined as a shock for rapid ventricular tachyarrhythmias. The secondary end-point was all-cause mortality.
There were 1189 patients (447 AAs and 712 non-AAs) enrolled. Over a median follow-up of 5.1 years, a total of 137 patients experienced an appropriate ICD shock, and 343 died (294 of whom died without receiving an appropriate ICD shock). The multivariate adjusted hazard ratio (95% confidence interval) comparing AAs vs non-AAs were 1.24 (0.96-1.59) for all-cause mortality, 1.33 (1.02, 1.74) for all-cause mortality without receiving appropriate ICD shock, and 0.78 (0.51, 1.19) for appropriate ICD shock. Ejection fraction, diabetes, and hypertension appeared to explain 24.1% (10.1%-69.5%), 18.7% (5.3%-58.0%), and 13.6% (3.8%-53.6%) of the excess risk of mortality in AAs, with a large proportion of the mortality difference remaining unexplained.
In patients with primary prevention ICDs, AAs had an increased risk of dying without receiving an appropriate ICD shock compared to non-AAs.
The clinical importance of the J-point elevation on electrocardiogram is controversial.
To study intracardiac J-point amplitude before ventricular arrhythmia.
Baseline 12-lead electrocardiogram and ...far-field right ventricular intracardiac implantable cardioverter-defibrillator electrograms were recorded at rest in 494 patients (mean age 60.4 ± 13.1 years; 360 72.9% men) with structural heart disease (278 56.3% ischemic cardiomyopathy) who received primary (463 93.9% patients) or secondary prevention implantable cardioverter-defibrillator. Ten-second intracardiac far-field electrograms before the onset of arrhythmia were compared with the baseline. The J-point amplitude was measured on the baseline 12-lead surface electrocardiogram and the intracardiac far-field electrogram. The relative J-point amplitude was calculated as the ratio of J-point amplitude to peak-to-peak R-wave.
The paired t test showed that the relative intracardiac J-point amplitude was significantly higher before polymorphic ventricular tachycardia/ventricular fibrillation (VF) onset (0.28 ± 0.08 vs -0.19 ± 0.39; P = .012) than at baseline. In a mixed-effects logistic regression model, adjusted for multiple episodes per patient, each 10% increase in relative J-point amplitude increased the odds of having ventricular tachycardia/VF by 13% (odds ratio 1.13 95% confidence interval 1.07-1.19; P < .0001) and increased the odds of having polymorphic ventricular tachycardia/VF by 27% (odds ratio 1.27 95% confidence interval 1.11-1.46; P = .001).
The relative intracardiac J-point amplitude is augmented immediately before the onset of polymorphic ventricular tachycardia/VF in patients with structural heart disease.
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