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XVII
International Symposium
on Progress
in Clinical Pacing
2016
- December 2, 2016 Ergife Palace Hotel
Rome, Italy November 29
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
www.pacing2016.com
XVII
International Symposium
on Progress
in Clinical Pacing
2016
- December 2, 2016 Ergife Palace Hotel
Rome, Italy November 29
FREE PAPERS
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCHRONIZATION THERAPY:
PATIENTS SELECTION AND OPTIMAL PROGRAMMING
DECISION TIMINGS IN CARDIAC
RESYNCHRONIZATION THERAPY
AND PATTERNS OF RESPONSE:
DO NOT WAIT TO MUCH, BE PERSISTENT
LOOKING FOR IMPROVEMENT!
N. Cabanelas 1, P.S. Cunha 2, B. Valente 2,
A. Lousinha 2, R. Pimenta 2, M. Braz 2,
A.S. Delgado 2, M. Nogueira Da Silva 2,
M. Oliveira 2, R. Ferreira 2
1
Hospital Amadora-Sintra, Amadora,
PORTUGAL, 2 Hospital Santa Marta, Centro
Hospitalar de Lisboa Central, Lisbon, PORTUGAL
Introduction: Response to cardiac
resynchronization therapy(CRT) can be
improved by timely decision making and
early referral when indications are fulfilled.
After implantation, close follow-up with
correction of potential harmful conditions
helps in obtaining better results.
Aims: Evaluate how variations in baseline
parameters usually used to stage left
ventricule (LV) systolic dysfunction affect
temporal patterns of resynchronization
effects after implant.
Methods: Consecutive patients undergoing
CRT implant were analyzed, and those with
at least one year of follow-up were selected
(n=149). Clinical and echocardiographic
baseline characterstics were studied
looking for baseline predictors of response.
The patterns of response to CRT in the first
two semesters were analysed. Clinical
response was defined as stable
improvement of, at least, one NYHA class.
Results: Five patterns of clinical response
were identified: a)improvement in the first
2
6 months “early responders”–52% of the
patients; b) progressive lowering in
functional class along the year “constant
responders”–15% of the population; c)
functional class lowering only in the second
semester “late response”–12%; d) no
response–15%; and e) initial improvement
but subsequent worsening “biphasisc
response”–5% of the patients. Among
baseline data, predictors of patterns a, b
and c were: lower LV telediastolic diameter
(p=0.021,OR0.97;IC95%:0.95-0.99), lower
telesystolic
diameter
(p=0.045,OR0.98;IC95%:0.95-0.99), and
lower
left
atrial
diameter
(p=0.035,OR0.97;IC95%:0.94-0.99).
Conclusions: CRT response is better
achieved before progression to extremely
high grades of left chambers dilatation.
Clinical improvement can be seen
immediately in the first months in 2/3 of the
patients, in 12% it can be progressive along
all the first year, and in 15% NYHA class
reduction is only observed after 6 months
of therapy.
ELECTROPHYSIOLOGY TEST TO
INDICATE CARDIAC
RESYNCHRONIZATION THERAPY WITH
OR WITHOUT IMPLANTABLE
CARDIOVERTER DEFIBRILLATION.
FOLLOW UP WITH REMOTE MONITORING
R. Robledo-Nolasco, R. Leal-Diaz, O. TorresJaimes, E. Sanchez-Guevara, R. Borrego
Centro Medico Nacional 20 De Noviembre. Issste.
Servicio De Hemodinamia Y Electrofisiologia,
Mexico, MEXICO
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Introduction: Choice single cardiac
resynchronization therapy (CRT-P) or with
implantable cardioverter defibrillator (CRTD) is a medical decision. Guidelines of
cardiac implanted device (CID) do not
recommend one in particular. The aim of
the present study was to establish
whether the positive electrophysiological
test (EPS+) was a predictor of tachycardia
and ventricular fibrillation (VT and VF) in
patients with CRT-P and CRT-D.
Methods: Patients with heart failure with
criteria for CRT were included. Before the
implant of the CID were underwent to ET
with programmed ventricular three
extrastimuli. Patients in who were induced
VT or VF (ET+) was chosen for CRT-D and
CRT-P was the control. Follow-up of the
patients was performed with RM. TV, FV,
catheter ablation procedures (CAP) and
deaths from any cause were analyzed.
Results: Ninety-seven patients were
included, 62 for CRT-D and 35 for CRT-P.
Were 43(69%) and 17(49%) men, aged
57+11 and 55+11 years in patients with
CRT-D and CRT-P respectively. Causes of
heart failure were: a)ischemic in 28(45%)
and 11(31.4%) and b)cardiomyopathy in
21(60%) and 24(39%) in groups CRT-D
and CRT-P respectively. Follow-up of
patients was 10.9+4.2 and 11.3+5.0
months (p=ns) to CRT-P and CRT-D
respectively. During the follow-up, 128
events were recorded: TV, 1 and
96(p<0.001); FV, 0 and 15(p<0.003);
catheter ablation procedures, 1 and
7(p=ns) and mortality was 3 and 5(p=ns)
in patients with CRT-P and CRT-D
respectively.
Conclusions: The ET+ was a predictor of
VT and VF events in patients with the CRTD and the RM allowed closely follow-up of
these events.
EXERCISE TRAINING AFTER CARDIAC
RESYNCHRONIZATION MODULATES
PRO-INFLAMMATORY CYTOKINE TNFALPHA IN HEART FAILURE PATIENTS
A. Abreu 1, H. Santa Clara 2, V. Santos 2,
T. Pinheiro 3, P. Napoleão 4, M. Selas 1,
M. Oliveira 1, I. Rodrigues 1, P. Rio 1, L. Morais 1,
G. Portugal 1, M. Nogueira 1, P. Silva Cunha 1,
R. Cruz Ferreira 1, M. Mota Carmo 1,5
1
Serviço Cardiologia, Hospital Santa Marta,
Lisbon, PORTUGAL, 2 Exercise and Health
Laboratory, Centro Interdisciplinar de Estudo
da Performance Humana (CIPER), Faculdade
de Motricidad, Lisbon, PORTUGAL, 3 Instituto
de Bioengenharia e Biociências (IBB),
Departamento de Engenharia e Ciências
Nucleares, Instituto Superior Técn, Lisbon,
PORTUGAL, 4 Carlota Saldanha Lab, Instituto
Medicina Molecular (iMM), Faculdade de
Medicina, Lisbon, PORTUGAL, 5 Centro de
Estudos de Doenças Crónicas (CEDOC),
Faculdade Ciências Médicas, Lisbon,
PORTUGAL
Evaluation of high intensity interval
training (HIIT) in inflammatory and
apoptotic processes in heart failure (HF)
patients
submitted
to
cardiac
resynchronization therapy (CRT) has not
been investigated so far.
3
FREE PAPERS
CARDIAC RESYNCHRONIZATION THERAPY:
PATIENTS SELECTION AND OPTIMAL PROGRAMMING
TUESDAY, NOVEMBER 29, 12.30-14.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCHRONIZATION THERAPY:
PATIENTS SELECTION AND OPTIMAL PROGRAMMING
Our aim was to evaluate HIIT modulation
of inflammatory and apoptosis markers
and their relationship with reverse
remodeling, after cardiac resynchronizer
implant in advanced HF patients.
Methods: A randomized clinical controlled
trial was performed in advanced HF
patients selected for CRT with
randomization to HIIT. A longitudinal
monitoring was established for 50 HF
patients, pre CRT, at 3 and 6 months of
exercise. Clinical functional class (NYHA),
echocardiographic LVEF, brain natriuretic
peptide (BNP) and inflammation/apoptosis
circulating markers (TNF-alpha, IL-6, CRP
and sFasL) evaluations were performed.
Results: After 7 months of CRT (6 months
of exercise), EXTG group presented more
clinical responders (>1 class NYHA) and
echocardiographic responders (>5% left
ventricular ejection fraction – LVEF) than
CG. A greater improvement in NYHA class
was observed in the EXTG group.
Significant decrease of TNF-alpha
concentration and increase in sFasL were
observed only in EXTG patients at 6
months exercise. Longitudinal changes of
TNF-alpha were correlated with LVEF and
LVED, indicating a relationship between
TNF-alpha decrease and left ventricular
reverse remodelling.
Conclusion: The innovative application of
HIIT protocol in HF patients after CRT
resulted in positive modulation of markers
of inflammation and apoptosis, clinical
functional class and responder rate. These
4
findings are relevant in clinical terms as
they point towards improvement of
pathophysiologic mechanisms of cardiac
failure by exercise training.
FEASIBILITY OF ANODAL LEFT
VENTRICULAR STIMULATION FOR
BETTER CRT
G. Dell’Era, F. De Vecchi, C. Devecchi,
A. Degiovanni, E. Occhetta, A. Magnani,
P. Marino
AOU Maggiore della Carità,
Cardiologica, Novara, ITALY
Clinica
Purpose: anodal myocardial capture is
often considered an undesirable side
effect of left ventricular (LV) pacing during
CRT. However, anodal capture from a LV
catheter bipole may increase the area of
captured myocardium, resulting in a kind
of “multipoint LV pacing” without the need
for multicathode devices. We evaluated
the feasibility of anodal stimulation in an
acute setting.
Method: we enrolled 30 consecutive
patients undergoing CRT (all received a
quadripolar LV lead) at our hospital and
evaluated cathodic (- on LV catheter pole
and + on skin) and anodal (+ on LV
catheter pole and – on skin) capture
threshold for each LV stimulating pole
during implant.
Results: anodal capture was obtained from
at least 3 poles in 23 patients; in these
patients, cathodic capture was obtained
for all the poles in all but one case. Anodal
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
capture was not feasible in two patients;
the other five showed anodal capture from
2 of 4 LV poles. Mean anodal capture
threshold was 3,80±2,23Vx0,5ms vs
cathodic threshold of 2,24±1,81Vx0,5ms
(p<0,001).
Conclusion: we demonstrated technical
feasibility of LV anodal stimulation with
pacing amplitude higher than that used for
cathodic one (but with a cumulative
energy not higher than multicathodal
stimulation); anodal stimulation may be
used in case of bipolar (between two
different poles of the catheter) LV pacing
to obtain a wider myocardial capture and
a better wavefront of electrical activation.
Future perspective studies are needed to
verify clinical impact of this kind of
stimulation.
CARDIAC RESYNCHRONIZATION
THERAPY IN VALVULAR HEART
FAILURE – CLINICAL
ECHOCARDIOGRAPHIC AND
PROGNOSTIC SPECIFICITIES
L. Almeida-Morais, N. Cabanelas, M.
Oliveira, P. Silva Cunha, M. Nogueira Silva,
L. Moura Branco, A. Galrinho, J. Feliciano,
B. Valente, R. Cruz-Ferreira
Hospital De Santa Marta, Lisbon, PORTUGAL
Background: Cardiac resynchronization
therapy (CRT) has proven its benefits in
ischemic
and
non-ischemic
cardiomyopathies. Heart failure (HF) and
left ventricle dysfunction from valvular
heart diseases are underrepresented in
clinical trials.
To
evaluate
the
clinical
and
echocardiographic profile of CRT patients
with HF secondary to VHD and to assess
its prognosis.
Methods: Patients submitted to CRT
implantation with defibrillator between
2002 and 2012 with more that one year
follow-up (158). Patients were divided
according to HF etiology: A – VHD group
(n= 24, 11 after aortic valve implantation,
2 after mitral valve implantation, 2 after
mitral and aortic valves implantation, 2
after mitral valvuloplasty, 4 mitral
insufficiency;
B
–
ischemic
cardiomyopathy (n=48); C – non-ischemic
cardiomyopathy (n=86). Clinical follow-up
was
49±24
months
and
echocardiographic evaluation was made 1
year after device implantation.
Results: Clinical, echocardiographic and
prognostic evaluations at baseline and at
1st year follow-up are detailed in table 1
and 2.
Conclusions: In patients with HF
secondary to VHD, CRT was associated
5
FREE PAPERS
CARDIAC RESYNCHRONIZATION THERAPY:
PATIENTS SELECTION AND OPTIMAL PROGRAMMING
TUESDAY, NOVEMBER 29, 12.30-14.00 [Orage 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Cesarea]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCHRONIZATION THERAPY:
PATIENTS SELECTION AND OPTIMAL PROGRAMMING
with a good clinical and echocardiographic
improvement at 1st year follow-up. The
benefits in this group were intermediary
when compared with other HF etiologies
(ischemic and non-ischemic).
COMPARISON OF SEVERAL ECG AND
ECHO PARAMETERS TO PREDICT THE
OPTIMAL AV AND VV DELAY TO
HAEMODYNAMICS OBTAINED WITH A
NEW MINIMALLY INVASIVE MONITOR,
THE MOSTCARE
M. Bisi, P.G. Golzio, D. Castagno, C.
Budano, A. Bussolino, F. Gaita
AOU Città della Salute e della Scienza di
Torino-Divisione di Cardiologia, Turin, ITALY
Cardiac resynchronization therapy (CRT)
may lead to remarkable improvement in
selected patients with heart failure (HF)
and ventricular conduction delay.
Approximately 30% of patients may not
respond to this treatment, at least in some
instances for suboptimal programming of
the device. We compared the ability of
several ECG and echocardiographic
6
parameters to predict the optimal AV and
VV delay to haemodynamic parameters
obtained with a new minimally invasive
monitoring system, the MostCare system.
Twenty-five patients with symptomatic HF
despite optimal medical therapy, sinus
rhythm, and left bundle branch block, had
CRT implanted. AV and VV optimization
was obtained with MostCare, searching for
the highest stroke volume (SV) and cardiac
output (CO) and with several
echocardiographic techniques: mitral and
aortic VTI, the Ritter’s method, myocardial
performance index (MPI). Also QRS width,
axis and morphology were evaluated on
surface electrocardiogram.
Simultaneous biventricular pacing with
standard programming showed a
significant improvement in SV and in CO
compared to basal evaluation. There was
a further gain with haemodynamically
optimized AV delay and then VV delay
proving that a significant improvement in
haemodynamic performance can be
achieved by optimizing CRT intervals.
Mitral and aortic VTI showed the best
correlation with the haemodynamic
evaluation both for AV and VV delay, while
the MPI and the Ritter’s method did not
achieve a significant concordance. While
QRS duration alone did not correlate with
MostCare for the VV optimization,
comprehensive QRS evaluation (axis,
duration, R in V1) improved the accuracy
of the ECG in predicting the optimal VV
delay.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
UOC Cardiologia- Policlinico Casilino, Rome,
ITALY
Carotid sinus hypersensitivity is frequently
found in patients with syncope and
trauma, but it may also be common finding
in younger patients. PM implantation is
recommended in patients with recurrent
syncope Clinical case: a 42-years old
female patient, with no heart disease, was
referred to our centre for documented CSH
syncope, greatly limiting daily activity. The
patient refused PM implantation.
Autonomic nervous system modulation
through GP ablation has been recently
reported. Basic study: AH 68 ms, HV 50
msec with sinus arrest of up to 5.4 sec at
carotid sinus massage (CSM) bilaterally.
Electroanatomical map of the right atrium
was obtained and right phrenic nerve
course was identified (left panel fig.1).
Anterior right GPs (ARGP) ablation at the
level of the septal aspect of superior vena
cava determined a reduction of basal sinus
cycle lenght (from 975 ms to 730 ms).
CSM bilaterally did not cause asystolic
pauses. After 20 minutes, a new CSM
showed suprahissian atrioventricular block
with normal HV (RR max of 2608
msec)(right panel fig.1). Ablation of inferior
right GPs, posterior to the coronary sinus
ostium was performed. At carotid massage
post RF and after 30 minutes of
observation no longer pathological pauses
were evident (RR max 1.4 sec). Shorter AV
conduction parameters was observed (AH
48 msec, HV 50 msec). At three months
follow up the patient is still asymptomatic
for syncope and dizziness.
Conclusions: Modulation of the autonomic
nervous system, if properly standardized,
could be an attractive alternative to PM
implant, especially in youngers
TARGETS AND ENDPOINTS IN CARDIAC
AUTONOMIC DENERVATION
PROCEDURES
E. Rivarola, D. Hachul, C. Hardy, S. Lara, C.
Pisani, F. Darrieux, T. Wu, M. Scanavacca
Heart Institute, University of Sao PauloArrhythmia Unit., Sao Paulo, BRAZIL
Purpose: Autonomic denervation is an
alternative approach for patients with
symptomatic bradycardia. There is no
7
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CAROTID SINUS HYPERSENSITIVITY
SYNCOPE: IS IT POSSIBLE AN
ALTERNATIVE?
Z. Palamà, E. De Ruvo, D. Grieco, A. Borrelli,
A. Scarà, P. Golia, L. De Luca, M. Rebecchi,
L. Sciarra, L. Calò
TUESDAY, NOVEMBER 29, 12.30-14.00 [Tarragona]
CARDIAC SYNCOPE
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Tarragona]
CARDIAC SYNCOPE
consensus yet about the endpoints of the
procedure and the critical targets. The aim
of this study is to identify immediate
endpoints and critical atrial regions
responsible for vagal denervation.
Method: Fourteen patients (50% male,
34.0±13.8 years old) with cardioinhibitory
syncope, advanced atrioventricular (AV)
block or sinus arrest and no structural
heart disease were enrolled. Anatomic
mapping of ganglionated plexuses was
performed, followed by radiofrequency
(RF) ablation. Before and after every RF
pulse, heart rate (HR), sinus node recovery
time (SNRT), Wenckebach cycle (WC)
length and atrial-his (AH) interval were
measured. Mann-Whitney nonparametric
test was used for comparison.
Results: After ablation, it was observed a
significant shortening of the RR
(p=0.0003), WC length (p=0.03) and AH
interval (p=0.007). The HR elevation was
23.8±12.5% and the WC and AH
shortening was 18.2±11.5% and
25.4±18.2% respectively. Atropine bolus
injection (0.04mg/Kg) did not increase HR
any further.
During the ablation it was observed that
targeting a single spot of the left side
(64% of the patients) or right side (36%)
of the interatrial septum was responsible
for 80% or more of the final RR and AH
intervals shortening.
Conclusions: Targeting a small area of the
interatrial septum is followed by a
increase in HR and AV nodal conduction
8
properties and might be critical for vagal
attenuation. The RR, WC and AH intervals
shortening, associated with a negative
response to Atropine could be considered
immediate endpoints of the procedure.
CARDIAC PACING IN CARDIOINHIBITORY CAROTID SINUS
SYNDROME: WHEN SHOULD WE PACE?
A SYNCOPE UNIT EXPERIENCE
G. Rivasi, M. Rafanelli, F. Tesi, A.
Ceccofiglio, F.C. Sacco, S. Venzo, A. Ungar
Syncope Unit, Department of Geriatrics,
Florence, ITALY
Introduction: There is still controversy as
to the efficacy of cardiac pacing in cardio-
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CSS, whereas those refusing PM showed
the lowest recurrence rate. Even if
recorded in a small, highly selected
population, these data show that patient
selection for pacing is not effective if
merely based on asystole. Clinical features
suggesting hypotensive susceptibility may
help identifying patients who could not
benefit from PM.
LONG-TERM OUTCOME OF PATIENTS
WITH CARDIOINHIBITORY VASOVAGAL
SYNCOPE INDUCED BY HEAD UP TILT
TEST
V. Russo 1, A. Rago 1, A.A. Papa 1, N. Rovai 2,
M. De Rosa 1, A. Carbone 1, G. Nigro 1
1
Syncope Unit, Chair of Cardiology; Second
University of Study of Naples, Monaldi Hospital,
Naples, ITALY, 2 Biotronik Italia, Clinical
Department, Biotronik Italia Spa, Milan, ITALY
Background: Vasovagal syncope (VVS) is
the most common cause of fainting. VVS
is generally considered as a benign
condition, although some authors have
linked it to rare events of sudden death.
The aim of this study was to assess the
long term outcome of a large cohort of
head-up tilt test (HUTT) induced
cardioinhibitory-VVS patients.
Methods and Results: We enrolled 181
cardioinhibitory-VVS patients (41.4±17.8
years, 58.6% male) and followed them for
a period of 44.7±20.2 months. 50 (27.6%)
patients (54.2±11.3 years, 72% male)
with age>40 years, HUTT cardioinhibitory
9
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inhibitory Carotid Sinus Syndrome (CICSS), due to the lack of large randomized
trials and frequent recurrence reported in
Literature. The present study analyzed
syncopal recurrence in patients with CICSS or Hypersensitivity (CSH) paced or
not.
Methods. A retrospective analysis of
clinical data concerning patients with CICSS/CSH was performed, investigating
syncopal recurrence (mean follow-up
61.2±17.8 months). Data were collected
from clinical records and patients
interview.
Results: A cardio-inhibitory response was
observed in 124 (9.74%) of 1273
consecutive patients undergoing Carotid
Sinus Massage. Follow-up data from 108
patients were available: 79 (73.1%) were
diagnosed with CI-CSS, 29 (26.9%) had
CI-CSH. 76 patients (70.4%) underwent
PM implantation, mainly for CI-CSS
(85.5%). 15/108 patients (13.9%)
experienced syncopal recurrence; in the
CI-CSS group, syncope recurred in the
16.9% and 7.1% of paced and not paced
patients, respectively. Among those
reporting syncope after pacing, the 81.8%
had neurally-mediated prodromes, the
54.5% had a positive Tilt Testing and the
63.6% was on hypotensive drugs. 14 CICSS patients refused PM implantation, the
92.9% did not experience recurrence. No
predictors of recurrence were identified.
Conclusions: Symptoms recurrence was
more common in paced patients with CI-
TUESDAY, NOVEMBER 29, 12.30-14.00 [Tarragona]
CARDIAC SYNCOPE
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Tarragona]
CARDIAC SYNCOPE
response, unpredictable, recurrent,
unresponsive to alternative therapies
spontaneous syncope, underwent dualchamber pacemaker implantation with
closed loop stimulation algorithm (CLSPM). The remaining 131(72.4%) patients
(36.5±17.4 years, 53.4% male) were
treated with physical m The recurrence of
syncopal events percentage after HUTT in
the total study population was 30%
(55/181): 14% (7/50) in the subgroup
underwent CLS-PM implantation and 37%
(48/131) in the subgroup of patients
treated with medical therapy and physical
maneuvers. The CLS-PM implantation,
compared to medical therapy and physical
maneuvers, reduced the syncope
recurrence risk of 88%, HR: 0.12 (95%
CI:0.04–0.40, p=0.001) in patients with
age>40 years and recurrent, frequent
unpredictable syncope. No sudden cardiac
deaths were reported and no patient
underwent major therapeutic procedures
during the follow up. Conclusions: HUTT
induced cardioinhibitory-VVS is associated
with a good long term prognosis. The
CLS-PM implantation is a valid therapeutic
option for syncope recurrences prevention
in patients affected by HUTT induced
cardioinhibitory-VVS with age > 40 years
and recurrent, frequent, unpredictable
syncope.
10
IMPLANTABLE LOOP RECORDER IN
REFLEX SYNCOPE: DIAGNOSTIC YIELD
AND NOT ONLY…THERAPEUTIC
PLACEBO EFFECT OR SIMPLY
STATISTICAL FEATURE?
F. Baessato, M. Unterhuber, W. Rauhe,
M. Manfrin, M. Tomaino
Department of Cardiology, Bolzano, ITALY
Through a retrospective study concerning
the experience of our center in patients
affected by severe clinical presentation of
Neurally Mediated reflex Syncope (NMS),
we wanted to verify not only the diagnostic
yield of ILR but also its possible placebo
therapeutic effect.The selection of patients
was made according to the ISSUE criteria:
certain or suspected reflex syncope, age
>40, severe clinical presentation. The
exclusion of patients involved cardiac
abnormalities, symptomatic orthostatic
hypotension, cardioinhibitory carotid sinus
syndrome, non-syncopal loss of
consciousness.
All were followed by ILR and observed till
the first documented syncopal recurrence
or arrhythmic event.
We analysed 85 patients (40 male and 45
female, mean age 71 years), during the
period 2009-2016. All patients completed
a 3-year Follow-Up. 33 (39%) had no
recurrences. 52 (61%) had recurrences
and a specific diagnosis after an average
period of 7±8 months.The prevalent form
was tied between cardioinhibitory (24
patients, 28%), and vasodepressive NMS
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SYNCOPE UNIT MANAGEMENT OF
PATIENTS WITH HYPERTROPHIC
CARDIOMYOPATHY AND SYNCOPE:
PATHOPHYSIOLOGIC INTERPRETATION
AND CLINICAL APPROACH
M. Rafanelli 1, G. Filice 2, I. Olivotto 2,
N. Marchionni 2, A. Ungar 1
1
Syncope Unit, Department of Geriatrics,
Careggi University Hospital, Florence, ITALY,
2
Referral Centre for Cardiomyopathies,
Department of Cardio-Thoracic-Vascular
Medicine, Careggi University Hospital,
Florence, ITALY
of syncope in hypertrophic cardiomyopathy.
Methods: Patients with hypertrophic
cardiomyopathy referred for syncope from
the Referral Centre for Cardiomyopathies
to the Syncope Unit, Careggi University
Hospital, Florence between May 2004 and
May 2016, were retrospectively analyzed.
Three presyncope and 3 unexplained falls,
were included.
Results 20 consecutive patients. Mean
age 55 ± 19 years. The 70% had syncope,
65% presyncope, 15% unexplained falls.
Initial diagnosis: 25% orthostatic
hypotension, 20% neurally-mediated
syncope, 10% cardiac syncope, 35%
unexplained. Tilt Test was diagnostic in
58%, 71% vasodepressive. Orthostatic
hypotension was confirmed in 50%. A loop
recorder was implanted in 5 patients,
diagnostic in 60%. Final diagnosis: 50%
neurally-mediated syncope-orthostatic
hypotension, 20% arrhythmic, 10%
unexplained. Tailored treatment was made.
Conclusion: A standardized management
of
syncope
in
hypertrophic
cardiomyopathy reduces unexplained
episodes, allowing a proper treatment.
Background: Prognostic stratification and
clinical management of patients with
hypertrophic cardiomyopathy and syncope
are complex. This is a pilot Syncope Unit
experience on standardized management
11
FREE PAPERS
(24 patients, 28%). Tachyarrhythmias were
diagnosed in 2 patients (2,4%) and 3rd
degree- AV- Block in 2 patients (2,4%).
ILR maintains its diagnostic capacity, but
there is still one third of the patients
without a diagnosis at the end of the
follow-up. At first glance this result could
be explained considering a possible
placebo effect of the implantable device.
Starting from the cyclicity characterizing
the NMS itself a very long observation
period (decades) is necessary to improve
the diagnostic power. This allows
statistical phaenomena like “regression to
the mean” to grow and to mislead the
clinicians’ result interpretation.
TUESDAY, NOVEMBER 29, 12.30-14.00 [Tarragona]
CARDIAC SYNCOPE
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Spalato]
IMPLANTABLE LEADS INFECTION AND EXTRACTION
RISK FACTORS OF LATE INFECTIOUS
COMPLICATIONS IN PATIENTS WITH
CARDIAC IMPLANTABLE ELECTRONIC
DEVICES
A. Polewczyk 1, W. Jachec 2, A. Tomaszewski 3,
W. Brzozowski 3, M. Janion 3, A. Kutarski 1
1
Faculty of Medicine and Health Scientes The
Jan Kochanowski University, Swietokrzyskie
Cardiology Center, Kielce, POLAND, 2 2nd
Department of Cardiology, Silesian Medical
University, Zabrze, POLAND, 3 Department of
Cardiology Medical University, Lublin, POLAND,
Background: In recent years we are the
whitnessess a growing number of
transvenous leads extraction (TLE) in
patients with cardiac implantable
electronic devices (CIED). There are two
groups of indications to TLE: infectious
(cardiac device infections-CDI) and
noninfectious (nonifectve indications –NI).
Methods: Comparative analysis of clinical
data of 1837 patients undergoing TLE in
single References Center in years 20062015 due to CDI (751 pts) amd NI
(1086pts) was conducted. Potential
infectious risk factors were assessed.
Results: Patients with late CDI were older
(HR 1,035 CI [1,029-1,041]; p=0,000) ,
more often male (HR 1,354 CI [1,1451,1,601]; p=0,000), with high prevalence
of renal failure HR-1,144 CI [1,0591,235]; p=0,000) and lower frequency of
anticoagulation treatment HR- 0,552 CI
[0,463-0,658]; p-0,000 and antiplatelet
therapy HR- 0,603 CI [0,509-0,715]; p-
12
0,000). Among procedural factors in
patients with CDI more often multileads
systems were implanted HR-1,322 CI
[1,198-1,459], with greater number of
defibrillation leads HR 1,915 CI [1,5462,372] and higher ratio of intracardiac
abrasion of the leads (ILA) HR 1,393
[1,161-1,671].
The
number
of
reinterventions below 2 months before
TLE was higher in in patients with CDI HR1,730 CI [1,193-2,227]; p=0,002.
Conclusions: Primary cause of the
development of late CDI is unclear. Older
patients, male with renal failure, bigger
number of the leads, ICD leads presence,
after reinterventions directly leading TLE
are particularly predisposed to the
infectious complications. This factors
influence on the development of ILA- most
important risk factor of CDI. The
anticoagulation and antiplatelet agents
throughout the prevention of thrombosis
probably reduce the inflammatory
process.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ASL Bologna U.O. Cardiologia Ospedale di
Bentivoglio, Bentivoglio, ITALY
CIEDs infections worldwide are increasing;
some studies show reduction of infection
rate by prolonged antibiotic prophylaxis.
Antimicrobial envelopes approved for
infection prophylaxis release two drugs for
7 days, but still is not defined optimal
prophylaxis coverage. The aim of study
was evaluation of infection rates and
usefulness of extended prophylaxis from
2009 to 2016. Definitions: relative
infection rate=number of infection/number
of procedures/year; absolute
infection rate=total number
of infection/total number of
implants. We divided the
observation period in 2 time
windows: lower and higher
infection rates. Cut off value
for higher vs lower was
fixed
at
0.75%.
Perioperative prophylaxis
from 2009 to 2013 was
ampicillin i.v. followed by
ampicillin/sulbactam tid for
3 days. In 2014 we applied
guidelines prophylaxis with cefazolin 2 gr
i.v. before and 5 hours after operation.
Since 2015 we perform preoperative
cephazolin 2 gr i.v. followed by cephazolin
2gr i.v. every 8h until 24h. We had 4
infections to 623 procedures: 1 was ICD
implant in 2013, 2 were PM implants in
2014 and 1 was PM replacement in 2015.
Mean time to infection was 143±38 days.
Comparing lowest infection rate period
2009-2013+2016, and highest infection
rate period 2014-2015 we observed lower
incidence in the former period; Tab 1-2.
Because the operative technique was
unchanged, we evaluated the relationship
between infection rates and prophylaxis
duration, finding a discrete grade of
correlation (R2=0,72 for relative, and 0,91
for absolute infection rates); fig 1-2.
Conclusions: lowest infection rates are
related to duration of prophylaxis in CIEDs
procedures.
13
FREE PAPERS
RELATIONSHIP BETWEEN INFECTION
RATES AND DURATION OF ANTIBIOTIC
PROPHYLAXIS AFTER CARDIAC
DEVICES PROCEDURES
G. Boggian, S. Saccà, R. Vandelli, A.
Lombardi, F. Serafini, R. Parlangeli, F. Lai,
A. Musuraca, B. Brasciani, E. Mazzoni, L.G.
Pancaldi
TUESDAY, NOVEMBER 29, 12.30-14.00 [Spalato]
IMPLANTABLE LEADS INFECTION AND EXTRACTION
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Spalato]
IMPLANTABLE LEADS INFECTION AND EXTRACTION
PREDICTING THE DIFFICULTY OF A
LEAD EXTRACTION PROCEDURE:
VALIDATION OF THE LEAD EXTRACTION
DIFFICULTY (LED) INDEX
F. Vassanelli 1 , A. Curnis 1 , L. Inama 1 ,
F. Salghetti 1, N. Dasseni 1, C. Villa 1, D. Liberto 1,
D. Giacopelli 2, M. Cerini 1, L. Bontempi 1
1
Division and Chair of Cardiology, University
and Spedali Civili Hospital, Brescia, ITALY,
2
Biotronik Italia Spa, Vimodrone, Milan, ITALY
Background: Transvenous lead extraction
(TLE) remains a challenging procedure
with inherent risks and guidelines
recommend referring patients to centre
with high experience. Indexes or scores
reliably predicting the difficult procedures
are highly desirable in order to make an
adequate risk assessment. A Lead
Extraction Difficulty (LED) score was
defined in a previous study considering
the strongest predictors of high
fluoroscopy time.
Aim: To validate the LED index on an
independent data set of TLE cases.
Methods: We collected data from
consecutive patients who underwent TLE
of CIED leads between 01/2014 and
01/2016. Different techniques and tools
were available in our site and used at the
discretion of the operating physician. The
LED score was defined in a previous study
combining the major predictors of difficult
procedure and calculated for each
procedure and dichotomized as above or
below 10.
Results: A total of 446 permanent leads
14
were removed during 233 TLE procedures.
No failure occurs.
The LED index resulted above the cut-off
value of 10 in 83 (35.6%) procedures. The
sensitivity and the specificity of the LED
index in predicting complex cases resulted
86.9% and 70.0% respectively, with a NPV
of 98.0% and PPV of 24.1%. The overall
accuracy of the LED score was 71.7%.
Conclusions: The model is highly effective
in the detection of simple cases. The LED
score may allow less experienced centers
to identify the TLE procedures safely
feasible internally.
EXTRACTION OF RECALLED ICD
LEADS: A SINGLE CENTRE EXPERIENCE
G. Domenichini, I. Harding, H. Gonna, S.
Jones, M.M. Gallagher
St. George’s University Hospitals NHS
Foundation Trust, London, UNITED KINGDOM
Introduction: The long-term performance
of recalled ICD leads is unpredictable and
the generator replacement seems to be
associated with an increased risk of
Medtronic Sprint Fidelis® lead failure. The
mechanical dilator sheaths are safe and
effective tools for lead extraction
encouraging the prophylactic removal of
recalled ICD leads at the time of the
generator replacement.
Methods: We evaluated the outcome of
recalled ICD lead extraction procedures
performed in our Institution since 2005.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
1
Department of Cardiology Medical University
of Lublin, Lublin, POLAND, 2 Department of
Cardiac Surgery Medical University of Lublin,
Lublin, POLAND, 3 Department of Radiography
Medical University of Lublin, Lublin, POLAND,
4
Department of Cardiology The Pope John Paul
II Province Hospital, Zamosc, POLAND, 5 The
Jan Kochanowski University, Department of
Medicine and Health Sciences, Kielce, POLAND,
6
2nd Department of Cardiology, Silesian
Medical University, Zabrze, POLAND, 7 District
Hospital, Intensive Care Cardiac Unit, Kielce,
POLAND, 8 Specialistic Hospital, Tarnow,
POLAND, 9 1st Department Of Cardiology,
Medical University of Warsaw, Warsaw,
POLAND
Introduction: Major complications appear
to be an inherent problem of Transvenous
Lead Extraction (TLE) but there are no
reports dedicated to cardiac tamponade.
Objective: Analysis of cardiac tamponade
(CT)
appearance, and
effective
management.
Methods: Using standard non-powered
mechanical systems we have extracted
ingrown 3426 PM/ICD leads from 2049
patients. Results are presented in the
table. Major complications appeared in
15
FREE PAPERS
The results were compared according to
the indication for extraction.
Results: A total of 57 recalled ICD leads
were extracted in 56 patients (age 63 (IQR
46-71) years), 48 Medtronic Sprint
Fidelis® (models 6930, 6931 and 6949)
and 9 SJM Riata® ST (models 7000 and
7002). The indications for extraction were
lead failure, local or systemic infection and
prophylactic extraction at the time of the
generator replacement (29, 11 and 17
leads respectively). The characteristics of
the leads and the types of extraction tools
are shown in the Table. Complete
extraction was achieved in 98% (56/57) of
leads overall and in all leads extracted
prophylactically. There were no procedural
or post procedural complications.
Conclusion: When performed by expert
operators, the prophylactic extraction of
recalled ICD leads at the time of generator
replacement may be a reasonable strategy
to potentially avoid the clinical
consequences of the ICD lead failure and
to reduce the possibilities of further
procedures. However larger studies are
required to confirm the safety and
feasibility of this approach.
CARDIAC TAMPONADE AS LEAD
EXTRACTION COMPLICATION:
APPEARANCE AND EFFECTIVE
MANAGEMENT
A. Kutarski 1, M. Czajkowski 2, R. Pietura 3,
B. Obszanski 4, A. Polewczyk 5, W. Jachec 6,
M. Polewczyk 7, K. Mlynarczyk 8, M. Grabowski 9,
G. Opolski 9
TUESDAY, NOVEMBER 29, 12.30-14.00 [Spalato]
IMPLANTABLE LEADS INFECTION AND EXTRACTION
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Spalato]
IMPLANTABLE LEADS INFECTION AND EXTRACTION
1,8% (37/2049) of patients. Cardiac
tamponade was the predominant major
complication (occurring in 30/37 patients),
and was the main cause of mortality.
Tamponade appeared in 1,8% of atrial,
0,3% of right ventricular, and 0,1% of left
ventricular extracted leads. Fatal
tamponade occurred at a rate of 9% in
atrial leads, 40% in ventricular leads, and
in 67% coronary sinus extracted leads.
There was no association between lead
location and tamponade-related mortality;
however, lead location influenced
pericardiocentesis success. Moreover,
tamponade-related mortality was 37%
when TLE was performed in the
electrophysiology laboratory and 0% when
performed in a cardiac surgery or hybrid
operating room.
Conclusions: Cardiac tamponade was
the predominant reported complication.
16
There was no association between lead
location and fatal cardiac tamponade.
However, lead location influenced
pericardiocenthesis success. Moreover,
procedure localization (operating theatre
versus EPS laboratory) influenced
tamponade-related mortality.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
1
Hospital General Universitario de Valencia,
Valencia, SPAIN, 2 Universidad Católica de
Valencia, Valencia, SPAIN
Background and objectives: Although
cardiac resynchronisation therapy (CRT)
guidelines recommendations are equal for
both genders,, CRT implants remain
notably lower iin women. Our objective
was to investigate if female gender is a
significant factor to deny CRT.
Method: We retrospectively enroled 914
patients (17,4% women)from our center
with left ventricular eyection
fraction
<35%
on
an
echocardiogram exam performed
between 2004 and 2015. 189 were
excluded
after
coronary
revascularisation, after valve repair
or replacement or if they died
during the first month after the
echocardiogram. 47 (5.14%)
patients were excluded due to a
severe concomitant disease. Our
final population included 678
patients. We used a multivariate
analysis by means of a binomial
logistic regression. Left and right
bundle block (LBBB,RBBB), complete AVblock and left atrial dilatation were
predictive factors for a CRT implantation.
An increase in the eyection fraction and
female gender were predictive factors
against a CRT implantation. Figure 1
shows a prediction based on the simplified
equation obtained using the regression
model for the probability to implant a CRT
device adjusted to the rest of the variables
to evaluate the effect of the different
variables and their behavior depending on
gender. It focuses on the effect of LBBB
and gender independent of the rest
variables, showing that female gender has
a lower probability of CRT-implantation
which increases with higher eyection
fraction.
Conclusion: on equal conditions, women
have a lower probability to receive it. It is
required a thorough analysis to clarify why
CRT is less used in women.
17
FREE PAPERS
GENDER DIFFERENCES IN PATIENT
SELECTION FOR CARDIAC
RESYNCHRONISATION THERAPY
A. Quesada 1, B. Quesada 1, A. Prieto 2,
B. Bochard 1, J. Jiménez 1, R. Payá 1,
J.L. Pérez-Boscá 1, F. Arteaga 2, R. De La
Espriella 1, C. Fernández-Díaz 1, B. Trejo 1,
S. Sánchez-Álvarez 1, F. Ridocci 1
TUESDAY, NOVEMBER 29, 12.30-14.00 [Pola]
CARDIAC RESYNCRONIZATION THERAPY OUTCOME
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Pola]
CARDIAC RESYNCRONIZATION THERAPY OUTCOME
PLASMA B TYPE NATRIURETIC
PEPTIDE AS AN INDICATOR TO
PREDICT RESPONDERS AFTER CRT
A. Nawar, W. Samy, H. Alassar, A. Rizk, S.
Mokhtar
Critical Care Department - Faculty Of Medicine
- Cairo University, Cairo, EGYPT
Heart failure patients have been shown to
have increased levels of type B natriuretic
peptide (BNP), and these levels correlate
with the severity of heart failure.[46]
Numerous studies report that observing
BNP levels could be a useful technique to
diagnose heart failure and perform risk
stratification and that they could act as an
independent predictor of adverse events
helping clinicians arrive at a prognosis.
[51]
To achieve this purpose we studied 30
patients with CHF (27 males, mean age 57
years) undergoing CRT implantation.
The primary finding of our study was that
CRT showed a siginficant decrease in
plasma BNP levels in responders, yet not
in nonresponders following 3 months
follow-up (229.64 pg/ml ±111) as
compared to Non-Responders (468 pg/ml
±96) P value <0.01. Response could be
predicted with a cut-off value of 360
pg/ml, with a sensitivity and specificity of
90.9% and 87.5%, respectively.
In conclusion, BNP monitoring is
potentially a good prognostic indicator of
LV functional recovery and reverse
remodeling after CRT can precisely
18
identify echocardiographic responders
following CRT. Percentage change in
plasma BNP levels from baseline to 3
months was the strongest predictor of
long-term response to CRT and may have
potential to predict outcome.
RELATION OF QRS DURATION TO
RESPONSE TO CARDIAC
RESYNCHRONIZATION THERAPY IN
PATIENTS WITH LEFT BUNDLE BRANCH
BLOCK
M. Beltrami 1, M. Bertini 2, H. Kuwornu 3,
M. Malagù 2, G. Pasanisi 3, L. Padeletti 4,
B. Sassone 5
1
Heart and Vessels Department, University of
Florence, Florence, ITALY, 2 Department of
Cardiology, S. Anna Hospital, University of Ferrara,
Ferrara, ITALY, 3 Department of Cardiology, Delta
Hospital, Azienda Unità Sanitaria Locale Ferrara,
Ferrara, ITALY, 4 Cardiovascular Department,
IRCCS MultiMedica, Sesto San Giovanni (MI),
ITALY, 5 Department of Cardiology, SS.ma
Annunziata Hospital, Azienda Unità Sanitaria
Locale Ferrara, Ferrara, ITALY
Aims: Left ventricular (LV) dyssynchrony
is necessary condition for a successful
cardiac resynchronization therapy (CRT).
Despite left bundle branch block (LBBB)
represents a reliable surrogate of LV
dyssynchrony, not all LBBB patients will
respond to CRT. Our aim was to investigate
the relation between QRS duration and LV
dyssynchrony in LBBB patients who
underwent CRT.
Methods: We retrospectively studied 165
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
LONG-TERM OUTCOMES OF CARDIAC
RESYNCHRONIZATION THERAPY IN
PATIENTS WITH CHRONIC CHAGAS
CARDIOMYOPATHY
A. Da Silva Menezes Jr 1, C. Caetano Lopes 1,
P. Cavalcante Freire 1, E. Martins 2
1
Pontificia Universidade Católica De Goiás,
Goiânia, BRAZIL, 2 Universidade Federal De
Goiás, Goiânia, BRAZIL
Introduction: Chagas Disease represents
an important health problem, with
socioeconomic impacts in many countries
in Latin America. It is estimated that 20%
to 30% of the people infected by
Trypanossoma Cruzi will develop the
Chronic Chagas Cardiomyopathy (CChC),
generally evolving along with Heart Failure
(HF). Cardiac Resynchronization Therapy
(CRT) can be indicated for patients with HF
and electromechanical dysfunctions.
Purpose: The primary endpoint was to
analyze the response of CRT in patients
with CChC and the secondary endpoint
was to estimate their survival rates.
Methods: This study was an
observational, cross-sectional and
retrospective study, with the analysis of 50
patient’s records, with a CRT pacing
device implanted between June 2009 and
June 2015. In the statistical analysis,
Pearson’s correlation was used, along with
Student’s T-Test and the survival analysis
through the Kaplan-Meier method,
establishing a significance level of 5%
(p<0.05). Results: Of 50 patients, 56%
19
FREE PAPERS
patients with LBBB who underwent CRT
implantation according to the current
guidelines. A 6-month reduction of LV endsystolic volume more than 15% identified
responders to CRT. Baseline LV
dyssynchrony was defined as the delay
between peak systolic velocities of the
septum and lateral wall assessed by colorcoded tissue Doppler imaging.
Results: Baseline characteristics of
responders (61%) and nonresponders
(39%) were comparable except for greater
LV dyssynchrony (75 ms [25%–75% IQR
60-90] vs 30.5 ms [25%–75% IQR 14.570.5], p=0.0001) and narrower QRS
duration (160 ms [25%–75% IQR 148171] vs 180 ms [25%–75% IQR 156-190],
p=0.0001) in responders. At multivariate
analysis only QRS duration and LV
dyssynchrony remained independent
predictors of response to CRT. In patients
with
nonischemic
etiology
of
cardiomyopathy the linear regression
analysis documented a significant inverse
relationship between QRS duration and LV
dyssynchrony,
as
dyssynchrony
progressively decreased as QRS widening
increased (p=0.006). This was not evident
in patients with ischemic etiology.
Conclusion: In LBBB patients with
nonischemic etiology and marked QRS
widening the absence of LV dyssynchrony
may account for a lower response to CRT
as compared to patients with intermediate
QRS widening.
TUESDAY, NOVEMBER 29, 12.30-14.00 [Pola]
CARDIAC RESYNCRONIZATION THERAPY OUTCOME
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
were male, with a mean age of 63.4±13.3
years and the average time of CRT use of
41.2±21.7 months. The mean QRS
duration was 150.12±12.4 msec before
and 116.04±22.4 msec after the therapy
(p<0.001). The mean of left ventricular
ejection fraction were 29±7% and
39.1±12.2%, before and after the use of
the CRT, respectively (p<0.001). 34
patients (78%) had a reduction of, at least,
one New York Heart Association functional
class after 6 months of therapy (p=0.014).
The survival rate after 60 months was
80%.
Conclusion: This study showed clinical
improvement and a significant survival
rate of the patients with CChC in use of
CRT.
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Pola]
CARDIAC RESYNCRONIZATION THERAPY OUTCOME
IMPACT OF MULTI-POINT LEFT
VENTRICULAR PACING ON LEFT
VENTRICULAR EJECTION FRACTION
AND QRS. RESULTS FROM A
MULTICENTER REGISTRY
V. Ribatti 1, L. Calò 2, V. Calabrese 3, B. Bolzan 4,
R. Massaro 5, F. Zanon 6, C. Pignalberi 7,
M. Giammaria 8, A. Curnis 9, L. Santini 10,
G. Forleo 1
1
Policlinico Tor Vergata, Rome, ITALY, 2 Policlinico
Casilino, Rome, ITALY, 3 Policlinico Universitario
Campus Biomedico, Rome, ITALY, 4 Azienda
Ospedaliera Universitaria di Verona, Verona,
ITALY, 5 Ospedale Casa Sollievo della Sofferenza,
S. Giovanni Rotondo, ITALY, 6 Ospedale Santa
Maria della Misericordia, Rovigo, ITALY,
7
Ospedale S. Filippo Neri, Rome, ITALY, 8
Ospedale Maria Vittoria, Turin, ITALY, 9 Spedali
Civili di Brescia, Brescia, ITALY, 10 Presidio
Ospedaliero Giovan Battista Grassi, Ostia (RM),
ITALY
This registry was created to describe the
experience of 35 Italian centers with a
large cohort of recipients of multipoint
pacing
(MPP)
capable
cardiac
resynchronization therapy (CRT) devices.
Methods: A total of 306 patients were
enrolled between August 2013 and
January 2016. We analyzed the acute and
follow-up data.
Results: At baseline, in 71 patients (23%),
acute QRS width was tested in both pacing
modes (MPP ON and OFF). With MPP
pacing, the QRS was significantly shorter
compared to Biventricular pacing (135±25
20
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
(difference in % between baseline QRS
and Follow-up QRS) was evaluated.
The Delta_QRS% was significantly higher
in patients with Delta_EF%>5%
compared to the other patients (19±16%
vs 11±22%, p=0.008).
In the same group, the patients with MPP
ON had a greater Delta_QRS% compared
to the biventricular group. (-23±15%; 17±15%, p=0.04; fig.1B)
Conclusions: Compared to conventional
CRT, MPP resulted in an additional
increase in EF. In addition to that, QRS
narrowing was significantly greater in
MPP ON patients.
INFECTIOUS COMPLICATIONS IN
PATIENTS WITH CARDIAC
RESYNCHRONIZATION THERAPY
A. Polewczyk 1, W. Jachec 2, G. Opolski 3,
M. Grabowski 4, M. Janion 5, A. Kutarski 6
1
Faculty of Medicine and Health Sciences The
Jan Kochanowski University, Swietokrzyskie
Cardiology Center, Kielce, POLAND, 2 2nd
Department of Cardiology, Silesian Medical
University, Zabrze, POLAND, 3 1st Department
Of Cardiology, Medical University, Warsaw,
POLAND, 4 1st Department Of Cardiology,
Medical University, Warsaw, POLAND, 5 Faculty
of Medicine and Health Sciences The Jan
Kochanowski University, Swietokrzyskie
Cardiology Center, Kielce, POLAND, 6 Department
of Cardiology Medical University, Lublin, POLAND
Background: Cardiac resynchronisation
therapy (CRT) is increasingly being used
in patients with severe heart failure.
21
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ms vs 140±26 ms, p=0.0012). The
patients were divided into two groups
according to whether MPP was
programmed to “ON” (n=114, 37%) or
“OFF” (n=192) at the time of pre-hospital
discharge. Data from 297 patients at
follow up were analyzed, as 9 patients
died before the first follow-up (7 in
Biventricular group and 2 in MPP group).
At 8±5 months, the Delta_EF% (difference
in % between baseline EF and Follow-up
EF) was significantly higher in patients
with MPP ON (10.5±9.9% vs 7.5±8.7%;
p=0.006; Fig1A).
In 172 patients (56%), the Delta_QRS%
TUESDAY, NOVEMBER 29, 12.30-14.00 [Pola]
CARDIAC RESYNCRONIZATION THERAPY OUTCOME
XVII
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2016
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FREE PAPERS
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CARDIAC RESYNCRONIZATION THERAPY OUTCOME
Simultaneously escalating problem of
infectious complications is observed
especially in patients with more complex
implantable systems.
Methods: Comparative analysis of clinical
presentation, potential infectious risk
factors and long-term outcomes ( mean
follow-up 2,86 ± 1,72 years) of 144
patients with CRT (42 CRT-P) and 485
with implantable cardioverter defibrillator
(ICD) undergoing transvenous leads
extractions (TLE) in single center in years
2006-2015 was conducted.
Results are presented in the table and
figure
Conclusions: The risk of infectious
complications in patients with CRT was
higher than in ICD recipients, moreover
with higher incidence of systemic
infections- lead related infective
endocarditis (LRIE). Probably the bigger
number of procedural risk factors :loops
of the leads, abrasion of the leads,
previous procedures before TLE
determined higher frequency of infections
22
in CRT patients. Long-term survival was
also worse in infective patients with
CRTsystem in comparison with ICD (30%
vs 58% ).
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
RADIOFREQUENCY ABLATION OF
ATRIAL FIBRILLATION: A NONRANDOMIZED COMPARISON BETWEEN
THREE CIRCULAR ABLATION METHODS
FOR PULMONARY VEIN ISOLATION
M. Pozzi, E. Piazzi, S. De Ceglia, E.
Montemerlo, F. Achilli, G. Rovaris
San Gerardo Hospital, ASST Monza, Monza,
ITALY
Introduction: Pulmonary vein isolation
(PVI) using circular ablation catheter is
used as effective therapy for atrial
fibrillation (AF). The aim of this study is to
compare 3 different technologies: (1) firstgeneration circular ablation catheter
(PVAC); (2) second-generation circular
ablation catheter (PVAC-GOLD); (3)
irrigated circular ablation catheter
(nMARQ).
Methods: From May 2013 186 patients
(74% Male, 59 ± 11 years mean left atrial
diameter 42±5
mm; 72% Paroxysmal AF) underwent PVI.
The follow up was obtained using
implantable loop recorder. The endpoints
were procedural times, number and type
of adverse events and long-term success
rate.
Results: 90 (48%) patients were treated
with PVAC, 61 (33%) with PVAC-Gold and
35 (19%) with nMARQ. 93% of patients
were followed for a median time of 24
months. Mean procedural times were
115.6 ± 34.0 min, 81.6 ± 28.2min and
137.4 ± 41.7 in PVAC, PVAC-GOLD and
nMARQ groups, respectively (P<0.001).
The acute success rate and the rate of
acute procedural complications were
similar among the 3 groups. The 18 month
freedom of AF recurrence probability was
53.3% , 76.9% and 49.1% in PVAC, PVACGOLD and nMARQ, respectively (p=ns)
Conclusions: In our study all 3 technology
catheters gave similar results in PVI long
term success rate, even if the procedural
time are shorter in PVAC-GOLD group.
SAFETY AND EFFICACY OF THE
THORACOSCOPIC-PERCUTANEOUS
“TRUE-HYBRID” APPROACH FOR THE
TREATMENT OF PERSISTENT ATRIAL
FIBRILLATION
F. Pizzamiglio 1, G. Fassini 1, M. Moltrasio 1,
E. Merati 2, A. Filtz 1, V. Catto 1, G. Polvani 2,
C. Tondo 1
1
Cardiac Arrhythmia Research Center, Centro
Cardiologico Monzino, IRCCS, Milan, ITALY,
2
Cardiovascular Surgery Unit, Centro
Cardiologico Monzino, IRCCS, Milan, ITALY
Introduction: In the population of patients
with persistent atrial fibrillation (P-AF), the
alternative approach of sequential surgical
(SA) and percutaneous ablation has been
proposed to increase success rate and
reduce adverse events. Aim of our study
was to assess safety and efficacy of a
concomitant hybrid surgical and
electrophysiological approach.
Methods: We enrolled patients aged less
than 75 years with P-AF as per Heart
23
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XVII
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on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
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Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION TECHNIQUES
Rhythm Society recommendations for
ablation. Patients underwent sequentially:
electroanatomical map of left atrium (LA);
thoracoscopic SA with the Cobra Adhere
XL system (Estech, San Ramon, Calif); LA
re-mapping; and eventually point-by-point
radiofrequency ablation (RFA). Rhythm
outcome was assessed at 3, 6, 12 and 18
months by 24-hours ECG monitoring and
“on demand” office visit in case of
symptoms. All patients signed informed
consent.
Results: From April 2014 to June 2016,
41 consecutive patients were enrolled
(n=21 early P-AF, n=20 long P-AF). In
15/41 (37%) patients a point-by-point RFA
completed the SA procedure (n=6 gaps
along posterior wall, n=2 cavo-tricuspid
isthmus, n=1 mitral isthmus, n=4
pulmonary vein, n=2 other). The survival
rate free of AF is illustrated in Figure 1. We
observed 1 (2%) major complication (n=1
ischemic stroke) and 15 (37%) minor
complications (n=11 pneumothorax or
pleural effusion with prolongation of
drainage, n=1 surgical revision, n=1
pace-maker implantation, n=2 persistent
diaphragm elevation). No patients died.
24
Conclusions:
The
thoracoscopicpercutaneous hybrid approach for the
treatment of P-AF appears to be a safe
and efficient approach. More data on
larger sample size and long-term followup are needed.
TWO- AND THREE-YEAR OUTCOME
AFTER PULMONARY VEIN ISOLATION
USING THE SECOND-GENERATION 28MM CRYOBALLOON IN PATIENTS WITH
PAROXYSMAL AND PERSISTENT
ATRIAL FIBRILLATION
D. Brala, C. Drephal, S. Tessin, J.P. Rudolph,
O. Goeing, A. Schirdewan
Sana Klinikum Lichtenberg, Department of
Cardiology, Cryoablation Center, Berlin,
GERMANY
Background: Standard cryoballoon
ablation using the 2nd generation
cryoballoon in pts with paroxysmal and
persistent atrial fibrillation (PAF/PERAF)
has demonstrated convincing acute and
mid-term results. Long-term outcome
data are rare or missing. We investigated
the 2- and 3-year clinical outcome after
PVI. METHODS: 49 pats (age 64 ± 10
years) with PAF (25 /49, 51%) or
PERAF(24/49, 49%) underwent PVI. We
used a single 28mm-balloon catheter
approach, 180s/freeze following a safety
freeze-cycle after successful PVI. Followup (FU) was based on a repeated 3 month
intervall till 36 months, including 24h
Holter-ECGs. Recurrence was defined as
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International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
any symptomatic/documented AT episode
>30s.RESULTS: A two-year FU was
available for 49/49 patients and a threeyear FU for 27/49 patients. After 2 years a
total of 41/49 (84%) patients remained in
stable sinus rhythm (SR). In patients with
PAF, 24/25 (96%) were in SR, in PERAF
17/24 (71%). A stable SR was seen for
19/27 (70%) patients in the 3 year FU, of
whom 5/12 (42%) were pts with PERAF
and 14/15 (93%) were PAFs. The
differences between PAF and PERAF
reached no significance. Three pts
underwent a second ablation or minimal
surgical maze procedure and 5 pts at 3
year FU were under antiarrhythmics,
resulting in an overall success rate of 94%
after 2 years and 89% after three
years.Conclusion:Patients with PAF
showed a stable 3 year outcome in
contrast to pts with PERAF who
demonstrated a moderate success of 42%
after 3 years vs 71% after 2 years of a
single ablation procedure.
SECOND-GENERATION CRYOBALLOON
ABLATION OF ATRIAL FIBRILLATION:
ONE YEAR FOLLOW-UP BASED ON
INSERTABLE CARDIAC MONITORING
G. Sirico, S. Panigada, L. Ottaviano, G.
Pensa, D. Fanelli, V. De Sanctis, M. Mantica
Istituto Clinico S. Ambrogio-Unità di
Aritmologia clinica ed Elettrofisiologia, Milan,
ITALY
Introduction: There are limited data on
second-generation cryoballoon (CB-2)
efficacy based on insertable cardiac
monitoring (ICM). We here report 12
months follow-up based on either non
invasive or ICM after atrial fibrillation (AF)
ablation using CB-2.
Methods: From July 2014 to July 2016,
52 patients (33 males, mean age 57.7
±11.8 years) with drug refractory AF
(92.3%
paroxysmal)
underwent
pulmonary vein isolation (PVI) using CB-2.
A Reveal Linq ICMTM was implanted in 25
patients following ablation (ICM group).
Holter electrocardiograms were used in
the remaining 27 patients for follow-up
evaluations (non ICM group). Table 1
shows baseline characteristics for both
groups. Arrhythmic recurrences (ARs)
were considered as any episode of AF,
atrial flutter or atrial tachycardia lasting at
least 30 seconds after blanking period.
Results: Overall, 99% of pulmonary veins
were successful isolated. At mean follow
up of 12 months, freedom from ARs was
achieved in 76.6% (90.5% paroxysmal
AF). ICM group showed higher incidence
rate of ARs than non ICM group (30.4% vs
16.7%, respectively; log rank P=0.08)
(Fig.1). ICM data showed that in 18
patients AF burden was 0%, in 3 it varied
from 0,1% and 1%, in 4 it varied from 1%
to 10%. Antiarrhythmic drugs were equally
distributed in both groups (33.3% in ICM
and 36.0% in non ICM group, p>0.05).
Conclusions: In our experience, freedom
from any AR after cryoablation using CB-
25
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
TUESDAY, NOVEMBER 29, 12.30-14.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION TECHNIQUES
2 is achieved in 83.3% of patients.
However, real success appears to be
69.6% at 12 months follow-up when ICM
is adopted.
LASSO® CATHETER ENTRAPMENT IN
MITRAL VALVE APPARATUS REQUIRING
EMERGENCY SURGERY: A RARELY
REPORTED COMPLICATION OF
PULMONARY VEIN ISOLATION
PROCEDURE FOR ATRIAL
FIBRILLATION
M. Sabar 1, A. Bajpai 2,4, S. Nair 3, A. Momin 3,
R.A. Kaba 1,2,4
1
Department of Cardiology, Ashford & St
Peter’s Hospitals NHS Trust, Chertsey, UNITED
KINGDOM, 2 Department of Cardiology, St
George’s University Hospitals NHS Trust,
London, UNITED KINGDOM, 3 Department of
Cardiac Surgery, St George’s University
Hospitals NHS Trust, London, UNITED
KINGDOM, 4 Department of Cardiology, Epsom
and St. Helier University Hospitals NHS Trust,
Epsom, UNITED KINGDOM
26
Objective: To highlight one of the first
reported cases in the United Kingdom of a
rare but potentially serious complication,
requiring emergency surgery, of catheter
entrapment in mitral valve (MV) apparatus
during atrial fibrillation (AF) ablation
procedure.
Methods: A 59-year old gentleman with
persistent AF underwent ablation
procedure. A routine transthoracic
echocardiogram was undertaken eight
weeks prior to the catheter ablation. The
procedure was then performed under
general anaesthesia, with TOE (TransOesophageal Echocardiogram) facilities,
but a serious complication occurred during
catheter ablation, necessitating urgent
surgical intervention.
Results: Transthoracic echocardiogram
revealed structurally normal heart
including the MV apparatus. Catheter
ablation was undertaken in the form of
wide area circumferential lesions around
ipsilateral pulmonary veins. During
ablation of right pulmonary veins, the
LASSO® catheter (Biosense Webster Inc.)
inadvertently traversed the MV into the left
ventricle and became deeply entangled in
the MV apparatus. Various manoeuvres
including repeated traction, catheter
rotation and advancement of sheath were
unsuccessful in releasing the catheter
from the MV. The patient was transferred
for urgent surgical removal of the
LASSO® catheter. Our patient made
complete recovery from surgery and a
XVII
International Symposium
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in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
transthoracic echocardiogram 2-weeks
later demonstrated good function of MV
without mitral regurgitation.
Conclusion:
Extreme
care
is
recommended whilst manoeuvring the
LASSO® catheter, as modest inadvertent
movements can have serious sequelae.
Urgent surgical intervention can help to
minimise the damage to the MV
apparatus, if simple manoeuvres do not
suffice.
REMOTE MAGNETIC NAVIGATION FOR
ATRIAL FIBRILLATION ABLATION: A
SINGLE CENTRE EXPERIENCE
S. Grossi, C. De Rosa, F. Bianchi, A. Sibona
Masi, M.R. Conte
Mauriziano Hospital, Turin, ITALY
Introduction: Remote magnetic navigation
has proved to be effective in the atrial
fibrillation ablation. We assess safety and
clinical outcome in a group pf patients who
underwent to atrial fibrillation ablation
using Niobe remote magnetic navigation in
our EP laboratory.
Methods and results: From 2009 to
2015, a total of 278 patients 179 male
(median age 69 ± 3 years) underwent to
atrial fibrillation ablation with Stereotaxis
magnetic navigation system and 3D left
atrial reconstruction (CARTO RMT).
Median Chads2 vasc score was 3 ± 1.
21% of total patients had an underlying
CAD. 12% of patients underwent to a redo
procedure.
Patter of atrial fibrillation was divided as
follows: 57% (158 pts) parossistical, 36%
(100 pts) persistent, 7% (19 pts) long
lasting persistent. Mean procedure time
was 57± 13 minutes.
Median follow up was 49±22 months.
After procedure, final rhytm was sinus
rhytm in 234 patients (84%); at follow up,
79 % of total patients was in stable SR
(86% parossistical, 12% persistent AF, 2%
long lasting persistent. At follow up, 64%
(177 pts) of total patients used
antiarrhythic drugs.
Cardiac tamponade occurs in 0.7% of total
procedures, while minor complications (as
peripheric vascular complications) occur
in 2% of total patients.
Conclusion: In our experience, Niobe
remote magnetic navigation is a safe and
feasible, with low fluoroscopy time.
27
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ELECTRICAL AND CHEMICAL SUPPRESSION
OF ATRIAL FIBRILLATION
HIGH INCIDENCE OF ATRIAL
FIBRILATION AFTER ABLATION OF
ISOLATED TYPICAL ATRIAL FLUTTER
DURING LONG TERM FOLLOW-UP
L. Aguinaga, A. Bravo, J. Secchi, P. Gallaro,
E. Hasbani, R. Quintana
Cpc, Tucuman, ARGENTINA
Purpose: The purpose of this study was to
provide information about the long term
risk of atrial fibrillation in patients
presenting with isolated typical atrial
flutter.
Methods: We analyzed 312 consecutive
patients who had flutter ablations
(cavotricuspid isthmus) in our center
between 1997 and 2014. Patients with no
apparent history of atrial fibrillation before
their flutter ablation were identified.
Postablation atrial fibrillation and other
arrhythmias
were
identified
by
electrocardiography, Holter monitoring and
subsequent clinical records.
Results: Postablation atrial fibrillation was
identified in 96 /184 patients (52%) after a
mean follow-up of 132.4±24.5 months. In
63 patients the atrial fibrillation was
persistent and in 33 patients the atrial
fibrillation was paroxystical. The incidence
of atrial fibrillation was progressive, with
40% ocurring after 3 years. There was no
difference in age, left atrial size, structural
heart disease, hypertension or ventricular
function in patients who developed atrial
fibrillation compared with those who did not.
Conclusions: Atrial fibrillation occurs in
28
over half of patients who present with
isolated typical flutter after cavotricuspid
isthmus ablation. The patients should be
screened for recurrent arrhythmias
indefinitely after ablation. In some
patients, atrial fibrillation and flutter may
be expressions of the same electrical
disease, and the treatment of the flutter
will not prevent the occurrence of atrial
fibrillation in the long term.
PROPHYLACTIC PULMONARY VEIN
ISOLATION DURING ISTHMUS
ABLATION FOR ATRIAL FLUTTER THE
PREVENT AF STUDY I
S. Bayramova 1, A. Romanov 1, J. Steinberg 2,
D. Musat 2, S. Artyomenko 1, V. Shabanov 1,
D. Losik 1, E. Pokushalov 1
1
Novosibirsk State Research Institute of
Circulation Pathology, Novosibirsk, RUSSIA,
2
The Valley Health System, New York, USA
Introduction: Although catheter ablation
of isthmus-dependent atrial flutter (AFL) is
extremely successful at eliminating the
target arrhythmia, many patients
subsequently experience new onset atrial
fibrillation (AF). The development of AF
may necessitate additional interventions
and expose patients to long-term risk.
Methods: This trial was a prospective
single-blind parallel-controlled randomized
clinical trial designed to test if reduction of
AF could be achieved by specific ablation
of AF during intervention for AFL. Patients
were eligible if their sole detected clinical
XVII
International Symposium
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in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
arrhythmia was AFL with no known AF.
Patients were randomized to undergo
either cavo-tricuspid isthmus (CTI) ablation
alone or CTI with concomitant pulmonary
vein isolation (PVI). All patients received an
implantable loop recorder (ILR) at the
ablation procedure.
Results: A total of 50 patients completed the
trial. CTI was successful in all 50 patients;
PVI was successful in the 25 randomized
patients to CTI + PVI. More patients in the
CTI only group experienced new onset AF,
52% vs 12%, during follow-up for minimum
of one year (p = 0.005). The one-year AF
burden on ILR also favored the CTI + PVI
group compared to the CTI only group: 8.3%
vs 4.0% (p = 0.034). In the CTI only group,
32% patients subsequently required another
ablation for AF.
Conclusions: In the PREVENT-AF Study I
randomized clinical trial of patients in
whom only typical AFL had been observed
clinically, the addition of PVI to CTI ablation
resulted in a marked reduction of new
onset AF during clinical follow-up as
assessed by continuous ILR.
IMPROVED MAPPING RESOLUTION FOR
PULMONARY VEIN (PV) ISOLATION
G. Tola 1, A. Scalone 1, A. Setzu 1, C. Franchin 2,
M. Malacrida 2, V. Garofalo 2, M. Porcu 1
1
S.C Cardiologia - AO Brotzu, Cagliari, ITALY,
Boston Scientific Italia, Milan, ITALY
2
We report the case of successful pulmonary
vein (PV) isolation performed with a novel
mini-electrodes (MEs) ablation catheter.
Detailed 3D electro-anatomic map was
undertaken in order to reconstruct the entire
LA and the LA–PV junction. An unbroken
ablation line was deployed starting at the
left superior PV and continued around the 4
veins. RF was applied using the novel 4.5mm IntellaTipMiFiOI® open irrigated-tip
catheter (BostonScientific), equipped with 3
MEs at the distal tip for electrograms
recording and pacing. The detection of spike
signals at MEs allowed to clearly verify the
location of the ablation tip with respect to
the line of block and PV [Figure_1A,B]. In
contrast, the signals obtained from the
conventional dipole did not consent to
detect correct signals reported to the
anatomical location due to the far field and
the consequent electrical noise.
The RF delivery could be interrupted based
on the amount of the decrease in MEs
signal amplitude or based on the change
in local signal [Figure_2]. Being confirmed
29
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WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ELECTRICAL AND CHEMICAL SUPPRESSION
OF ATRIAL FIBRILLATION
the absence of signal inside the veins
[Figure_3], the electrical PV disconnection
was verified through standard pacing
protocols. The findings in this case
demonstrate that electrograms signals
recorded from the same tissue can differ
between the MEs and the conventional
proximal and distal ablation electrodes.
The MEs resulted in improved mapping
resolution and allowed collection of
signals to detect lesion maturation. The
adoption of MEs could allow easier and
shorter ablation procedures.
ACUTE EFFECTS OF UNILATERAL,
TEMPORARY STELLATE GANGLION
BLOCK ON HUMAN ATRIAL
ELECTROPHYSIOLOGIC PROPERTIES
AND ATRIAL FIBRILLATION
INDUCIBILITY
D. Leftheriotis 1, P. Flevari 1, C. Kossyvakis 2,
D. Katsaras 1, C. Arvaniti 1, C. Batistaki 1,
G. Giannopoulos 1, S. Deftereos 1,
G. Kostopanagioyou 1, I. Lekakis 1
1
Atttikon University Hospital of Athens, Athens,
30
GREECE, 2 G. Gennimatas General Hospital,
Athens, GREECE
Background: In experimental models,
stellate ganglion block (SGB) reduces the
induction of atrial fibrillation (AF), while
data in humans are limited.
Objective: In this study, we assessed the
effect of unilateral SGB on atrial
electrophysiologic properties and AF
induction, in patients with paroxysmal AF.
Methods: Thirty-six patients with
paroxysmal AF were randomized in 2:1
order to temporary, transcutaneous,
pharmaceutical SGB with lidocaine or
placebo before pulmonary vein isolation.
Lidocaine was 1:1 randomly infused to the
right or left ganglion. Before and following
randomization, atrial effective refractory
period (ERP) of each atrium, difference
between right and left atrial ERP (dERP),
intra-atrial and inter-atrial conduction
time, AF inducibility and AF duration were
assessed.
Results: Following SGB, right atrial ERP
was prolonged from 240 (220-268) ms to
260 (240-300) ms (p<0.01) and left atrial
ERP from 235 (220-260) ms to 245 (240280) ms (p<0.01). AF was induced by
atrial pacing in all 24 patients before SGB,
but only in 13 (54%) following the
intervention (p<0.01). AF duration was
shorter after SGB: 1.5 (0.0-5.8) min from
5.5 (3.0-12.0) min (p<0.01). Intra- and
inter-atrial conduction time was not
significantly prolonged. No significant
XVII
International Symposium
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2016
Rome, Italy - NOV 29 - DEC 2, 2016
differences were observed between right
and left SGB. No changes were observed
in the placebo group.
Conclusions: Unilateral temporary SGB
prolonged atrial ERP, reduced AF
inducibility and decreased AF duration. An
equivalent effect of right and left SGB on
both atria was observed. These findings
may have a clinical implication in the
prevention of drug-refractory and postsurgery AF, and deserve further clinical
investigation.
LONG-TERM SUPPRESSION OF ATRIAL
FIBRILLATION BY BOTULINUM TOXIN
INJECTION INTO EPICARDIAL FAT PADS
IN PATIENTS UNDERGOING CARDIAC
SURGERY ONE-YEAR FOLLOW-UP OF A
RANDOMIZED PILOT STUDY
S. Bayramova 1, A. Romanov 1, A. Strelnikov 1,
A. Bogachev-Prokophiev 1 , S. Po 2 ,
J. Steinberg 3, E. Pokushalov 1
1
State Research Institute of Circulation
Pathology, Novosibirsk, RUSSIA, 2 Heart
Rhythm Institute, University of Oklahoma
Health Sciences Center, Oklahoma, OK, USA,
3
The Valley Health System, New York, USA
Background: Animal models suggest that
the neurotransmitter inhibitor, botulinum
toxin, when injected into the epicardial fat
pads can suppress atrial fibrillation
inducibility. The aim of this prospective
randomized double-blind study was to
compare the efficacy and safety of
botulinum toxin injection into epicardial fat
pads
for
preventing
atrial
tachyarrhythmias.
Methods and Results: Patients with
history of paroxysmal atrial fibrillation and
indication for coronary artery bypass graft
surgery were randomized to botulinum
toxin (Xeomin, Merz, Germany; 50 U/1 mL
at each fat pad; n=30) or placebo (0.9%
normal saline, 1 mL at each fat pad; n=30)
injection into epicardial fat pads during
surgery. Patients were followed for 1 year
to assess maintenance of sinus rhythm
using an implantable loop recorder. All
patients in both groups had successful
epicardial fat pad injections without
complications. The incidence of early
postoperative atrial fibrillation within 30
days after coronary artery bypass graft
was 2 of 30 patients (7%) in the botulinum
toxin group and 9 of 30 patients (30%) in
the placebo group (P=0.024). Between 30
days and up to the 12-month follow-up
examination, 7 of the 30 patients in the
31
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XVII
International Symposium
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in Clinical Pacing
2016
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FREE PAPERS
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Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ELECTRICAL AND CHEMICAL SUPPRESSION
OF ATRIAL FIBRILLATION
placebo group (27%) and none of the 30
patients in the botulinum toxin group (0%)
had recurrent atrial fibrillation (P=0.002).
There were no complications observed
during the 1-year follow-up.
Conclusions: Botulinum toxin injection
into epicardial fat pads during coronary
artery bypass graft provided substantial
atrial tachyarrhythmia suppression both
early as well as during 1-year follow-up,
without any serious adverse events.
ALCOHOL ABLATION OF VEIN OF
MARSHALL FOR TREATMENT OF
PERIMITRAL ATRIAL FLUTTER
G. Gromyko, S. Epifanov, S. Novichkov, D.
Mangutov, D. Kranin
Burdenko Main Military Clinical Hospital,
Moscow, RUSSIA
Introduction: The aim of our study is to
evaluate effectiveness of alcohol ablation
of vein of Marshall in treatment of
perimitral atrial flutter, refractory to
32
previous attempts of radiofrequency
ablation.
Methods: Study population included 27
patients (19 men, mean age 69,8 + 6,2
years), who underwent RF ablation of
perimitral flutter. Patients were divided in
two groups: group 1 - 22 patients with
perimitral flutter terminated by RF energy
and group 2 – 5 patients in whom RF
ablation was not effective and perimitral
flutter was terminated by alcohol ablation
of vein of Marshall. Mean follow-up was
13,2 + 6,7 months. Tachycardia
termination, incidence of mitral isthmus
block, safety and freedom from atrial
flutter during follow-up were assessed.
Results: Mean procedure duration was
196,3 + 74,2 min in group 1 and 135,0 +
21,2 min in group 2 (p=0,3). Mean
fluoroscopy time was 24,0 + 15,7 min in
group 1and 9,5 + 7,8 min in group 2
(p=0,051).
Perimitral flutter was terminated in all
cases. Mitral isthmus block was noted in
11 of 22 patients(50%) in group 1 and in
all patients(100%) in group 2. During
follow-up period there were 5 reccurences
(23%) of perimitral flutter in group 1 and
no reccurences in group 2. There were no
complications in both groups.
Conclusion: Alcohol ablation of vein of
Marshall is an effective tool for treatment
of refractory to RF ablation perimitral atrial
flutter.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
INTERMUSCOLAR TWO-INCISIONS
TECHNIQUE FOR SUBCUTANEOUS
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR IMPLANTATION:
RESULTS FROM A MULTICENTER
REGISTRY
F. Migliore 1, G. Allocca 2, V. Calzolari 3,
M. Crosato 3, D. Facchin 4, M. Zecchin 5,
E. Daleffe 4 , S. Cannas 6 , R. Arancio 6 ,
P. Marchee 7 , F. Zanon 8 , S. Iliceto 1 ,
E. Bertaglia 1
1
University of Padua, Department of Cardiac,
Thoracic and Vascular Sciences, Padua, ITALY,
2
Division of Cardiology, Conegliano Hospital,
Conegliano, ITALY, 3 Division of Cardiology,
Treviso Hospital, Treviso, ITALY, 4 Division of
Cardiology, University of Udine, Udine, ITALY,
5
Division of Cardiology, University of Trieste,
Trieste, ITALY, 6 Division of Cardiology, Thiene
Hospital, Vicenza, ITALY, 7 Division of
Cardiology, Ascoli Piceno Hospital, Ascoli
Piceno, ITALY, 8 Division of Cardiology, Rovigo
Hospital, Rovigo, ITALY
Background: the traditional technique for
subcutaneous implantable cardioverter
defibrillator (SICD) implantation, which
involves 3 incisions and a subcutaneous
pocket, is associated with possible
complications, including
inappropriate interventions.
The aim of this prospective
multicenter study was to
evaluate the efficacy and
safety of an alternative
intermuscular twoincisions
technique
for
S-ICD
implantation. Methods: the study
population included 36 consecutive
patients [75% male,mean age 44±12
years (range 20-69)] who underwent SICD implantation using the intermuscular
two-incisions technique. This technique
abandons the superior parasternal incision
for the lead placement and consists in
creating an intermuscular pocket between
the anterior surface of the serratus
anterior and the posterior surface of the
latissimus dorsi muscles instead of a
subcutaneous pocket. Results: all patients
were successfully implanted in the
absence of any procedure-related
complications with a successful
defibrillator threshold testing with 65 J
standard polarity, except in one, who
received a second successful (DFT) after
pocket revision.
During a mean follow-up of 10 months
(range 3-30) no complications requiring
surgical revision were observed.At device
interrogation, stable sensing without
interferences was observed in all
patients.Two patient (5.5%) experienced
appropriate and successful shock on
ventricular fibrillation and in 4 patients
(11%) a total of 7 non sustained self-
33
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR
terminated ventricular tachycardia were
correctly detected. No inappropriate
interventions were observed. Conclusions:
our experience suggests that the twoincisions intermuscular technique is a safe
and efficacious alternative to the current
technique for S-ICD implantations and
may help to reduce complications
including inappropriate interventions and
offer a better cosmetic outcome especially
in thin individuals.
SUBCUTANEOUS IMPLANTABLE
CARDIOVERTER DEFIBRILLATOR AND
VENTRICULAR TACHYCARDIA
DEGENERATION
A. Mengoni 1, G. Zingarini 2, A. Tordini 1,
G. Ambrosio 1, C. Cavallini 2
1
Cardiology
and
Cardiovascular
Physiopathology, Santa Maria della Misericordia
Hospital, Perugia, ITALY, 2 Cardiology, Santa Maria
della Misericordia Hospital, Perugia, ITALY
The trans-venous (TV-ICD) and
subcutaneous (S-ICD) implantable
cardioverter-defibrillator are effective
treatment for primary
and
secondary
prevention of sudden
cardiac death.
We reported the case
of a 55 years old man
hospitalized
for
arrhythmic storm and
repeated
shocks
from S-ICD.
34
His clinical history was relevant for
cardiomyopathy post-myocarditis with
reduced left ventricular ejection fraction
(40%). He was implanted with a TV-ICD
owing to premature ventricular beats and
episodes of non sustained ventricular
tachycardia. Three years later, the device
was substituted with S- ICD because of a
lead endocarditis.
Amiodaron,
magnesium
sulphate,
potassium and esmolol induced a gradual
reduction of the events and the
stabilization of his hemodynamic
condition. Blood exams showed nothing
important.
The S- ICD interrogation showed episodes
of VT interrupted by device intervention
and VT degeneration in ventricular
fibrillation (VF) after some S-ICD shocks
(Figure 1).
Nevertheless a VT radio frequency
ablation, slow VT continued, so we
explanted S-ICD and implanted a
biventricular pacemaker-ICD.
One year follow-up, he developed VT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
episodes treated with anti tachycardia
pacing (ATP).
The stable VT transformed to unstable VT
o VF is reported in about 4% of TV ICD
therapy triggered by ATP but no case of SICD has been described.
It could be explain because an electrical
shock could induce different degrees of
prolongation of the action potential and
this creates a prerequisite for re-entry. The
dispersion of repolarization between
action potentials from the right ventricular
apex and outflow tract were correlated
with successful and unsuccessful
inductions and terminations of VF.
SUBCUTANEOUS DEFIBRILLATOR
IMPLANTATION AS A BRIDGE UNTIL
THE NORMALIZATION OF LEFT
VENTRICULAR FUNCTION
G. Bisignani 1, S. De Bonis 1, A. Bisignani 1,
G. San Pasquale 1, L. Candreva 2, C. Franchin 2,
M. Malacrida 2
1
Divisione di Cardiologia - Ospedale
Castrovillari - ASP, Cosenza, ITALY, 2 Boston
Scientific Italia, Milan, ITALY
We present the case of a young man,
habitual user of recreational cocaine and
alcohol, referred to our hospital for
symptomatic dyspnea.
Subsequent
diagnostic examination revealed a very
low LVEF (< 15%) at echocardiography
that was confirmed at cardiac magnetic
resonance imaging with absence of any
sign of scar. On the hypothesis of a
reversible cardiac impairment due to
drugs abuse or myocarditis we decided to
implant a subcutaneous cardioverterdefibrillator (S-ICD). The patient stopped
cocaine and alcohol use and LVEF
normalized during time. After about 2
years the patient suffered a trauma on the
thoracic area with a pocket erosion and a
little exposure of device can, which
subsequently
became
infected.
Considering the improvement in LV
function and the absence of arrhythmic
episodes we decided to explant the device
without re-implantation. Procedure was
easily performed without complication.
After 1 year the patient remained free from
any indication to defibrillator implantation.
The invasive nature of the implantation
procedure, the potential complications
related to an in-dwelling intravascular and
the hypothesis of reversible cardiac
impairment could provide the S-ICD as a
new prophylactic strategy for patients who
are at significant risk for VT/VF and without
a defined course from temporary to
permanent ICD indication. In our case the
patient improved LVEF during time and
definitely lose any indication to ICD
implantation. The noninvasiveness of the
S-ICD guaranteed an easy removal of the
entire system without exposing the patient
at risk of complications even in the case
of concomitant trauma or infection.
35
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR
A PATIENT SUITABLE TO HEART
TRANSPLANT FOR END-STAGE HEART
FAILURE: SUBCUTANEOUS OR
TRANSVENOUS ICD?
C. Ruperto, G. Ricca, G. Busacca, L.
Cassaniti, A.A. Arcidiacono, G. Licciardello
Cardiology Department - E. Muscatello
Hospital, Augusta (SR), ITALY
In 2003 a 43 year-old man was diagnosed
a viral myocarditis. He remained clinically
stable and asymptomatic until 2013 when
he experienced several hospitalizations for
acute on chronic HF despite of optimal
medical therapy. In February 2015 he was
referred to our Department to undergo ICD
implantation in primary prevention. Taking
into account no indications for bradycardia
or biventricular pacing, the absence of
ventricular arrhythmias previously, the
poor prognosis due to repeated HF
hospitalizations, severe left ventricular
dysfunction (EF 23%) with high filling
pressure and the valuation perspective for
heart transplantation, a subcutaneous-ICD
was implanted. The patient was referred
to Transplant Center and was inserted on
waiting list. In September 2015 he was
rehospitalized for a worsening of
compensation, refractory to diuretic and
inotropic support. Transferred to
Transplant Center, a left ventricular assist
device (LVAD) placement was necessary.
Related to the location of generatory near
the left mid-axillary line and to the risk of
interference in sensing or shock delivery
36
from ICD, the device was explanted and
transvenous ICD was inserted.
Although S-ICD may be a choice in
patients with HF, the natural history of
disease and the possible hemodynamic
instability that requires a long-term
mechanical circulatory support could limit
its use. To the best of our knowledge, only
two cases of concomitant S-ICD and LVAD
were described and in one of them a LVAD
interference with the sensing vectors of
the S-ICD was reported. As the data are
still lacking, in this setting a transvenous
ICD would be preferred.
OVERSENSING OF AN UNEXPECTED
ATRIAL FLUTTER. A NEW TOOL TO
IMPROVE DETECTION OF
SUPRAVENTRICULAR ARRHYTHMIAS
BY SUBCUTANEOUS DEFIBRILLATOR
N. Danisi 1, V. Schirripa 1, L. Santini 1,
A. Pappalardo 2, G.B. Forleo 3, F. Ammirati 1
1
Giovan Battista Grassi Hospital, Ostia (RM),
ITALY, 2 San Camillo Hospital, Rome, ITALY,
3
Policlinico Tor Vergata, Rome, ITALY
We report a case of a 32-years old male
patient whit a history hypertrophic
cardiomyopathy and persistent atrial
fibrillation. The patient was affected by
endocarditis due to infection of a
transvenous ICD lead and was, after
successful percutaneous extraction of the
transvenous system, implanted with a
subcutaneous ICD.
Before the implant, as suggested by the
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
device manufacturer, the patient
underwent to a pre-implantation EKG
screening and a single sensing vector was
found acceptable both in supine and
standing position, at rest and under
exertion. The S-ICD implantation was
conventionally performed with the lead
vertically positioned in the subcutaneous
tissue of the chest, 2 cm to the left of the
sternal midline.
The patient was discharged and after 1
week he came back at emergency room
of our hospital for ICD shock. The EGM
revealed two inappropriate shocks due to
“F”-wave oversensing (Panel A, figure 1).
The F-waves, due to a new atrial flutter,
and QRS complex had comparable
amplitude and were both detected by the
S-ICD as sensed complexes. This resulted
in the falling of the calculated heart rate
into the shock zone.
Different sensing vectors were tested to
reduce
atrial
oversensing, but the
originally
programmed vector
was confirmed as the
one associated with
the highest sensed
R-wave and the best
discrimination. Device
repositioning
or
replacement were
not
considered
acceptable solutions
for the patient since
he was awaiting heart transplantation and
was at high risk for infection.
Therefore
S-ICD
software
was
implemented by a new available sensing
algorithm, the SMART Pass. SMART Pass
is an algorithm that, first time worldwide
uploaded, when programmed, activates a
9 Hz high-pass filter designed to reduce
the amplitude of lower frequency signals,
while maintaining an appropriate sensing
margin, to improve the detection in the
case of high-amplitude T- or P -wave. The
amplitude of the “F”-wave appeared
immediately decreased and no more
detected by the S-ICD.
The SMART Pass functioning was
therefore tested during the course of the
arrhythmia, by temporarily disabling it
(SMART Pass OFF: Figure 1, Panel B;
SMART Pass ON: Figure1, Panel C). The
appropriate performance of the algorithm
was confirmed, as no F-waves were
37
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR
detected.
The annual rate of inappropriate shocks
by S-ICD reported in recent studies was
approximately 7%, and events were
largely ascribed to T-wave oversensing.
Supraventricular arrhythmias are the
cause of inappropriate shocks more
frequently in transvenous ICD than in SICD. Nonetheless, F- or P-wave
oversensing may occur, as reported in the
present case. We showed that the recently
updated version of the S-ICD software,
now equipped with a new high-pass filter,
allows
to
better
discriminate
supraventricular arrhythmias.
IS THE COMBINE BETWEEN THE
TRANSCATHETER LEADLES
PACEMAKER AND THE SUBCUTANEUS
DEFIBRILLATOR WINNING?
P. Artale 1,3, P. Filannino 1,2, A. Petretta 1,
A. Carigliano 1, A.R. Rafulla 1, G. Speziale 2,
S. Iacopino 1,2,3
1
Maria Cecilia Hospital, Cotignola, ITALY,
Anthea Hospital, Bari, ITALY, 3 Città di Lecce
Hospital, Lecce, ITALY
2
Background:
Permanent
cardiac pacing delivered by
conventional pacemaker is
the corner stone in the
treatment of bradycardia.
Occasionally, complications
related to the pacing lead and
pocket could prevent in
delivering
pacing
by
38
traditional pacemaker. In recent years,
major advancements have been achieved
using Transcatheter Pacemaker System
(TPS).
Methods: NA
Results: We report a case of a 70-yearold man implanted with a cardiac
resynchronization implantable defibrillator
(CRT-D) in 2008. Due to ineffective LV
pacing, the CRTD was programmed VVI 40
bpm. In May 2016, he was admitted to
hospital for a device-related infection.
CRTD devices had to be extracted and a
contralateral implantation failed due to the
presence of a vena cava thrombosis. As a
result a subcutaneous defibrillator (S-ICD)
was successfully implanted. In June 2016
the patient was admitted to ER for
syncope complicated by a head trauma
and arm injury. The S-ICD interrogation
was negative. A telemetry evaluation
revealed a paroxysmal complete AV block.
In July 2016 the TPS was implanted in the
septum of the right ventricle. During the
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR
FREE PAPERS
procedure, after TPS placement,
interference tests were performed to
exclude interactions between the devices.
(Fig 1) Moreover, the sensitivity of TPS
was set to 0.6 mV to allow the device to
sense heart voltage even in the case of
ventricular arrhythmias. The Sensing
Assurance function was programmed off.
On 2-month examination, no interaction
between the devices and no adverse
events were reported.
Conclusions: The co-existence of a
leadless pacemaker and defibrillator is
possible. No adverse events were
reported.
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
39
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCRONIZATION THERAPY:
NEW LEADS AND IMPLANT TECHNIQUES
LONG-TERM PERFORMANCE OF A
TRANSVENOUS ACTIVE FIXATION LEFT
VENTRICULAR LEAD FOR TARGETED
PLACEMENT
H. Keilegavlen 1, T. Hovstad 1, S. Faerestrand 1,2
1
Department of Heart Disease, Haukeland
University Hospital, Bergen, NORWAY,
2
Department of Clinical Science, University of
Bergen, Bergen, NORWAY
Background: Left ventricular (LV) lead
implant success may be compromised by
lead dislodgement, high pacing threshold
and phrenic nerve stimulation. Placement
of the LV lead remote from the latest
activated LV region reduces the probability
for beneficial response. The 4Fr Attain®
Stability™ (Model 20066, Medtronic, Inc.)
LV lead with active fixation by a side helix
represent a new option to achieve targeted
and stable placement in proximal coronary
vein segments.
Methods: The bipolar steroid eluting LV
lead was implanted in 179 patients. The
lead was targeted to a vein concordant to
the LV segment with latest mechanical
contraction decided by radial strain
echocardiography. The lead body was
rotated clockwise to engage the side helix
in the vein wall.
Results: A threshold <2,5V was achieved
in 98.7% of the patients, and the median
threshold was 0.99±0,58V. Within 21±10
months follow-up, 3 leads (1.6%) were
removed due to devices infection. In one
patient the lead was replaced by a
40
quadripolar lead due to unavoidable
phrenic nerve stimulation. In another
patient a new lead was added due to
unacceptable rise in pacing threshold two
year after implantation. In 3 patients
(1.6%) the LV leads dislodged the first day
and required a replacement. No late LV
lead dislodgement has been observed.
Conclusions: This thin active fixation LV
lead has excellent performance in terms
of stability and pacing thresholds. Active
fixation offers flexibility to place the lead
precisely and stable in targeted vein
segments.The need for removal of this LV
lead appears to be low.
RIGHT VENTRICULAR SEPTAL PACING
AS CRT IN PATIENTS WITH RBBB - THE
SPARK TRIAL
M. Giudici, G. Shantha
University of Iowa Hospitals, Iowa City, IA, USA
Background: Cardiac Resynchronization
Therapy (CRT) with pacing leads placed in
the right ventricle and lateral left ventricle
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
has been shown to improve left ventricular
function and outcomes in patients with
LBBB. Patients with RBBB, however, do not
benefit from this form of CRT. Since CRT
with a lateral LV lead is essentially left
bundle replacement therapy, it would
follow that patients with LBBB would
benefit. Studies have shown that RV septal
pacing (RVS) stimulates the right bundle
branch. We propose a study of properly
timed RV septal pacing to result in a
narrow QRS in RBBB patients with heart
failure.
Methods: in a pilot study, 78 consecutive
patients (56 M/22 F, mean age 74 yrs) with
RBBB underwent RVS. Bedside adjustment
of the paced AV delay was performed to
achieve the narrowest QRS with fusion. A
sample of these patients underwent preand post- echocardiograms.
Results: Baseline mean QRS duration was
147 +/- 19.1 ms (120-220). Fused QRS
duration (paced LBBB+native RBBB) was
112 +/- 19.5 ms (56-160). p<0.001.
Patients who underwent echocardiograms
showed improvement in LVEF.
Conclusions: Based on these early
positive results, we are proceeding with
the Septal Pacing in Right Bundle Branch
Block Trial – a randomized crossover study
of RVS in patients with RBBB and EF <
35%. Parameters studied include LVEF,
QRS narrowing, HF symptoms, QOL, HF
Biomarkers, and Ventricular Arrhythmias.
This is a multicenter trial and we are
recruiting other centers.
FEASIBILITY OF CARDIAC
RESYNCHRONISATION THERAPY
IMPLANTATION WITH ABNORMAL
CORONARY SINUS ANATOMY
I. Harding 1, G. Nero 1, G. Domenichini 1,
Z. Zuberi 2, I. Beeton 3, M. Gallagher 1
1
St. Georges Hospital, London, UNITED
KINGDOM, 2 Royal Surrey County Hospital,
Guildford, UNITED KINGDOM, 3 St. Peters
Hospital, Chertsey, UNITED KINGDOM
Aims: To investigate the prevalence of
abnormalities of the coronary venous
system in candidates for cardiac
resynchronization therapy (CRT) and
describe methods for circumventing the
resulting difficulties.
Methods: We examined a database of
1128 consecutive patients undergoing
CRT device implantation or pacing system
upgrade to CRT in 3 neighbouring
hospitals with large pacing units.
Abnormalities of cardiac venous drainage
that required deviation from normal
procedure were noted.
Results: Important abnormalities of the
coronary
venous
system
were
encountered in 5/1128 patients (0.44%),
including 3 in whom the coronary sinus
drained to the left subclavian vein rather
than the right atrium, 1 with a superior
vena cava (SVC) on the right as well as on
the left and 2 with a left SVC only. In all
cases, CRT was delivered successfully
using percutaneous transvenous access
alone. In 2 cases, the lead had to be
41
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CARDIAC RESYNCRONIZATION THERAPY:
NEW LEADS AND IMPLANT TECHNIQUES
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCHRONIZATION THERAPY:
NEW LEADS AND IMPLANT TECHNIQUES
implanted by a femoral approach and
pulled through to a pectoral position. The
duration of the implant procedure was
significantly longer in cases with abnormal
coronary sinus anatomy (189±63 Vs
113±48 minutes, p<0.001), as was the
fluoroscopy duration (30±11 Vs 14±15
minutes, p<0.05).
Conclusion: CRT devices can be
implanted percutaneously even in the
presence of substantial abnormalities of
coronary venous anatomy. Alternative
routes of venous access may be required.
FEASIBILITY AND BENEFITS OF HISIAN
PACING WITH DEMAND APICAL BACKUP
F. Zanon 1, L. Marcantoni 1, G. Pastore 1,
E. Baracca 1, D. Lanza 1, S. Aggio 1,
C. Picariello 1, L. Conte 1, L. Roncon 1,
A. Barbetta 2, F. Di Gregorio 2
1
Cardiology Complex Unit, S. Maria della
Misericordia General Hospital, Rovigo, ITALY,
2
Clinical Research Unit, Medico Spa, Rubano
(PD), ITALY
Permanent His-bundle pacing allows
physiological ventricular activation.
However, the pacing threshold is generally
higher and the R-wave amplitude lower
than at conventional pacing sites.
Implanting an additional back-up lead
could be advisable, provided that back-up
stimulation is inhibited by Hisian capture.
To this purpose, a 3-chamber stimulator
Helios or Hera (Medico, Italy) was
42
implanted in 12 patients presenting with
AVB. Channels V1 and V2 were
respectively connected to the Hisian and
the back-up lead, positioned in RV apex.
After successful Hisian pacing and
conduction along the His-Purkinje system,
V2 sensing entailed inhibition of apical
pacing. Conversely, in case of capture loss,
V2 sensing was missing and apical
stimulation was performed at the end of
the VV delay (120 ms). The risk of false
pacing inhibition was prevented by careful
programming of post-spike blanking and
haemodynamic
surveillance
by
transvalvular impedance (TVI) assessment.
Apical sensing was valid only if a systolic
TVI increase confirmed the occurrence of
ventricular ejection. Effective Hisian
pacing and corresponding inhibition of the
back-up pulse was achieved in all
patients. The interval from Hisian
stimulation to apical sensing averaged 98
± 11 ms, showing a good correspondence
with the V2 alert period. In 2 cases, the
conduction time exceeded the VV delay
with low energy stimulation, which
resulted in the recruitment of para-Hisian
myocardium only. Back-up apical
stimulation on demand increases Hisian
pacing reliability without increasing the
current drain. The energy cost might even
be reduced, as the Hisian pulse safety
margin can be lowered with no risk.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
WIRELESS LEFT VENTRICULAR (LV)
ENDOCARDIAL STIMULATION FOR CRT:
FINAL OUTCOMES OF THE SELECT-LV
STUDY
C. Butter 1, M. Siefert 1, V. Reddy 2, P. Neuzil 3,
S. Riahi 4, P. Søgaard 4, P. Delnoy 5, L. van
Erven 6, M. Schalij 6, L. Boersma 7
1
Brandenburg Heart Centre - Immanuel
Hospital, Bernau, GERMANY, 2 The Mount Sinai
Hospital, New York, USA, 3 Na Homolce
Hospital, Prague, CZECH REPUBLIC, 4 Aalborg
University Hospital, Aalborg, DENMARK, 5 Isala
Klinieken, Zwolle, THE NETHERLANDS, 6 Leiden
University Medical Centre, Leiden, THE
NETHERLANDS, 7 St. Antonius Ziekenhuis,
Nieuwegein, THE NETHERLANDS
Introduction: Patients indicated for CRT
do not always benefit due to acute or
chronic CS lead issues or not responding
to therapy. SELECT-LV assessed the safety,
performance and preliminary efficacy of a
novel Wireless CRT System (WiSE-CRT)
providing wireless, LV, endocardial
stimulation.
Method: This non-randomized prospective
EU study included failed CRT patients who
were classified as untreated, nonresponders or upgrades. The WiSE-CRT
System includes a sub muscularly
implanted transmitter and a wireless
electrode implanted on the LV endocardial
free wall. The transmitter emits an
ultrasonic pulse synchronized with the RV
pacing pulse; the electrode converts the
ultrasonic energy into electrical energy to
achieve synchronous biventricular pacing.
The primary endpoint at 1-month was
safety & performance; the secondary
endpoint at 6-months was safety,
performance & preliminary efficacy.
Results: 39 patients were enrolled, 3
patients failed screening and 1 patient
withdrew pre-implant. There were
successful implants in 34 of 35 patients
(97.1%) with 33 patients (97.1%)
completing the 6-month follow-up.
Biventricular pacing was demonstrated in
33 of 34 patients (97.1%) at 1-month and
in 31 of 33 patients (93.9%) at 6-months.
At 6-months, 66.7% patients improved >1
NYHA class; 52.0% patients improved
>15% LVESV; 62.5% patients demonstrated
>5% increase in EF; 84.8% patients
showed improvement in their clinical
composite score. There were 3 SAEs in 3
patients (8.6%) peri-operatively and 9 SAEs
in 9 patients (25.7%) by 1 month.
Conclusion: This multi-centre experience
demonstrated the feasibility of wireless, LV,
endocardial pacing; thereby providing new
hope to patients with previous CRT failure.
MAGNITUDE OF QRS DURATION
REDUCTION AFTER BIVENTRICULAR
PACING IDENTIFIES RESPONDERS TO
CARDIAC RESYNCHRONIZATION
THERAPY
G. Coppola 1, A. Mignano 1, G. Ciaramitaro 1,
G. Stabile 2, A. D’Onofrio 2, P. Palmisano 2,
P. Carità 2, G. Mascioli 2, D. Pecora 2, A. De
Simone 2, M. Marini 2, A. Rapacciuolo 2,
G. Savarese 2, G. Maglia 2, A. Pierantozzi 2,
43
FREE PAPERS
CARDIAC RESYNCHRONIZATION THERAPY:
NEW LEADS AND IMPLANT TECHNIQUES
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 12.30-14.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC RESYNCHRONIZATION THERAPY:
NEW LEADS AND IMPLANT TECHNIQUES
G. Arena 2, T. Giovannini 2, S.I. Caico 2,
M. Malacrida 3, E. Corrado 1
1
Operative Unit of Cardiology, EP Lab, AOUP
Paolo Giaccone, Palermo, ITALY, 2 on behalf of
CRT MORE Investigator, 3 Boston Scientific
Italia, Milan, ITALY
Background: Several studies have
investigated the association between
native QRS duration (QRSd) or QRS
narrowing and response to biventricular
pacing. However, their results have been
conflicting. The aim of our study was to
determine the association between the
relative change in QRS narrowing index
(QI) and clinical outcome and prognosis in
patients
who
undergo
cardiac
resynchronization
therapy
(CRT)
implantation.
Methods and Results: We included 311
patients in whom a CRT device was
implanted in accordance with current
guidelines for CRT. On implantation, the
native QRS, the QRSd and the
QI during CRT were measured.
After 6months, 220 (71%)
patients showed a 10%
reduction in LVESV. The median
[25th-75th] QI was 14.3%
[7.2-21.4]
and
was
significantly related to reverse
remodeling (r=+0.22; 95%CI:
0.11-0.32, p=0.0001). The
cut-off value of QI that best
predicted
LV
reverse
remodeling after 6months of
44
CRT was 12.5% (sensitivity=63.6%,
specificity=57.1%, area under the
curve=0.633, p=0.0002). The time to the
event
death
or
cardiovascular
hospitalization was significantly longer
among patients with QI>12.5% (log-rank
test, p=0.0155), with a hazard ratio (HR)
of 0.3 [95%CI: 0.11-0.78]. In the
multivariate regression model adjusted for
baseline parameters, a 10% increment in
QI (HR=0.61[0.44-0.83], p=0.002)
remained significantly associated with
CRT response.
Conclusions: Patients with a larger
decrease in QRSd after CRT initiation
showed greater echocardiographic
reverse remodeling and better outcome
from
death
or
cardiovascular
hospitalization. QI is an easy-to-measure
variable that could be used to predict CRT
response at the time of pacing site
selection or pacing configuration
programming.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
CLINICAL CHARACTERISTICS,
MANAGEMENT AND FOLLOW-UP OF
IDIOPATHIC VENTRICULAR
FIBRILLATION IN THE PEDIATRIC
POPULATION
A. Frontera 1, N. Thompson 1, M. Takigawa 1,
G. Cheniti 1, E. Teijeira Fernández 1, A.G.
Stuart 2, J. Kaski 3, A. Denis 1, A. Chaumeil 1,
S. Amraoui 1 , S. Ploux 1 , P. Ritter 1 ,
P. Bordachar 1 , J.P Maury 4, G. Fahy 5,
R. Cappato 6, F. Sacher 1, J. Pierre 1, M. Hocini 1,
J.B. Thambo 1, M. Haïssaguerre 1, N. Derval 1
1
Univ. Bordeaux, Centre de Recherche CardioThoracique de Bordeaux, Bordeaux, FRANCE,
2
Bristol Royal Hospital for Children, Bristol,
UNITED KINGDOM, 3 Great Ormond street
Hospital, London, UNITED KINGDOM, 4 Hopital
de Rangueil, Toulouse, FRANCE, 5 Bantry
General Hospital, Cork, IRELAND, 6 Humanitas
Hospital, Milan, ITALY
Idiopathic VF is rare and there is no clear
consensus regarding the management,
therapy and likelihood of arrhythmia
recurrence. Aim of this study was to
analyze the clinical characteristics,
management and follow up of idiopathic
VF occurred in children.
From a large dataset of 496 patients with
idiopathic VF collected worldwide, we
selected data on 45 children (<16.5 years
old) with aborted sudden cardiac death
(SCD), documented VF, and absence of
structural heart disease. Clinical
characteristics, ECG, investigations
including genetic testing were analyzed.
Follow up was performed at respective
out-patient clinics.
There were 45 patients (24 male), with a
mean age of 12.9 years (1.5 - 16). 24
patients (53%) experienced syncope
before the presenting VF arrest (median of
2 events per patient). Most of them
preceded SCD event by 2 months and
occurred with exertion. There was a family
history of SCD in 15 patients (33%). SCD
event occurred in 10 patients (22%) with
organized sports, 9 (20%) with strong
emotion, 8 (18%) at rest, 8 (18%) awake
during the day, 5 (11%) with physical
exertion and 2 (7%) while asleep. An ICD
was implanted in 42 patients (93%) during
the index hospitalization. 1 patient
declined a device and 2 (4%) were
implanted at a later date. Of documented
VF 3 were associated with PVCs with a
short coupling interval (7%). Programmed
stimulation during EPS induced VF in 5
patients (11%). The majority of patients
were discharged on beta-blocker therapy.
During follow-up period (mean 92± 32
months) one patient (2.5%) developed
hypertrophic cardiomyopathy, while four
(9%) had positive genetic testing. 3
different genes were identified: triadine (2),
KCNH2 (1), SCN5A (1). 13 (29%) patients
received appropriate ICD therapy for
episodes of VT/VF (median number 3),
Inappropriate shocks occurred in 7
patients (17%) secondary to lead failure.
In this multi-center study, more than half
of the patients with idiopathic VF had
preceding episodes of syncope as well as
a strong family history of SCD. During
follow up period multiple episodes of VF
and appropriate discharges were
documented in a third of the patients.
45
FREE PAPERS
SUDDEN DEATH:
CLINICAL CHARACTERISTICS AND PREVENTION
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUDDEN DEATH:
CLINICAL CHARACTERISTICS AND PREVENTION
NATIONWIDE STUDY OF SUDDEN
CARDIAC DEATH CAUSED BY
CONGENITAL HEART DISEASE IN
PERSONS AGED 0-35 YEARS
A. Jeppesen 1, T.H. Lynge 1, B.G. Winkel 1,
L. Søndergaard 1, B. Risgaard 1, J. TfeltHansen 1,2
1
The Department of Cardiology, The Heart
Centre, Copenhagen University Hospital,
Rigshospitalet, Copenhagen, DENMARK,
2
Department of Medicine and Surgery,
University of Copenhagen, Copenhagen,
DENMARK
Introduction: Congenital heart defects
(CHD) is one of the leading causes of
sudden cardiac death (SCD) in the young.
However, the incidence of SCD caused by
CHD (SCD-CHD) in the young general
population is unknown. The aims of this
study were to investigate incidence,
causes of SCD-CHD, and how
implementation of nationwide prenatal
ultrasound screening in 2005 has changed
the epidemiology of SCD-CHD in children.
Methods and results: The study population
consisted of all persons aged 0-35 years in
Denmark from 2000-09, which equals 24.4
million person-years. All 11,451 deaths
were included. By using the descriptive
Danish death certificates, 1,094 cases of
sudden and unexpected death were
identified. Through review of autopsy
reports, and records from hospitals and
general practitioners, we identified 103
cases of SCD-CHD. Only 60 (58%) were
46
diagnosed with CHD before death. The
annual incidence rate of SCD-CHD was
0.42 per 100,000 person-years among
persons aged 0-35 years in the 10-year
period. The annual incidence rate for
infants (< 1 year old) born before
implementation of nationwide prenatal
ultrasound screening was higher than the
incidence rate for infants born after
implementation (incidence rate ratio 3.2.
95%-CI,1.4-7.2). The most common
cause of SCD-CHD was coarctation of the
aorta (n=16, 15%).
Conclusion: A total of 9.4% of all sudden
deaths in the young is caused by CHD.
Only 58% of SCD-CHD cases were
diagnosed with CHD before death. We
observed a significant decline in incidence
of SCD-CHD among infants born after
implementation of nationwide prenatal
ultrasound screening.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
CLINICAL USE OF AN AUTOMATIC
ALGORITHM SOFTWARE (PASO) IN
ELECTROANATOMIC CARTO MAPPING
AND ABLATION OF PREMATURE
VENTRICULAR BEATS
I. Capodaglio 1, M. Casella 1, V. Catto 1, M.
Moltrasio 1, F. Tundo 1, S. Conti 1, V. Ribatti 1,2,
E. Russo 1, G. Vettor 1, S. Pala 1, A. Dello
Russo 1, C. Tondo 1
1
Cardiac Arrhythmia Research Centre, Centro
Cardiologico Monzino IRCCS, Milan, ITALY,
2
Università degli Studi di Roma Tor Vergata,
Rome, ITALY
Introduction: Radiofrequency ablation is
usually curative for premature ventricular
contractions (PVCs) in normal hearts.
Ablation outcome depends on the
possibility to record frequent PVCs during
the procedure. In case of few PVCs, pacemapping (PM) remains a useful tool to
identify the optimal ablation site, but
manual comparison of ECGs is subjective
and time consuming.
Methods: We enrolled 45 patients (28
men, 47±19 years),without heart disease.
They underwent ablation procedure using
the automated PM analysis tool PaSo
(Biosense-Webster Inc.). PM was
performed in multiple sites where PaSo
software performed a lead-by-lead match
analysis calculating a 12-lead average
match score from 0 to 1.0. Reliable
ablation sites were considered only if PMmatching was at least 0.8 in 12/12 ECG
leads.
Results: During procedure patients
presented variable PVC frequencies: 13
(29%) patients had 1 PVC every 3 minutes
or more, 15 (33%) patients a PVC every
minute, 17 (38%) patients bi-trigeminal
rhythm. Sinus rhythm voltage map was
created in 26 patients (points 193±110);
activation map was performed in 28 (62%)
cases. PM was performed in a mean of
8±6 sites. Ablation was successfully
performed at right ventricle outflow tract
in 28 (62%) cases and left ventricle
outflow tract in 17 (38%) cases. Sites of
ablation showed average PaSo match
0.94±0.03 and mean precocity regarding
to QRS onset 33±7 ms.
Conclusions: These preliminary data
show that PaSo tool accurately localizes
the PVC origin and is a reliable indicator of
effective ablation. This tools is particularly
helpful in patients with few PVCs during
mapping phase.
UTILITY OF PACE-MATCHING USING
THE PASO ALGORITHM FOR CATHETER
ABLATION OF IDIOPATHIC
VENTRICULAR TACHYCARDIA
G. Lima Da Silva, N. Cortez-Dias, T.
Guimarães, I. Gonçalves, A. Bernardes, S.
Sobral, L. Carpinteiro, J. De Sousa, F.J.
Pinto
Cardiology Department, Santa Maria University
Hospital, LMAC, Lisbon, PORTUGAL
Purpose: To assess the utility of PaSo™
in mapping idiopathic ventricular
47
FREE PAPERS
SUDDEN DEATH:
CLINICAL CHARACTERISTICS AND PREVENTION
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUDDEN DEATH:
CLINICAL CHARACTERISTICS AND PREVENTION
tachycardia (iVT) and to determine the
optimal PaSo™ correlation coefficient
(CC) predictive of a successful iVT ablation
procedure
Methods: Single-center retrospective
study of consecutive patients submitted to
iVT ablation using the PaSo™ algorithm
(Figure 1). The acute efficacy of the
procedure was evaluated. The receiver
operating characteristic (ROC) curve was
created for correlation coefficient and
procedural success. The area under the
curve was calculated
using C-statistic and
an adequate cut-off
value was obtained.
Results:
Eighteen
patients
(67%
women, aged 53±15
years)
with
symptomatic iVT were
scheduled
for
transcatheter ablation
using the PaSo™ algorithm [10 right
ventricular outflow tract ventricular
tachycardias, 6 left ventricular outflow
tract ventricular tachycardias and 2
papillary muscle tachycardias]. The overall
success rate was 72%. The PaSo™ CC
was significantly higher in successful
ablations [97 (95-98) versus 92 (92-93);
p=0.007) andpresented a high diagnostic
accuracy in prediction of procedural
success [AUC: 0.91 (95% IC 0.77-1.0);
p=0.009 – Figure 1). The optimal cut-off
predicting procedure success was 95%
48
(sensitivity = 77%; specificity = 100%,
positive predictive value = 100%, negative
predictive value = 63%, overall diagnostic
accuracy = 83%).
Conclusion: In patients with iVT, pacemapping using the PaSo™ module has a
high overall diagnostic accuracy (83%)
and a PaSo™ CC over 95% predicts
sucess. This mapping strategy is of major
importance in patients with PVC
spontaneous suppression during the
ablation procedure.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
DIAGNOSIS AND TREATMENT
OF VENTRICULAR ARRHYTHMIAS
1
2
S.C. Cardiologia - AO Brotzu, Cagliari, ITALY,
Boston Scientific Italia, Milan, ITALY
A 60-year-old male patient presented for
ventricular tachycardia (VT) radiofrequency
catheter ablation. Goal of ablation was
non-inducibility of VT, scar homogenization
and elimination of late potentials (LPs).
Ablation procedure was performed with a
novel ablation catheter equipped with
mini-electrodes (MEs). Detailed LV
endocardial mapping was undertaken to
identify and localize regions displaying LPs
and to characterize healthy and scarred
areas using conventional voltage criteria.
Signals from 3 MEs at the distal tip of this
catheter allowed to identify LPs at
bordering zones. RF energy, at maximum
power of 25W, was delivered at all sites
displaying LPs until complete substrate
scar homogenization. The ablation area
was 7cm² and the ablation time
13minutes. Signals at MEs allowed to
clearly verify the location of LPs showing
double components separated by a mean
isoelectric interval of 79±10msec and a
QRS-to-first LP component of 35±9msec.
LPs signals on EGMs from MEs and
conventional dipoles revealed broad
differences in terms of signal clarity and
substrate characterization. [Figure1_a,b]
Substrate remap during stable SR
confirmed the complete abolition of any
late activity and previously observed
sustained ventricular arrhythmias were not
induced at programmed stimulation. In our
preliminary experience the small, close,
and low-noise MEs has been
advantageous for mapping areas of scar
tissue and substrate characterization,
including acutely ablated tissue. The use
of MEs technology may have major
implications for VT ablation, in terms of
better discrimination of local signal
morphology and shorter ablation
procedures. This hypothesis should be
verified with larger series.
FREE PAPERS
SUCCESSFUL VT ABLATION WITH A
NOVEL MULTI-ELECTRODES ABLATION
CATHETER
G. Tola 1, A. Scalone 1, A. Setzu 1, C. Franchin 2,
M. Malacrida 2, V. Garofalo 2, M. Porcu 1
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
49
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
DIAGNOSIS AND TREATMENT
OF VENTRICULAR ARRHYTHMIAS
LOW X RAY EXPOSITION ABLATION OF
IDIOPATHIC VENTRICULAR
TACHYCARDIAS
A. Scopinaro, G. Gandolfi, R. Massa,
M. Giglio, G. Pistis
Cardiology Unit – Osp. S.S. Antonio e Biagio,
Alessandria, ITALY
Idiopathic ventricular tachycardias often
affects young people with normal hearts.
3D mapping systems are often use to
improve ablation outcome and reduce x
ray exposure.
From January 2015 to January 2016, 50
consecutive patients were submitted to
ventricular tachycardia ablation. Mean age
was 43 (12-72) years and 41 were male.
All ablation were performed using a 3D
mapping system. Acute and 6 months
outcome were evaluated. Procedural
parameters were also collected. 31
patients presented a normal heart and 19
had a dilatation of at least one ventricle.
29 of 50 VT were targeted in right
ventricular outflow tract, 14 were targeted
in left ventricular outflow tract or aortic
valve, 3 in mitral annulus, 2 in mitro-aortic
junction and 2 around the tricuspid
annulus. All patient had acute success
procedure, after six month follow up 3
patients presented a residual VT burden (2
VTs targeted in aortic area and 1 in
tricuspid annulus).
Mean procedural time was 120+/-30
minutes, all procedures were guided only
by 3D system, fluoroscopy guide was used
50
only to exclude the RF delivery next to the
coronary artery ostia in patient presenting
an aortic VT focus.
No major complication were seen.
Rf ablation of idiopathic ventricular
tachycardias without using fluoroscopy
guide is effective and safe.
LONG-TERM FOLLOW-UP OF PATIENTS
WITH SURGICALLY CORRECTED
CONGENITAL HEART DISEASE AND AN
IMPLANTABLE CARDIOVERTERDEFIBRILLATOR
A. Monteiro, P. Silva Cunha, M. Oliveira,
M. Nogueira da Silva, A. Agapito, L. de
Sousa, J.A. Oliveira, S. Aguiar Rosa, S. Laranjo,
C. Trigo, J. Fragata, A. Delgado, R. Cruz Ferreira
Hospital de Santa Marta - Centro Hospitalar
Lisboa Central, Lisbon, PORTUGAL
Knowledge and experience about
implanted cardioverter defibrillators (ICD)
use in adults with congenital heart disease
(CHD) and structural defects surgically
treated is very limited with few data
regarding long-term outcomes of CHD
Paients (P) submitted to ICD implantation.
We aimed to evaluate the clinical evolution
and ICD-related complications in adults
with CHD and an ICD.Methods: 23 (18
men, 36.7 ± 16 years) with CHD surgically
corrected, who underwent an ICD
implantation due to spontaneous
ventricular tachyarrhythmias (VT/VF).
Results: These group of P represents 2%
of all ICD population followed for > 2 years
in our center. The index arrhythmia was
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
monomorphic ventricular tachycardia in
47.8% and ventricular fibrillation in 13%.
There were no complications related with
ICD implantation. In 1P, the polarity of the
shock was reversed to obtain a safe
margin during the DFT test. There was a
single chamber device in 15P, a double
chamber in 4P, a cardiac resynchronization
device with ICD in 1P, and a subcutaneous
device in 3P. During a mean follow-up of
45 ± 29 months, 11P received appropriate
ICD interventions due to VT/VF episodes
(representing 78.5% of arrhythmic
morbidity). One P needed surgical reintervention and 1P underwent heart
transplant. Seven P underwent pulse
generator replacement due to battery
depletion. The mortality rate was 28.5%
(4P).
Conclusions: P with CHD represent a very
small proportion of all ICD population, with
secondary prevention being the indication
for this therapy. However, despite a high
rate of effective appropriate interventions,
during very long-term follow-up the
mortality rate is still high.
PSEUDOARTIFACT MASQUERADING AS
POLYMORPHIC VENTRICULAR
TACHYCARDIA IN THE LINQ
IMPLANTABLE LOOP RECORDER
J. Catanzaro, J. Levine, K. Venkatesh,
S. Hsu, R. Kim
University of Florida, Jacksonville, FL, USA
Introduction: The implantable loop
recorders (ILR) is a long-term surveillance
option for detection of infrequent
arrhythmia, syncope or to monitor
arrhythmia burden. The device is capable
of detection using a Lorentz plot analyzing
the R-R interval prior to classification. The
ILR is especially susceptible to false
positives and cannot detect atrial
fibrillation less than 2 minutes duration.
Pseudoartifact and myopotential can
contribute to false positives which have
significant implications if clinically
misinterpreted.
Case Presentation: A 50 year old woman
with palpitations and atrial fibrillation
underwent implantation of a Reveal LINQ
loop recorder (Medtronic, Minneapolis MN,
USA) for palpitations with concern for
symptomatic sick sinus syndrome. The
LINQ logged the following recording as
VT/VF: Initial R-R interval of 570-700
milliseconds [Fig 1]. Physician adjudication
determined that the R-R intervals (570700msec) “march out” through the tracing
due to pseudoartifact. This was supported
by the beat-to-beat rate log, which
demonstrated non-physiologic coupling
intervals up to 300 bpm. After detailed
inspection and repetitive timing of each
episode on a daily basis, the patient
happened to be brushing her teeth
mimicking polymorphic ventricular
tachycardia. The patient ultimately had a
symptom rhythm correlation of
symptomatic sick sinus syndrome and
underwent a dual chamber pacemaker.
51
FREE PAPERS
DIAGNOSIS AND TREATMENT
OF VENTRICULAR ARRHYTHMIAS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
DIAGNOSIS AND TREATMENT
OF VENTRICULAR ARRHYTHMIAS
Conclusion: This case illustrates the
limitation of current implantable loop
recorder detection with respect to false
positives and the importance of correct
adjudication
of
such
events.
Improvements in detection algorithms,
coupled with prompt precise analysis of
the event by the physician may prevent
unnecessary treatments and foster safety.
RANDOMIZED CONTROLLED STUDY
COMPARING PEER-LED TRAINING
VERSUS CONVENTIONAL TRAINING
APPROACH TO BASIC LIFE SUPPORT
DEFIBRILLATION
M. Santomauro 1, L. Matarazzo 1, C. Riganti 2,
G. Palma 1, G. Castellano 1, A. Ferro 3,
C. Vosa 1
1
Department of Cardiology,Cardiac Surgery
and Cardiovascular Emergency, Federico II
University, Naples, ITALY, 2 Direzione
52
Sanitaria,Azienda Ospedaliera Universitaria
Federico II, Naples, ITALY, 3 Istituto di
Biostrutture e Bioimmagini, Consiglio
nazionale delle Ricerche,CNR, Naples, ITALY
This study was a randomized controlled
trial with a blinded outcome assessor.
We evaluated the feasibility and efficacy
of a peer to peer BLSD teaching to High
school students compared to a
professional led teaching. In years
2010-2013, 560 High School 15-18 years
old students were divided into two groups
(A and B) who underwent a BLSD course
for adult. The 276 Students in Group A
were thaught in peer to peer way while
Group B 284 students was trained in
conventional way by a professional
instructors AHA certified. The items value
was the percentage of check recoil by
means of a QCPR on the training
manikin used for CPR training by model
Resusci Anne manikin for measures
CPR performance by the Wireless
SimPad Skill-Reporter (Laerdal Medical
Stavanger, Norway), and semiautomatic
external defibrillator trainer (AED) and
retention of BLSD knowledge as assessed
by 10-point questionnaire.
The results demonstrate, that check
responsiveness percentage was 72.5%
in the peer-led group and 75.4% in
the professionalled group, that call 118
percentage was 82.5% in the peer-led
group and 86.9% in the professionalled
group. Open the airway and giving breaths
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
percentage was failed in 32% in the
Group A and 38% in the Group B (ns).
Chest compressions (position hand,
adequate depth, correct rate, complete
chest recoil, CPR ratio) percentage was
73.9% in the group A and 76.4% in
the group B. The percentage correct
use of AED was 53.5% in the peer-led
group and 52.4% in the professional led
group. On the questionnaire administered
after training, the peer led group scored
an average of 47.2 % in the Group A and
49.8 % in the Group B.
Conclusions: thehigh school students
who were trained by peer instructors
showed comparable skills in CPR for adult
to those who were trained by professional
instructors.
GENDER ASPECTS IN CATHETER
ABLATION OF ATRIAL FIBRILLATION: A
PROSPECTIVE STUDY OF EFFICACY,
SAFETY OF THE PROCEDURE AND
QUALITY OF LIFE OF THE PATIENTS
A. Patsyuk, D. Lebedev, E. Mykhaylov, M.
Abramov
Almazov North-West Medical Research Centre,
Saint-Petersburg, RUSSIA
Background: Atrial fibrillation (AF) is the
most common type of cardiac arrhythmia.
There is paucity of information regarding
gender differences in outcomes of patients
undergoing AF catheter ablation.
The aim of this prospective study was to
determine gender differences in clinical
characteristics, quality of life (QoL) and
outcomes of the patients referred for AF
catheter ablation.
Methods: the study comprised of 55
patients (25 men) with symptomatic AF, who
were referred for pulmonary vein isolation.
A variety of clinical characteristics,
echocardiography parameters, QoL before
and after catheter ablation, safety and
efficacy of the procedure over 12-months
follow-up period were compared between
men and women.
Results: At the baseline, women had lower
values of psychological parameters of QoL
comparing to men (15,9 versus 19,9, p
<0.05), and more severe symptoms.
Within 12 months after the procedure
arrhythmia recurred in 28% men and in
40% women. Women had more
complications during the procedure and in
early postablation period (12% women
and 5% men, P<0.05). All patients with no
arrhythmia recurrence had a significant
improvement in all QoL domains and a
decrease in AF EHRA score.
Conclusions: The psychological status of
women with AF associated with high
degree of clinical manifestations. QOL can
be an indicator of the efficacy of catheter
ablation.
ATRIAL FIBRILLATION ABLATION IN
ELDERLY PATIENTS: A SINGLE CENTRE
RESULTS
S. Grossi, C. De Rosa, F. Bianchi, A. Sibona
Masi, M.R. Conte
Mauriziano Hospital, Turin, ITALY
Background: The prevalence of atrial
53
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ATRIAL FIBRILLATION: CLINICAL ISSUES
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION: CLINICAL ISSUES
fibrillation increases with age. Catheter
ablation is an established treatment option
for patients with syntomatic AF.
We analized data of AF procedures in
patients over 75 years to determinate
safety and clinical short term efficacy.
Methods and results: From 2004 to
2015, a total of 171 patients 109 male
(median age 77 ± 2 years) underwent to
atrial fibrillation ablation in our centre. Of
these, 50 (29%) had hypertension like a
cardiovascular basal risk factor. Median
Chads2 vasc score was 4 ± 1. 16% of
total patients had CAD as basal
cardiopathy. 22% of patients underwent to
a redo procedure.
Patter of atrial fibrillation was divided as
follows: 52% (72 pts) parossistical, 37%
(53 pts) persistent, 11% (13 pts) long
lasting persistent.
Median follow up was 49±22 months.
After procedure, final rhytm was sinus
rhytm in 149 patients (87%); at follow up,
72% of total patients was in stable SR
(83% parossistical, 13% persistent AF, 4%
long lasting persistent. At follow up, 71%
(122 pts) of total patients used
antiarrhythic drugs.
Mayor complications occur in 1% of total
procedures, while minor complications
occur in 3% of total patients.
Conclusion: in our elderly population,
catheter ablation is associated with a
favourable clinical outcome, and safety
profile of AF ablation is comparable with
patients of younger age.
54
IS IT POSSIBLE TO STOP ORAL
ANTICOAGULATION AFTER
SUCCESSFUL ATRIAL FIBRILLATION
ABLATION?
E. Pelissero, C. Amellone, M. Giuggia,
G. Trapani, B. Giordano, G. Senatore
Ospedale Civile di Ciriè, Ciriè, ITALY
Background: Management of oral
anticoagulation therapy (OAT) among
patients treated with successful atrial
fibrillation catheter ablation (AFTCA) is
controversial, The aim of the present study
is to evaluate the safety of a long term
antithrombotic management based on
arrhythmic recurrences.
Methods: We retrospectively analyzed
management of OAT after AFTCA in
patients followed up with continuous
rhythm assessment with implantable
cardiac monitor (ICM). Patients were
divided into 4 groups: patients in SR on
OAT , patients in SR off OAT (group B),
patients in SR off OAT but on Aspirin
(group C), and patients in AF continuing
OAT (group D). An AF burden higher
than1% and/or a single episode of AF
lasting more than 1 hour were set as cutoffs to define AFTCA as unsuccessful.
Results: 257 patients were enrolled, and
followed up for a mean of 35.04 ± 19.36
(4-116) months; 176 patients (68.4%)
maintained SR during the whole follow-up,
and 125 (71%) of them discontinued OAT
irrespective from CHA2DS2VASC score. No
stroke, transient ischemic attack nor
systemic embolism were documented.
Nine bleedings were observed (3 major, 6
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
minor): in 8 cases among patients in SR,
1 on aspirin therapy and seven on OAT
therapy. OAT continuation among patients
in SR appeared to be the strongest
predictor of bleeding risk, not
counterbalanced by an increase in
thromboembolic risk.
Conclusion: OAT management through
continuous rhythm monitoring by ICM
appears to be a safe method to balance
thromboembolic and bleeding risk in
patients maintaining SR after AFTCA.
NEWLY DIAGNOSED ATRIAL
FIBRILLATION AFTER DUAL CHAMBER
PACEMAKERS IMPLANTATION: THE
IMPORTANCE OF RIGHT VENTRICLE
PACING SITE
A. Monteiro, M. Oliveira, P. Silva Cunha,
A. Lousinha, P. Osorio, B. Valente, S. Aguiar
Rosa, D. Severino, A. Delgado, S. Covas,
M. Braz, R. Cruz Ferreira
Hospital de Santa Marta - Centro Hospitalar
Lisboa Central, Lisbon, PORTUGAL
Little is known about the incidence of
atrial fibrillation (AF) and AF burden after
atrial and dual-chamber (DDD) pacing
implantation, and what is the relation of
AF occurrence with the right ventricle (RV)
pacing site.Purpose: assess the incidence
of newly AF episodes after DDD
pacemaker implantation and analyzed the
its correlation with lead location in RV.
Methods: from 2011 to 2015, a total of
657 consecutive DDD pacemaker patients
(P) with AV block or sick sinus syndrome,
with no prior history of AF, were followed
for a mean of 20.9±16.7 months.
Occurrence of AF, total AF burden and
cumulative atrial and RV pacing % were
investigated for both pacing sites: RV apex
(RVap) and septal (RVsp) sites.Results: RV
pacing leads were located in the RVap and
RVsp positions in 56.2% and 43.8%,
respectively. Newly occurrence of AF was
observed in 171P (26.0%) during the
follow-up period.Compared to non-AF P,
those with AF had similar age (73.9±9.96
vs. 72.8±10.9 years, p=ns), % of RV
pacing (64.9±39.0% vs. 58.7±44.3%,
p=ns) and % of atrial pacing (53.4±33.5%
vs. 49.9±42.7%, p=ns). P with lead
position in RVsp site presented similar %
of RV pacing (58.8±43.0% vs.
58.4±44.0%, p=ns) and % of atrial pacing
(51.6±40.3% vs. 49.1±39.8%, p=ns),
with a lower incidence of AF (16.2% vs.
32.9%, p<0.001). Conclusions: RVap lead
position and RVap pacing >50% were
strongly associated with AF episodes.
Regarding the recognized clinical impact
of AF, careful RV lead location and device
algorithms for minimization of RV pacing
should be taken into consideration.
THE BURDEN OF ATRIAL FIBRILLATION
IN PATIENTS WITH DILATED
CARDIOMYOPATHY AND IMPLANTABLE
CARDIOVERTER-DEFIBRILLATOR:
THE ROLE OF REMOTE MONITORING
R. Morgagni, A. Sanniti, C. Peccenini,
L. Santini, G.B. Forleo, F. Romeo
Fondazione Policlinico Tor Vergata, Rome, ITALY
Introduction: implantable cardioverter55
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Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION: CLINICAL ISSUES
defibrillator (ICD) is effective in detecting
and
promptly
treating
cardiac
tachyarrhythmias. Atrial fibrillation (AF),
the most common tachyarrhythmia, often
silent, carries a five-fold risk of stroke, a
three-fold incidence of heart failure and
higher mortality. Methods: we studied 215
patients (mean age 73.7 ± 8.6) with DCM
and ICD implanted for primary prevention
of SCD. All patients had remote monitoring
(RM). Follow-up was 24 months. Exclusion
criteria: single chamber ICD, history of any
kind of AF, short and single episodes of AF.
Results: 19/215 patients (8,83%) had > 1
episode of AF, most of them (14/19)
asymptomatic, therefore undetectable
without RM. 9 patients had persistent AF,
whereas 10 had the paroxysmal form;
subsequently, in 3 patients of the latter
group, AF switched to persistent. Detection
of AF by RM triggered an appropriate
treatment: all patients were called back
and admitted to the outpatient clinic of our
hospital, then underwent to a thorough
clinical evaluation and were administered
oral anticoagulation drugs. 9 patients were
hospitalized and treated successfully by
DC shock, 1 patient chose a rate-control
therapy. No embolic events were
documented. Conclusions: RM plays a
pivotal role in detecting episodes of AF in
DCM patients with ICD. Early detection of
symptomatic as well as asymptomatic AF
is clinically relevant triggering timely
treatment of the tachyarrhythmia,
optimization of medical therapy, ICD reprogramming.
56
THE DIAGNOSIS OF SUBCLINICAL
OBSTRUCTIVE SLEEP APNEA BASED
ON RESPIRATORY MONITORING
ALGORITHMS OF PACEMAKERS IS
ASSOCIATED WITH HIGHER BURDEN OF
ATRIAL FIBRILLATION
T. Guimarães 1, P. Marques 1, G. Lima Da
Silva 1, M. Nobre Menezes 1, J. Agostinho 1,
I. Gonçalves 1, M. Dias 2, N. Cortez-Dias 1,
P. Pinto 2, J. De Sousa 1, F.J. Pinto 1
1
Santa Maria University Hospital- Department
of Cardiology, Lisbon, PORTUGAL, 2 Santa
Maria University Hospital- Department of
Pneumology, Lisbon, PORTUGAL
The cause-effect relationship between
obstructive sleep apnea (OSA) and atrial
fibrillation (AF) is controversial and it´s
debatable whether OSA is only a
coexisting condition among patients with
AF or true causal factor.
Purpose: To compare the arrhythmic
burden of AF in patients with diagnosis of
OSA by polysomnography (PSG) criteria or
by pacemaker monitoring algorithms (RDIPM) criteria.
Methods: Single center prospective study
of consecutive patients without previous
diagnoses of AF submitted to doublechamber pacemaker implantation or
generator replacement, using the Reply
200TM device. Patients underwent clinical
interview to access OSA symptoms and
PSG overnight study with RDI
determination. RDI-PM during the period
of the PSG study was registered.
Results: A total of 24 patients (63% male,
aged 75±11 years) were studied. The
XVII
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2016
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ATRIAL FIBRILLATION: CLINICAL ISSUES
FREE PAPERS
diagnosis of OSA was established based
on the AASM criteria, RDI-PM greater than
20 and RDI-PM greater than 17,5 in 50%,
54% and 58%, respectively. AF burden
was statistically similar in patients with
OSA diagnosis based on AASM criteria
versus non-OSA patients (0 [0 - 3.3] vs 0
[0 -1.4], p = NS). Similar findings were
found in patients with OSA diagnosis
based on RDI-PM greater than 20 (0 [0 24.5] vs 0 [0-0]; p = NS). However, using
the RDI-PM greater than 17,5 criteria,
patients with OSA have higher AF burden
versus non-OSA patients (6,5 [0 - 14.3] vs
0 [0-0 ] p = 0.028).
Conclusion: Early diagnosis of subclinical
forms of OSA by RDI-PM may have
potential implications in the detection of
concomitant arrhythmias.
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
57
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION:
IMPACT OF MODERN TECHNOLOGIES
IS A SYSTEMATIC USE OF MAPPING
SYSTEMS DURING CATHETER
ABLATION PROCEDURES IN CHILDREN
AND TEENAGERS “COST - EFFECTIVE”?
A SNAPSHOT OF OUR EXPERIENCE
F. Guarracini 1, M. Marini 1, M. Del Greco 2,
D. Ravanelli 3, A. Cima 2, A. Coser 1, G.
Porcedda 4, A. Valentini 3, R. Bonmassari 1
1
Department of Cardiology, S. Chiara Hospital,
Trento, ITALY, 2 Department of Cardiology, S.
Maria del Carmine Hospital, Rovereto (TN),
ITALY, 3 Department of Physics, S. Chiara
Hospital, Trento, ITALY, 4 Department of
Pediatrics, Meyer Hospital, Florence, ITALY
Introduction: The aim of this study was to
evaluate the cost effectiveness of an
extended use of mapping systems (MS)
during paediatric catheter ablation (CA) in
an adult EP Lab.
Methods: This study is a retrospective
analysis that includes consecutive young
patients (58 pts, aged between 8-18) who
underwent CA. We compare the
fluoroscopy data of group I (pts who
underwent CA from 2005 to 2008 using
only fluoroscopy) and group II (pts who
underwent CA from 2008 to 2015
performed also using MSs).
Results: The use of a MS during CA
resulted in a reduction of the fluoroscopy
time for pts in Group II by comparison with
pts in Group I and the difference between
the two groups in median effective dose
was 2.8 mSv (3.04 mSv in Group I and
0.25 mSv in Group II, MW-test P < 0.05).
58
If we consider the man-sievert monetary
value, i.e. the monetary reference value of
the avoided unit of exposure, we can use
this value to judge the cost-effectiveness
of the use of MS during CA. Our extra cost
of using a MS for CA is € 2,500 per pt. It is
evident if we compare our cost with the
average man-sievert monetary value in
Europe, it is cost-effective (1361.64
Euro/mSv*2.8 mSv= 3811.75 Euro/pt vs
€ 2,500 per pt).
Conclusions: The amount of X-ray
exposure reduction reported in our “reallife” study makes a strong case for the
daily use of a MS during CA and it seems
to be cost effective.
PREDICTION OF ATRIOVENTRICULAR
BLOCK DURING RADIOFREQUENCY
ABLATION OF TYPICAL
ATRIOVENTRICULAR NODAL REENTRY
TACHYCARDIA
N. Fragakis, L. Krexi, M. Sotiriadou,
S. Tsakiroglou, G. Kotsiouros, P. Kyriakou,
V. Skeberis, V. Vassilikos
Hippokrateion Hospital, Medical School,
Aristotle University of Thessaloniki - Third
Cardiology Department, Thessaloniki, GREECE
Background: Occasionally radiofrequency
(RF) ablation of the slow pathway (SP) of
atrioventricular nodal reentry tachycardia
(AVNRT) is complicated with various
degrees of atrioventricular block (AVB)
predicted by junctional beats (JB) with loss
of ventriculo-atrial conduction.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Aim/Methods: We sought to evaluate
whether the conduction time measured
between the atrial electrograms recorded
on the His-bundle position, the distal
ablation catheter [A(H)-A(RFd)] and on the
proximal coronary sinus catheter [A(H)A(CS)] as well as the A(RFd)-A(CS) may
predict a) the risk of AVB b) the acute
recurrence and c) the modification or
complete elimination of SP. We also
investigated whether age influences the
risk of AVB. We analysed retrospectively
the above intervals in 153 patients.
Results: The A(H)-A(RFd) and A(CS)-A(RFd)
intervals were much shorter in RFs
causing JB with loss of conduction than in
RFs with JB with ventriculo-atrial
conduction
(35±11ms
vs
29±11ms,P<0.001,
17±8ms
vs
8±8ms,P<0.001, respectively). The A(H)A(RFd) interval was also shorter in
complete elimination than in modification
of slow pathway (34±11ms vs
37±10ms,P<0.05). In contrast, reinduction of AVNRT after RFs with JB could
not be predicted. In patients aged 48 years
old and over loss of ventriculo-atrial
conduction was 20.71% more likely to
occur than youngers possibly due to a
shorter A(H)-A(CS) interval that was found
in this age group (18±8ms vs
21±10ms,P=0.023).
Conclusions: The A(H)-A(RFd) and A(CS)A(RFd) intervals can be used as markers
for
predicting AVB and complete
elimination of SP during RF of AVNRT. JB
with loss of ventriculo-atrial conduction
occur more often in older age possibly due
to a closer location of fast pathway to the
area of slow pathway.
ELECTROGRAM CHARACTERISTICS
OF SPECIFIC SUBSTRATE
MECHANISMS DURING ATRIAL
TACHYCARDIA WITH HIGH-DENSITY
MAPPING
A. Frontera, M. Takigawa, N. Thompson, E.
Teijeira, G. Cheniti, J. Wielandts, S.
Amraoui, C. Camaioni, A. Chaumeil, A.
Denis, F. Sacher, M. Hocini, P. Jais, M.
Haissaguerre, N. Derval
Univ. Bordeaux, Centre de recherche CardioThoracique de Bordeaux, Bordeaux, FRANCE
Introduction: Multiple mechanisms have
been described that result in EGM
fractionation in the atrium. With the
Rhythmia mapping system, we
investigated the relationship between
different substrate phenomena and EGM
characteristics at those sites.
Methods: 20 consecutive patients
underwent high-density atrial mapping
during AT. Activation maps (17556±6093
points per patient) were collected before
ablation. Activation and voltage maps
were analyzed offline. Slowly conducting
wave-fronts, lines of block and wave
collision were identified. EGMs were
analyzed in terms of amplitude, duration,
and morphology.
Results: 20 atrial maps and 143 sites of
59
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WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 2]
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
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WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION:
IMPACT OF MODERN TECHNOLOGIES
interest (a total of 678 EGMs) were
analyzed. 53 sites of slow conduction
were identified. EGM fragmentation at
these sites were comparatively low
amplitude (mean 0.13 mV ±0.05 mV) with
long duration (mean 96±14.9 ms). There
was an inverse relationship between
voltage amplitude and duration of
fractionation. These EGMs clustered
mostly at the margins of dense scar. 61
wavefront collisions were identified. EGM
fragmentation at these sites were short in
duration (44.5 ± 10 ms) with higher
voltage (0.40 ±0.3 mV). 29 lines of block
were identified (mean amplitude 0.11 ±
0.08 mV and mean duration 120 ms ± 24
ms) and were characterized by a double
potential (with wavefronts on either side
of the line) separated by an isoelectric line.
Conclusions: With high-density mapping
during AT, specific and reproducible
characteristics of fractionated signals are
observed with different substrate
mechanisms. The accurate identification
of sites of slow conduction may help guide
the ablation of atrial arr<hythmias and
insight into the substrate critical to the
maintenance of AF.
HIGH RESOLUTION MAPPING FOR
ATYPICAL RIDGE-DEPENDENT LEFT
ATRIAL FLUTTER ABLATION
M. Russo 1 , C. Pandozi 1 , C. Lavalle 1 ,
M. Galeazzi 1, F. Piergentili 2, F. Colivicchi 1
1
San Filippo Neri Hospital, Rome, ITALY, 2 on
behalf of Boston Scientific
60
We present the case of a 54 year-old male
referred to our hospital for symptomatic
persistent atypical atrial flutter that was
finally eliminated using a novel high
density mapping system.
The 3-D right atrial geometry was created
from the basket mapping catheter
IntellaMap Orion and the RHYTHMIA™
Mapping System (Boston Scientific). A
trans-septal access was carried out in
order to completely map the left atrium.
The standard activation map revealed a
usual peri-mitralic atrial flutter with
concealed entrainment in left appendage.
(Fig 1)
The remap with the Orion catheter showed
a lazy propagation around the ridge
suggesting the presence of a masked slow
conduction. The propagation map showed
two different fronts: the first located
around the mitral valve and rear the left
PVs; this faster wave-front reached the
mitral isthmus area and stopped as met a
block line. The second wave-front
emerged from the roof and joined the front
ridge front and channeling into a merged
propagation wave-front supporting the
circuit. (Fig2-A,B,C). We applied
radiofrequency in this area interrupting the
tachycardia and restoring the sinus
rhythm. (Fig 3)
The small, close, and low-noise minielectrodes of OrionTM catheter may be
advantageous for mapping very low
voltage potentials thus allowing fast
geometrical and electrical reconstruction
XVII
International Symposium
on Progress
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2016
Rome, Italy - NOV 29 - DEC 2, 2016
of critical areas during mapping and
ablation.
Additionally,
“Donut”
representation of the propagation map
allowed a clear comprehension of the
activation pathway ensuring an effective
and safe ablation approach.
MULTI-CATHETER CRYOABLATION VS.
OPEN-IRRIGATED RADIOFREQUENCY
FOR ABLATION OF CHRONIC
PERSISTENT ATRIAL FIBRILLATION:
ACUTE PROCEDURAL RESULTS FROM A
RANDOMISED TRIAL
Y. Gang, G. Domenichini, I. Harding, H.
Gonna, M. Sampson, A. Bajpai, Z. Zuberi,
A.J. Camm, M.M. Gallagher
Cardiology Clinical Academic Group, St.
George’s University Hospitals NHS Foundation
Trust, London, UNITED KINGDOM
Background: Comparative data remain
regarding the relative efficacy of
cryoballoon
(CB)
ablation
and
radiofrequency (RF) ablation in chronic
persistent atrial fibrillation (CPAF). The
objective of restoring sinus rhythm by
ablation alone is
commonly used in RF
cases but has not
been
attempted
systematically with
cryotherapy.
Methods: Consecutive
patients undergoing
their first left atrial
ablation for persistent AF of >3 months
duration were prospectively screened.
Participants were ran<<<domised to CB
or RF in a 1:1 manner. For CB, a 28mm
Arctic Front Advance was used in tandem
with focal cryoablation catheters. Openirrigated, non-force sensing catheters
were used in the RF group with a 3D
mapping system. Pulmonary vein (PV)
isolation (PVI) and non-PV triggers were
targeted in all cases. All procedures were
performed by the same experienced
operator who was blinded to the
randomisation group before scrubbing. All
participants were systematically followed
up at 3, 6, and 12 months post-procedure.
Results: Clinical characteristics were
similar except that AF duration was longer
in the CB group (table). Acute PVI was
achieved in all cases. Significantly more
patients in the CB group were ablated to
sinus rhythm, and procedure time was
shorter in the CB group (table). No
significant difference was found between
the study groups in fluoroscopic time,
anaesthesia mode, or rate of
61
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WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 2]
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Orange 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION:
IMPACT OF MODERN TECHNOLOGIES
complications.
Conclusion: CB ablation leads to acute
restoration of SR in more cases and
shortens overall procedure time compared
with conventional RF ablation. Longer
follow-up is needed to determine whether
multi-catheter cryoablation can improve
long-term procedural efficiency and
efficacy.
THORACOSCOPIC ABLATION FOR
ATRIAL FIBRILLATION IN UNSELECTED
GROUP OF PATIENTS
E. Kropotkin, E. Ivanitskiyvanitskiy, O.
Bobrovskiy , V. Sakovitch
Federal Centre For Cardiovascular Surgery Department of Cardiac Surgery Unit 2,
Krasnoyarsk, RUSSIA
Aim of a study: to assess safety and
effectiveness of minimally invasive video
assisted thoracoscopic ablation for atrial
fibrillation in unselected group of patients.
Methods and patients: 36 consecutive
patients (mean age 56 + 18 years) with
symptomatic atrial fibrillation refractory to
at least 1 anti arrhythmic drug were
enrolled in a study. 14 patients were
present with a paroxysmal atrial
fibrillation, in 12 of them unsuccessful
radio frequency catheter ablation was
performed; 19 patients - with persistent,
in 6 patients at least one unsuccessful
radio frequency catheter ablation was
performed; 3 patients were present with
long standing persistent form. Anti
62
arrhythmic drugs were discontinued after
6 month’s of follow up. 24 hours hotter
monitoring and echocardiographic
examinations were performed at 6 and 12
month;s of follow up period. 3 month’s
after the procedure was defined as
blanking period. Two patients were lost
from the study. In first 12 patients
procedure was performed by using Gemini
device, in the other - by using Atri Cure.
Mean follow up period was 18 + 6
month’s.
Results: 6 month’s effectiveness in
unselected group of patients was 84%
and at 12 month’s effectiveness was 72%.
No convertions to sternotomy due to
bleeding were performed. Mean inhospital stay was 6,7 + 1,2 days.
Conclusion: video-assisted thoracoscopic
minimally invasive atrial fibrillation
ablation in unselected group of patients is
safe and effective and could a variant of
choice in patients after unsuccessful radio
frequency catheter ablation.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
STANDARD VERSUS EXTRATHORACIC
VEIN PUNCTURE IN DEVICE LEAD
IMPLANTATION: A SINGLE-CENTRE,
NON-RANDOMIZED RETROSPECTIVE
STUDY
R. Nangah 1, R. Marinigh 1, K. Brunzin 1, K.
Pettenuzzo 1, A. Crepaldi 2, F. Di Pede 1
1
Uoc Cardiologia Ulss 10 ‘Veneto Orientale’,
San Dona di Piave, ITALY, 2 St Jude Medical,
Milan, ITALY
Aim: The most widely used approach for
lead insertion in patients requiring device
implants is the percutaneous subclavian
vein puncture technique (SV). This may
however lead to complications such as
hematoma, pneumothorax etc. Recent
studies demonstrated that the extra
thoracic puncture (ET) is superior to the
classical SV in terms of complications. In
this study we report our experience
focusing on complications and length of
hospital stay in patients who undergo
device implantation
Method: We conducted a singlecenter,
retrospective,
non-randomized comparison of the
two approaches. We reviewed
patients who had consented to
receiving a permanent pacemaker
or cardioverter defibrillator implant
from January 2010 to December
2015. The population was divided
into two classes: the SV class and
the ET class. For all the 381
procedures (186 ET) we retrieved
multiple information concerning type of
device implanted, procedural times, acute
complications (pocket drainage or
infection, hematoma, emphysema, lead
dislodgment,
pneumothorax
and
pericardial effusion), and length of hospital
stay
Results: No difference was observed
between ET and SV group in mean patient
age, implant indications and fluoroscopy
times. The ET group showed longer
procedural time (72,7±42,9 vs 64,1±35,4
min, p=0,0349) probably due to a higher
percentage of CRT devices implanted
(13% vs. 7%, p=0,0399). The ET group
registered less complications (2,4% vs.
13,8%, p=0,0001) and a shorter
hospitalization period (number of patients
demanding a hospitalization period longer
than 5 days: 15,4% vs 28,7%, p=0,0035)
Conclusion: ET approach correlates with
less complications and, as a consequence,
shorter hospitalizations
63
FREE PAPERS
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
LEFT VENTRICULAR LEAD PLACEMENT
BY TRACTION FOR CARDIAC
RESYNCHRONIZATION: A FEASIBILITY
EVALUATION
G. Lima Da Silva, P. Marques, T. Guimarães,
A. Bernardes, J. De Sousa, F.J. Pinto
Cardiology Department, University Hospital of
Santa Maria, LMAC, Lisbon, PORTUGAL
Purpose: Evaluate the feasibility of LV
lead implantation by traction with
guidewire support and Snare extraction
system in patients with unfavorable
venous anatomy that failed implantation
by the conventional technique..
Methods: Single-center study of
consecutive patients referred to CRT
implantation in which the conventional LV
lead implant approach was ineffective due
to unfavorable venous anatomy and
placement of the LV lead by
traction with support of a
guidewire and Snare extraction
was performed. The first part of
the technique consists of CS
cannulation as usual. The
guidewire is then advanced
through collateral veins until it
reenters the CS and, in some
cases, the right atrium. A snare
system is then introduced through
another subclavian puncture, and
the guidewire is captured and
pulled to the exterior forming a
loop. The LV lead is then advanced
antidromically or orthodromically
64
to the target position (Figure 1).
Results: LV lead implant by traction was
attempted on 39 patients, after failure of
the conventional implant techniques. The
technique was effective in all patients. LV
lead positioning in a lateral (N=21),
anterolateral (N=4) or posterolateral
(N=14) vein. The mean duration of the
procedure was 95 minutes, with a
fluoroscopy mean time of 16 minutes
There were no immediate complications.
Conclusion: LV lead implantation by
traction with support of guidewire and
Snare extraction system enables proper
positioning of the LV lead in patients with
unfavorable venous anatomy in whom the
conventional technique was unsuccessful,
thereby minimizing the need for surgery
and an epicardial implant.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
TRICUSPID VALVE REGURGITATION IN
PATIENTS AFTER DEVICE
IMPLANTATION
E. Kropotkin, E. Ivanitskiy, A. Pavlushkin, D.
Shlyakov, V. Sakovitch
Federal Centre for Cardiovascular Surgery Department of Cardiac Surgery Unit,
Krasnoyarsk, RUSSIA
Aim of a study: to assess tricuspid valve
regurgitation in patients after anti
arrhythmic device implantation.
Patients and methods: we retrospectively
analyzed data of 620 patients (mean age
51 + 34 years) who came in our centre for
device replacement due to battery
depletion. 518 patients had pacemaker
implanted (56 with single chamber
pacemaker, 462 with dual chamber
pacemaker); 34 patients had CRT-P
implanted; 28 patients had CRT-D
implanted; 22 patients with single
chamber ICD; 18 patients with dual
chamber
ICD.
Echocardiographic
examination for tricuspid valve function
assessment was performed in all patients
in our centre. We could find
echocardiographic data with tricuspid
valve parameters before or at the moment
of device implantation in 86 patients. 28
patients were present with two ventricle
leads, 6 patients were present with 3
ventricle leads. In 312 patients ventricle
leads were positioned in the right ventricle
apex, in 308 patients ventricle leads were
positioned into the right ventricle outflow
tract. 381 leads had screw in type of
fixation and 239 leads had passive type of
fixation. Mean follow up period was 7,4 +
3,6 years.
Results: tricuspid valve regurgitation in
patients with resynchronization devices
decreased from 3,2 to 2,1(p=0,0008)
grade. In patients with pacemakers
tricuspid valve regurgitation increased
from 1,3 to 2,1 grade (p=0,009).
Conclusion: many factors affect tricuspid
valve regurgitation in patients with
implanted device including ventricle
remodeling, place of lead fixation, type of
arrhythmia, type of device and valve
damage by ventricle leads.
UNEXPECTED TECHNICAL PROBLEMS
DURING TRANSVENOUS LEAD
EXTRACTION. EXPERIENCE AMONG
2022 PROCEDURES
A. Kutarski 1, W. Jachec 2, A. Tomasik 2, M.
Czajkowski 3, R. Pietura 4, B. Obszanski 5,
M. Polewczyk 6, A. Polewczyk 7
1
Department of Cardiology, Medical University
of Lublin, Lublin, POLAND, 2 2nd Department
of Cardiology, Silesian Medical University,
Zabrze, POLAND, 3 Department of Cardiac
Surgery Medical University of Lublin, Lublin,
POLAND, 4 Department of Radiography Medical
University of Lublin, Lublin, POLAND, 5
Department of Cardiology The Pope John Paul
II Province Hospital, Zamosc, POLAND, 6
District Hospital, Intensive Cardiac Care Unit,
Kielce, POLAND, 7 The Jan Kochanowski
University, Department of Medicine and Health
Sciences, Kielce, POLAND
65
FREE PAPERS
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
Introduction: Major and
minor TLE complications
were described widely,
however less attention
was paid to unexpected
TLE technical problems,
which unsolved may
cause procedure failure or
may lead to following complications.
Objective: retrospective analysis of our
data-base in aspects of appearance of
different lead extraction related technical
problems.
Methods: Using standard non-powered
mechanical systems we have extracted
ingrown PM/ICD leads from 2022 patients,
(60% males), non-infectious indications
consisted 60%, infective - 40%. 42% were
PM DDD system, 13% PM VVI, 21% ICD,
6% CRT-D. 15% patients had abandoned
leads. Average dwell time of all leads was
83 months. Left subclavian lead entry
(&combined) was utilized in 95%, right
subclavian in 2%. Combined approach
(“difficult lead” extraction) - subclavian +
femoral + jugular in different compilation
was used in 3%. Results are presented in
the table. Observations: Technical
„complications” may prolong the
procedure and make it extremely difficult;
serious technical problems appear in < 7
% of TLE if mean lead body dwelling time
> 7 years, bag of technical problems is
large and in most cases non-standard tips
and tricks with utility of TLE-dedicated &
non-dedicated tools are required.
66
Conclusions: Technical TLE problems
using non-powered mechanical sheaths
appeared in 16% cases, prolonging the
procedure. In such cases the operator
must be experienced with numerous
complementary techniques to complete
the procedure. Management with rescue
options to solve the problem should be the
part of TLE education and training.
A LEAD THAT COULD HELP US TO
SURMOUNT SOME PROBLEMS
A. Mengoni 1, G. Zingarini 2, A. Tordini 1, G.
Ambrosio 1, C. Cavallini 2
1
Cardiology
and
Cardiovascular
Physiopathology, Santa Maria della
Misericordia Hospital, Perugia, ITALY, 2
Cardiology, Santa Maria della Misericordia
Hospital, Perugia, ITALY
In the biventricular implant, the left
ventricle (LV) lead is positioned in a branch
of coronary sinus but its anatomy can be
unfavourable to progress or to fix the lead
to the target position. We can have a
suboptimal placement of the lead or its
dislodgement or a phrenic nerve
stimulation. These situations are reasons
of not responder at the cardiac
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
resynchronization therapy (CRT). We
reported three cases in which we had
used the Model 20066 Medtronic LV Attain
Stability®. It is a bipolar active fixation
lead, with exposed side helix that enables
fixation by clockwise rotation. If lead
reposition
is
necessary,
a
counterclockwise rotation easily allows
the manoeuvre.
Case 1. The coronary sinus angiography
showed a wide main vein and wide
branches. We used the Stability lead® to
have more probability of lead firmness. At
the 6 month follow-up LV stimulation
threshold remains good (Pannel A-B).
Case 2. A 66 years old man, with a
biventricular
pacemaker-implantable
cardioverter defibrillator (biv PM-ICD), was
referred to our hospital for LV lead
dislodgement. The PM electronic control
showed a high threshold capture (8V-0.5
ms). We replaced the dislodged LV lead
with the Stability®. The threshold capture
was good and it remains stable at 7
months (Pannel C-D).
Case 3. A 72 years old man with a biv PMICD implanted, came into our clinic for
persisting phrenic nerve stimulation. We
overhauled the implant and used
Stability®. A good stimulation threshold
without phrenic nerve capture was
obtained and remained stable at 3 month
follow-up.
THE IMPACT OF CHANGES IN LEFT
VENTRICULAR EJECTION FRACTION
AND RENAL FUNCTION AT FIRST
REPLACEMENT ON THE PROGNOSIS OF
ICD PATIENTS
B. Vandenberk, T. Robyns, C. Garweg, J.
Ector, R. Willems
University of Leuven, Leuven, BELGIUM
Background: Whether changes in EF or
renal function at the time of ICD
replacement should guide the decision to
replace remains unclear.
Methods: All patients who received an ICD
with ischemic (ICM) or non-ischemic
cardiomyopathy (NICM) were included in
a retrospective registry. The association of
changes in EF and renal function at ICD
replacement with mortality was studied
using Cox regression analysis. EF was
dichotomized at 35%, renal function by a
67
FREE PAPERS
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC PACING TROUBLES AND TROUBLESHOOTING
change in creatinine of 0.40mg/dL.
Results: In a total of 727 patients, 243
(33.4%) underwent ICD replacement
(mean device longevity: 6.2±2.2y and
mean follow-up: 9.5±3.4y).
The EF remained stable >35% in 70
(28.8%) patients and stable <35% in 90
(37.0%) patients. Worsening of EF was
observed in 48 (19.8%) patients and was
more frequent in ICM (87.5%, p<0.001).
EF improvement occurred in 35 (14.4%)
patients, with 51.4% primary prevention
indication and an equal distribution for
etiology. Of 56 patients with a CRT device,
in 17.9% EF improvement was observed
and only 1.8% had EF worsening. In nonCRT devices EF deterioration was more
common (25.1%, p<0.001). Compared to
patients with stable EF >35%, only
patients with stable EF <35% were at
increased risk of mortality (HR 2.98,
95%CI 1.63-5.45).
Worsening of renal function was observed
in 45 (18.5%) patients and was associated
with lower baseline EF (32±10% versus
38±10%, p=0.001). Renal worsening was
associated with increased mortality (HR
4.79, 95%CI 2.69-8.54).
Conclusions: EF assessment and
worsening of renal function at the time of
ICD replacement are predictors of
mortality.
68
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
TRANSCORONARY GRADIENT OF
CIRCULATING MICRORNAS IN HEART
FAILURE
F. Esposito 1, S. De Rosa 2, J. Sabatino 2, A.
Strangio 2, A. Agresta 1, C. Carella 1, A.
Curcio 2, E. Koci 1, C. Indolfi 2, A.
Rapacciuolo 1
1
Federico II University, Naples, ITALY, 2 Magna
Grecia University, Catanzaro, ITALY
Background: Circulating levels of
microRNA (miRs) are emergent promising
biomarkers for cardiovascular disease.
Altered expression of miRs has been
related to heart failure and cardiac
remodeling.
Purpose: To identify the heart as a
potential source for miRs released into the
circulation,
we
measured
the
concentration gradients across the
coronary circulation for the miR-34a
(whose levels have been associated to LVremodeling and prognosis); miR-126
(whose decrease has been associated to
an impaired cardiac repair capacity); the
miR-21-3p, actively involved in mediating
HF and LV-hypertrophy, and the miR-423
that is highly regulated in HF patient.
Methods: Circulating miRs were
measured by TaqMan polymerase chain
reaction in EDTA-plasma simultaneously
obtained from the aorta (Ao) and the
coronary venous sinus (CVS) in patients
with non-ischemic heart failure (nonICMHF, n=23), or ischemic heart failure
(ICM-HF) (n=41).
Results: Circulating levels of the miR-34a
(2.3-fold increase), the miR-423 (4.4-fold
decrease), the miR-21-3p (1.6-fold
decrease), and the miR-126 (1.3-fold
decrease) were differently modulated in
nonICM-HF compared to ICM-HF patients.
Interestingly, there was a positive
transcoronary concentration gradient for
the miR-34a in the nonICM-HF group
(p<0.05) as well as of the miR-423 in the
ICM-HF group (p<0.05), suggesting a
release of a specific microRNA into the
coronary circulation of HF patients with
different etiology.
Conclusions: Multiple circulating miRs
are differently regulated between
ischemic and non-ischemic HF patients.
The differential regulation of circulating
miRs during the transcoronary passage in
HF might foster their use as cardiac
biomarkers, especially to differentiate
between HF of different etiologies.
CLINICAL MANAGEMENT USING
CONGESTION MONITORING IN
PATIENTS IMPLANTED WITH DUALCHAMBER OR SINGLE CHAMBER
PACEMAKER (ASSURE CARE):
PRELIMINARY DATA
G. Giannola 1, G. Picciolo 2, P. Vaccaro 3, G.
Carreras 4, A. Cardinali 5, V. Nissardi 6, V.
Calabrese 7, R. Torcivia 1, P Crea 2, E. Lo
Giudice 3, S. Donzelli 8, B. Iadanza 5, R.
Floris 6, D. Ricciardi 7
1
Fondazione HSR G. Giglio, Cefalu’, ITALY, 2
Policlinico G. Martino, Messina, ITALY, 3 Ao
69
FREE PAPERS
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
Ospedali Riuniti Villa Sofia e Cervello, Palermo,
ITALY, 4 San Giovanni Hospital, Rome, ITALY, 5
Cdc Villa Letizia, L’Aquila, ITALY, 6 San Giovanni
di Dio Hospital, Cagliari, ITALY, 7 Policlinico
Universitario Campus Biomedico, Rome, ITALY,
8
Ao S. Maria, Terni, ITALY
Background: With the progressive ageing
of the population, the incidence of heart
failure (HF) and the use of permanent
pacemakers have increased over the
years.
Most of HF hospitalizations is caused by
fluids accumulation; this condition may be
associated with a decrease of
transthoracic impedance (TTI). Some
implantable cardiac devices measure the
TTI to detect the fluid accumulation in the
lungs, allowing the early detection of
pulmonary congestion caused by
heart failure.
This feature may be an effective
tool
for
a
preventive
management of HF.
Methods: ASSURE CARE is an
observational
multicenter
prospective registry that aims to
verify
the
congestion
management
in
patients
implanted with single-chamber
and dual-chamber pacemakers
through remote monitoring, when
compared with the patient selfassessment with audible alarms.
The registry enrolled 130 patients
to be followed up to 2 years every
70
6 months (50% remote monitoring and
50% via the audible alarms).
Results: From December 2014 to August
2016, 130 patients were enrolled: 66 pts
in the remote group and 64 in audible
alarms, in 7 Italian sites. The assignment
to the 2 groups (remote or audible alarms)
is based on the sites’ clinical practice. The
statistical analysis showed that there were
no significant differences between the two
group as in the Table 1.
Conclusion: The ASSURE-CARE registry
was designed to assess if it is possible to
follow-up these patients also using selfmanaged alarms instead of remote
monitoring. The final results of the registry
will be able to respond in the future to this
important question.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
EFFECTS OF AN EARLY OR LATE
UPGRADE FROM CRT-D TO MPP ON
THE MYOCARDIAL AND PERIPHERAL
VASCULAR FUNCTION IN PATIENTS
WITH A PRIMARY DILATED
CARDIOMYOPATHY
A. Capria 1, S. Ventresca 2, G. D’Ascoli 2, P.
Paolisso 2, V. Ribatti 2, D.G. Della Rocca 2,
G. Panattoni 2, F. Condemi 2, D. Sergi 2, G.
Magliano 2, L. Santini 3, G.B. Forleo 2, F.
Romeo 2
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 University of
Rome Tor Vergata - Department of Internal
Medicine, Rome, ITALY, 3 Ospedale G.B. Grassi,
Department of Cardiology, Ostia (RM), ITALY
Introduction: Patients with congestive
heart failure due to primary dilated
cardiomyopathy (IDCM) develop a
significant functional response to CRT-D.
We evaluated if the systemic response of
an upgrade to a MPP, is able to ameliorate
the myocardial systolic function, in
coherence with a positive peripheral
vascular remodeling.
Methods: We studied 27 patients treated
with CRT-D for IDCM. All of them were
upgraded to a MPP in a double-blind
randomized study; as receiving the MPP
just enrolled to the 3rd month (group A) or
from the 3rd to the 6th month (Group B).
Results: The improved MPP stimulation
induces an overt improvement in the LVEF
in all our cases; moreover, the group A
patients showed a marked and long-
lasting increase of the LVEF, paired with
positive but non persistent FMD (4.0 ± 3.2
to 6.6 ± 4.5, P = ns), poor NYHA and poor
6MWT responses; the group B patients,
that actived the MPP later, had minimal
changes in the FMD (6.5 ± 6.2 to 6.7 ±
4.0, P = ns), 6MWT and NYHA class, in
presence of lower and further decreasing
BNP levels (1706 ± 1811 to 1216 ± 781
pg/mL, P = ns)
Conclusions: Our study suggests that
patients, especially if early treated with
MPP, may develop clinical and functional
positive changes; the late-actived MPP
confirm an impressive myocardial
response, uncoupled to clear changes in
the peripheral vascular responses to
exercise or reactive hyperemia.
ELECTRICAL PERFORMANCES AND
SAFETY OF THE SONR CARDIAC
CONTRACTILITY SENSOR
M. Luzi 1, G. Pistis 2, A. Vado 3, V. Calzolari
4
, M. Piacenti 5, F. Zoppo 6, A. Capucci 1
1
University Hospital Osp. Riuniti delle Marche,
Ancona, ITALY, 2 Osp. SS Antonio e Biagio,
Alessandria, ITALY, 3 Osp. S Croce e Carle,
Cuneo, ITALY, 4 Osp. Ca’ Foncello, Treviso, ITALY,
5
Fondazione Toscana G. Monasterio, Pisa,
ITALY, 6 Ospedale Civile, Mirano (VE), ITALY
Background: The SonRtip atrial lead
features a micro-accelerometer sensor
located at the tip of the lead (Figure),
converting myocardial vibrations into a
voltage signal transmitted to a CRT-D
71
FREE PAPERS
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
device. The amplitude of the signal is a
validated index of contractility. The SonRsystem (SonRtip lead and CRT-D device)
allows for weekly optimization of the atrioventricular and inter-ventricular delays.
Efficacy and safety of the SonR-system
were evaluated in the multicenter,
prospective, randomized RESPOND-CRT
trial. We aimed to report at 1-year (1Y): a)
lead-related safety and performance data;
b) amount of BiV pacing (%BiVp) delivered.
Methods: The SonRtip atrial lead was
successfully implanted in 1008/1010
attempted procedures (success rate:
99.8%). The acute (0-3 months) and
chronic (4-12 months) complication freerate (CFR) of the lead were assessed and
compared with pre-specified values of
91% and 94%, respectively (primary
safety endpoint). Data to assess electrical
performances of the lead and %BiVp were
retrieved from device memory up to 1Y
follow-up.
Results: The acute and chronic CFR were
98.5% and 99.8%, respectively (p<0.001
vs. pre-specified values). Mean electrical
performances were: pacing threshold
0.82V [95% CI: 0.80-0.85], sensing
amplitude 3.6mV [95% CI: 3.5-3.7],
pacing impedance 495.5ohm [95% CI:
491.3-499.7]. Electrical parameters were
stable over 1Y. Median %BiVp was 98%
(more than 75% of patients presenting
with median %BiVp>95%).
Conclusion: Over 1Y, the SonRtip atrial
lead reached the primary safety endpoint
72
of the RESPOND-CRT trial, showing
satisfactory and stable electrical
performances. The system could safely
and consistently deliver BiVp (median
%BiVp 98%).
VARIATIONS OF MYOCARDIAL
CONTRACTILITY MEASURED BY THE
SONR SENSOR DURING SPONTANEOUS
RHYTHM ARE CONSENSUAL WITH LV
EJECTION FRACTION CHANGES 6
MONTHS AFTER CRT IMPLANT
V. Ducceschi, M. Santoro, I. De Crescenzo,
G. Gregorio, A. D’Andrea
Ospedale S. Luca - Cardiology Department,
Vallo della Lucania, ITALY
Introduction: The amplitude of SonR
signal (SonR1) is known to be correlated
with myocardial contractility (LVdP/dt
max). However, few information are
available about the potential ability of the
SonR1 to mirror myocardial reverse
remodeling in patients treated with CRT.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
This pilot study aimed to compare in CRT
patients, during ventricular spontaneous
rhythm at 6-month follow-up (6M-FU), the
variations (vs. baseline) of SonR1 and LV
ejection fraction (LVEF), as potential
markers of reverse remodeling.
Methods: Data were gathered about n=16
patients implanted with a CRT-ICD
equipped with SonR sensor. At baseline
(after-implant) and 6M-FU visits, the
device was temporarily programmed in VVI
40bpm pacing mode. Each patient
underwent at rest two hemodynamic
assessments: 1) beat-to-beat SonR1
mean, min and max values (3min
continuous recording); 2) LVEF by
echocardiography (2D-Simpson’s rule).
Patients were considered responders
(Resp) when the LV end-systolic volume
had decreased at least 15% (6M-FU vs.
baseline).
Results: At 6M-FU visit, n=12 patients
were Resp (75%): among them (Figure),
the corresponding SonR1 values increased
from baseline in n=11 patients (92%). The
increase was significant only for the max
value (p=0,048). Similarly, the SonR1
decreased in all the n=4 Non-Responders,
with no statistical significance for any of
the SonR1 values (too small sample size).
Conclusions: At 6M-FU, SonR1 variations
are consensual with LVEF changes during
spontaneous rhythm in the vast majority
of CRT patients. According to the limited
amount of recordings carried-out, the max
value of SonR1 seems to be the most
reliable parameter to track reverse
remodeling.
SUCCESS OF AUTOMATIC
OPTIMIZATION OF AV AND VV DELAYS
USING THE SONR CONTRACTILITY
SENSOR
P. Pieragnoli 1, V. Calvi 2, R. Mantovan 3, F.
Zanon 4, L. Calò 5, M. Lunati 6, L. Padeletti 1
1
University Hospital Careggi, Florence, ITALY, 2
University Hospital Osp. Ferrarotto, Catania,
ITALY, 3 Osp. M. Bufalini, Cesena, ITALY, 4 Osp.
73
FREE PAPERS
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Spalato]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
HEART FAILURE:
DYNAMIC EVALUATION AND TREATMENT
S. Maria della Misericordia, Rovigo, ITALY, 5
Policlinico Casilino, Rome, ITALY, 6 Grande Osp.
Metropolitano Niguarda, Milan, ITALY
Background: The SonRtip atrial lead
features a contractility sensor located at
its tip. The SonR-system, composed of the
lead and the CRT-D device, allows for
weekly automatic optimization of the
atrio-ventricular (AVD) and interventricular
(VVD)
delays.
The
RESPOND-CRT trial is a multicenter,
prospective, randomized (2:1) trial
comparing regular SonR optimization over
1-year (1Y) vs. echo-based optimization
after implant. We aimed to determine the
efficacy of the SonR optimization in terms
of number of weeks with successful AVD
and VVD optimization in RESPOND-CRT
patients in whom the SonR optimization
function was enabled.
Methods: Data were retrieved from the
device memory up to 1Y follow-up.
Patients were
also categorized
as having a
reduced, stable
and increased
optimal AVD (OAVD) when the
mean difference
from
posthospital
discharge (PHD)
to 1Y was <-15
ms, [-15 ms;
74
+15 ms] and >15 ms, respectively.
Results: After implantation, the SonR
function was enabled in 670 patients, and
496 patients had eligible data for the
analysis. Over 1Y, SonR was able to
successfully optimize AVD and VVD 92%
of the weeks. Reasons for non-successful
optimization were mainly related to
rhythm unstability (AF, frequent
extrasystoly). Based on intra-patient
difference in O-AVD between PHD and 1Y,
O-AVD decreased in 30%, was stable in
55% and increased in 15% of the patients
(Figure).
Conclusion:
The
SonR-system
successfully optimized AVD and VVD 92%
of the weeks over 1Y follow-up; significant
changes in O-AVD were found after 1Y in
45% of the population in the RESPONDCRT trial.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
TACHYCARDIOMYOPATHIES:
STILL A LOT TO LEARN...
G. Domenichini, D. Altmann, R. Brenner, P.
Ammann
Cardiology Department, Kantonsspital St.
Gallen, St. Gallen, SWITZERLAND
Purpose and Methods: Tachycardiomyopaties
are potentially reversible once the arrhythmic
disturbance has been treated. However the
concomitant occurrence of life-threatening
ventricular arrhythmias (VA) is unpredictable
and little is known about how to prevent these
events.
We present a case of atrial fibrillation (AF)right atrial flutter (AFL) related
tachycardiomyopathy in whom a cardiac
arrest occurred after a successful cardiac
ablation.
Results: A 57-yr old male patient was
admitted to our hospital with
decompensated HF associated to
persistent AF-AFL with high ventricular
rate response. The LVEF was measured at
20%, coronary angiogram excluded
relevant coronary artery disease, and
cardiac MRI showed full viability of the
myocardium with no sign of myocarditis.
Pulmonary vein isolation and cavotricuspid
isthmus ablation were performed by
radiofrequency with sinus rhythm
restoration. No procedural complications
occurred and amiodarone was started to
prevent AF/AFL recurrences. The day after
the procedure a cardiac arrest associated
to ventricular tachycardia (VT) occurred
and the patient was successfully
resuscitated without consequences. The
decision was therefore to discharge the
patient with a wearable cardioverter
defibrillator (WCD) to treat VAs which could
occur during recovery of the LV systolic
function.
Six months later the LVEF was normalised.
No recurrences of AF/AFL were
documented and no VTs requiring
interventions of the WCD occurred.
Conclusions: The occurrence of lifethreatening
VAs
associated
to
tachycardiomyopaties should not be
underestimated even when the “culprit”
arrhythmias for the tachycardiomyopaty
itself has been treated. The use of a WCD
as a bridge to LVEF recovery is a
reasonable option to prevent SCD.
BRUGADA SYNDROME: LATE
POTENTIALS DETECTION BY SIGNALAVERAGED ELECTROCARDIOGRAPHY
PRE- AND POST-FLECAINIDE
PROVOCATIVE TEST
G. Lima Da Silva, P. António, N. CortezDias, T. Guimarães, I. Gonçalves, F. Gaspar,
I. Neves, L. Carpinteiro, J. De Sousa, F.J.
Pinto
Cardiology Department, Santa Maria University
Hospital, LMAC, Lisbon, PORTUGAL
Purpose: Evaluate the presence of late
potentials (LP) detected by Signal
avareged-ECG (SA-ECG) and describe its
modification after flecainide provocative
75
FREE PAPERS
SUDDEN DEATH: ELECTROCARDIOGRAPHIC
AND HISTOLOGICAL PREDICTORS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUDDEN DEATH: ELECTROCARDIOGRAPHIC
AND HISTOLOGICAL PREDICTORS
test (FT) in patients with BS.
Methods: Single-center prospective study
of consecutive patients with type 2
Brugada pattern (BP) and positive FT.
Patients underwent LP detection by SAECG pre- and post-FT, with measurement
of fQRS, RMS40 LAS40. LP were positive
if at least two of the following criteria were
met: fQRS > 114ms, RMS40 < 20 uV or
LAS40 > 38ms.
Results: We studied 16 patients with type
2 BP and positive FT (68.8% male, 45 ±
14 years). Seven patients (43.8%) had
evidence of LP pre-FT. The different
components of LP changed significantly
after flecainide infusion, with increased
duration of fQRS in 12 ms, LAS40 in 6 ms
and reduction of RMS40 in 6 uV. Post-FT,
13 patients (81.2%) had evidence of LP –
Figure 1. Both fQRS and RMS40 were
higher post-FT in patients with longer
baseline values [(R: 0.64; p = 0.018; Rho:
0.504, p = 0.056), (Rho 0.61, p= 0.016),
respectively], but had higher variation in
patients with baseline shorter values
[(Rho: -0.55; p = 0.032), (Rho -0.6; p =
0.018), respectively]. Finally, LAS40 was
higher post-FT in patients with larger
LAS40 at baseline (R: 0.53; P = 0.043;
Rho: 0.53; p = 0.04).
Conclusion: In patients with type 2
Brugada pattern and positive FT the
presence of late potentials and the
magnitude of their variation after
flecainide infusion may be strong
prognostic predictors.
76
THE QT/RR REGRESSION
CORRELATION COEFFICIENT AS NONINVASIVE RISK STRATIFICATION TOOL
B. Vandenberk, T. Robyns, C. Garweg, J.
Ector, R. Willems
University of Leuven, Leuven, BELGIUM
Background: An increased beat-to-beat
variability of repolarization as measure of
decreased cellular repolarization reserve
has been linked to arrhythmia. We studied
the use of the QT/RR linear regression
correlation coefficient (QT/RRcorr) as a
predictor of arrhythmic death.
Methods: All primary prevention ICD
recipients with ischemic cardiomyopathy
and a 2 lead 24h holter (ELA, Sorin)
available prior to implant were included.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Recordings with atrial fibrillation were
excluded. QT/RR linear regression analysis
was performed after manual beat
classification and template correction with
calculation of slopes and QT/RRcorr.
Multivariate Cox regression modelling was
performed including other non-invasive
risk tools.
Results: In total, 89 patients were
included: age 57±13y, LVEF 27±9% and
mean follow-up 4.0±2.9 y. Of these
25.8% died and 32.6% received a first
appropriate shock (AS). Of these 12
(13.5%) patients were excluded because
of limited data quality.
ROC analysis of QT/RRcorr showed an AUC
of 0.680 for predicting AS within 1y after
ICD implant (n=11, 12.4%), for the
complete follow-up AUC was 0.537.
Dichotomization was performed at a value
of r=0.80 with 68% sensitivity and 73%
specificity for predicting AS within 1y after
implant.
Cox regression identified QT/RRcorr <0.8
as an independent predictor of AS within
1y after implant (HR 8.08, 95% CI 1.4046.5), together with age, presence of VT
on holter and LFnu. It did not predict
mortality either within 1y (p=0.876) or
overall (p=0.358).
Conclusions: After meticulous manual
correction of 24h holter recordings a low
QT/RRcorr discriminated a high risk of
early arrhythmia from a risk of dying.
PROGNOSTIC VALUE OF
REPOLARIZATION AND
DEPOLARIZATION ECG
ABNORMALITIES IN BRUGADA
SYNDROME
F. Migliore, M. Testolina, A. Bellin, A. Zorzi,
G. Alloccata, E. Bertaglia, S. Iliceto, D.
Corrado
Department of Cardiac, Thoracic and Vascular
Sciences, University of Padua, Italy, Padua,
ITALY
Aim: to assess the prognostic value of
clinical
and
electrocardiographic
parameters in patients with type 1 “covedtype” Brugada ECG pattern.
Methods: Our study included 116
consecutive patients (82,8% male;mean
age 45±12.3years) with spontaneous
Brugada type 1 ECG pattern. Thirty-seven
(37) patients (31.9%) presented a history
of syncope, 3(2.6%) of cardiac arrest,
8(6.9%) of atrial fibrillation, while the
remaining 45(38.8%) were asymptomatic.
The primary outcome of the study was a
combined endpoint including sudden
cardiac death, cardiac arrest, appropriate
implantable cardioverter defibrillator (ICD)
intervention and unexplained syncope.
Results: During a mean follow-up of
83±48 months, 20 patients (17.2%)
experienced at least 1 arrhythmic event:
10(8.6%) unexplained syncope, 8(6.9%)
appropriate ICD intervention and 2(1.7%)
died suddenly. At univariate analysis, a
history of syncope/cardiac arrest
77
FREE PAPERS
SUDDEN DEATH: ELECTROCARDIOGRAPHIC
AND HISTOLOGICAL PREDICTORS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
SUDDEN DEATH: ELECTROCARDIOGRAPHIC
AND HISTOLOGICAL PREDICTORS
(p<0.0001),
and
first
degree
atrioventricular block (AV) (p=0.023) were
associated with a significant higher
incidence of arrhythmic events. At the
multivariate analysis, both parameters
remained independent predictors of total
arrhythmic events during follow-up, while
first degree (AV) block remained the only
predictive factor of major cardiac events,
such as cardiac arrest or appropriate ICD
intervention (HR=2.5;95%IC=1.5-4.3;
p<0.02). Neither S wave in leads I, II or III,
nor inducibility of ventricular arrhythmias
at programmed ventricular stimulation
predicted the arrhythmic outcome.
Conclusions: Our data demonstrated that
in BS patients with type 1 “coved-type”
ECG the arrhythmic risk was significantly
greater among those with previous
symptoms of syncope/cardiac arrest and
with 1st degree atrioventricular block. The
presence of 1st degree AV block was the
only independent predictor of major
arrhythmic events.
ECTOPIC FOCUS-GUIDED
ENDOMYOCARDIAL BIOPSY IN
DIAGNOSIS OF ARRHYTMOGENIC
RIGHT VENTRICULAR DYSPLASIA IN
PATIENTS UNDERGOING VENTRICULAR
ARRHYTHMIA CATHETER ABLATION
K. Simonova, E. Mikhaylov, R. Tatarskii, L.
Mitrofanova, D. Lebedev
Almazov Federal North-West Medical Research
Centre - Arrhythmia Department, SaintPetersburg, RUSSIA
78
Background: Endomyocardial biopsy
(EMB) is one of the diagnostic criteria for
arrhythmogenic right ventricular dysplasia
(ARVD). However, sensitivity and specificity
of EMB varies depending on biopsy
technique.
Purpose: We sought to compare ‘focusguided’ and ‘unselective’ EMB in diagnosis
of ARVD in patients undergoing focal
ventricular arrhythmia catheter ablation.
Methods: This retrospective study
comprised of 122 patients admitted for
catheter ablation of ventricular
tachycardia
and/or
symptomatic
premature ventricular contractions, in
whom diagnostic EMB was performed (64
men; mean age 39±14 years). The study
population was divided into 2 groups: 1) a
group of 44 (36%) patients with ‘focusguided’ EMB (at least 1 biopsy specimen
was taken from an area of a ventricular
arrhythmia focus (-es)); 2) a group of 78
(64%) patients with ‘unselective’ EMB
(specimens form different ventricular
areas, excluding the area of arrhythmia
focus).
Results: In 16 (13.1%) patients ARVD
diagnosis was definite according to the
2010 criteria. Acute ablation success was
achieved in 69.7% of patients, with a
significantly lower efficacy in the ARVD
group (43.8%). Sensitivity and specificity
of EMB in revealing of a major histological
criterion were higher in the ‘focus-guided’
group versus ‘unselective’ (100% and
91.7% versus 80% and 81.4%,
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
correspondingly).
Conclusion: In ARVD patients EMB
capturing specimens from areas of
arrhythmia origin significantly improves
both sensitivity and specificity in detection
of a major histological diagnostic criterion.
EVALUATION OF RISK INDICATORS
PREVALENCE FOR SUDDEN CARDIAC
DEATH IN YOUNG ATHLETES FROM
GOIÂNIA - BRAZIL
A. Da Silva Menezes Jr 1, J. Fernando Silva
Louzeiro 1, V. Batista De Magalhães Pere 1,
E. Martins 2
1
Pontificia Universidade Católica de Goiás,
Goiânia, BRAZIL, 2 Universidade Federal de
Goias, Goiânia, BRAZIL
Background: Sudden cardiac death (SCD)
in athletes during physical activity is an
uncommon; however, it has a great impact
in the public society. Although the physical
exercise prevents diseases, may increase
the risk of acute cardiovascular events,
especially in susceptible individuals. It is
necessary to improve the international
data to raise knowledge on this topic.
Objectives: To compare the risk indicators
signals for SCD in young athletes and
correlate
them
with
the
electrocardiographic data.
Methods: A case-control study comparing
athletes who attended the academies in
the city of Goiania-GO to sedentary
individuals. It applied the questionnaire
Sudden Cardiac Death Screening of Risk
Factors (SCD-SOS) and performed the rest
electrocardiogram.
Results: Sample of 398 participants,
(65.6%) of case group (athletes) and
(34.4%) in the control group (sedentary).
In athletes, 55.6% were male and 39.4%
control group. The whole group had a
mean age of 25.93 ± 5.68 years. In SCDSOS questionnaire, there were significant
differences in episodes of fainting, less
recurrent in athletes (OR 0.252 p <0.001).
Heart rate was not significantly different
(78 ± 14 bpm). The main found
electrocardiographic reports were sinus
arrhythmia, right bundle branch
conduction disturbance and early
repolarization.
Conclusion: The young athletes had a
lower frequency of responses to risk
indicators signals for sudden cardiac
death, as well as higher QRS values, PR
and QT interval. There was a positive
correlation between episodes of fainting
reported by athletes and QRS duration.
79
FREE PAPERS
SUDDEN DEATH: ELECTROCARDIOGRAPHIC
AND HISTOLOGICAL PREDICTORS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Pola]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC ARRHYTHMIAS AND PACING MANAGEMENT
USE OF DRONEDARONE IN ATRIAL
FIBRILLATION: COMPARISON
BETWEEN TRIALS AND REAL-WORLD
PRACTICE. META-ANALYSIS AND
METAREGRESSION ANALYSIS
G. Massaro 1, R. Mei 1, E. Zardi 1, S. Lorenzetti 1,
M. Gallucci 1, G. Tanzarella 1, M. Ziacchi 1, M.
Biffi 1, G. Boriani 2, I. Diemberger 1
1
2
Policlinico S.Orsola-Marpighi, Bologna, ITALY,
Policlinico di Modena, Modena, ITALY
Dronedarone showed divergent safety
profiles in randomized controlled trials
(RCT) in term of cardiac death and overall
mortality. We evaluated all available
evidence on the cardiovascular safety of
this drug. A systematic search was made
of the MEDLINE and the Cochrane Central
Register of Controlled Trials from January
2003 through April 2016 for RCT
comparing dronedarone to placebo/active
control and observational cohort studies
(OBS) reporting clinical outcomes in
patients treated with dronedarone
according to current guidelines, to obtain
a real-life comparator for the results
summarized by RTC analysis. The
literature search yielded 2335 papers and
after careful review we identified 12 RCT
and 7 OBS studies. RCT meta-analysis
showed that, despite high heterogeneity,
dronedarone was not associated with
increased all-cause mortality (OR 1.36,
95%CI 0.79-2.33; p=0.732, I2=57.0%) or
cardiovascular mortality (OR 1.51 95%CI
0.74-3.08; p=0.860, I2=64.4%). OBS
80
studies had a trend toward a better
survival with respect to RCT (ES 2.03,
95%CI 0.53-3.53 vs ES 3.03, 95%CI 1.234.83; p=0.115), reaching the significance
when restricted to the cardiovascular
mortality (ES 0.52, 95%CI 0.36-0.69 vs ES
1.86, 95%CI 0.62-3.09; p<0.001). Two
variables, co-administration of digoxin and
prevalence of non-permanent AF
completely abolished the dishomogeneity
among the analyzed RCT studies. In
conclusion the use of dronedarone for
prophylaxis
of
atrial
fibrillation
recurrences is not associated with an
increased risk of death, either
cardiovascular or total, and combination
with digoxin should be avoided.
Legend: OR = Odds Ratio, CI = Confidence
Interval, ES = Effect Size.
A NOVEL RISK SCORE TO SELECT
PATIENTS FOR DEVICE-BASED
REMOTE MONITORING
G. Portugal, M. Oliveira, P. Silva Cunha, A.
Lousinha, A.V. Monteiro, S. Aguiar Rosa, L.
Morais, P. Modas Daniel, B. Valente, R.
Cruz Ferreira
Department of Cardiology, Hospital Santa
Marta, Lisbon, PORTUGAL
Background: There is conflicting data
from retrospective studies and
randomized clinical trials regarding the
clinical benefit of device based remote
monitoring. The aim of this study was to
identify predictors of increased benefit
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
from remote monitoring in a long-term
follow-up cohort.
Methods: Retrospective cohort study of
patients who underwent ICD implant for
between 2002 and 2015. RM was initiated
according to availability of RM hardware.
Data on mortality was assessed using a
nationwide healthcare platform. Daily
verification of transmission was
performed. A Cox proportional hazards
model was employed to determine
predictors of time to any-cause death.
Multivariate predictors of the primary
outcome were used to calculate a risk
score (+1 if the variable was present, 0 if
absent).
Results: 312 patients were analysed,
median follow-up 37.7 months. 121
(38.2%) were under RM and 191 were in
conventional follow-up. No differences
were found regarding age, LVEF, heart
failure etiology or NYHA class. Patients
under RM had higher long-term survival
(hazard ratio[HR] 0.50, CI 0.27-0.93,
p=0.029). After multivariate analysis, the
variables associated with worse prognosis
were age>70 yrs, LVEF<30% and NYHA
class higher than 2. The calculated mean
Risk score was 1.07 +/- 0.79. A higher risk
score was strongly associated with worse
prognosis (HR 2.62, CI 1.84-3.73,
p<0.001). In subgroup analysis a higher
risk score was linked to increased benefit
from remote monitoring (Figure 1)
Conclusions: A higher risk score was
associated with increased clinical benefit
from remote monitoring. This score may
help discriminate which patients benefit
the most from RM
CAN AN INDEPENDENT PLATFORM
WITH REPOSITORY AND DATABASE
FUNCTION ENHANCE THE EFFICIENCY
OF A CARDIAC DEVICE
CLINIC?INSIGHTS FROM THE FIRST
ONEVIEWTM ADOPTION IN ITALY
A. Masci, C. Marchetti, F. Bonfatti, M.
Balbo, M. Salomoni, M. Ferrarini, J. Frisoni,
M. Biffi
1
University of Bologna, Bologna, ITALY, 2
Azienda Ospedaliero-Universitaria di Bologna,
Policlinico Sant’Orsola Malpighi, Bologna, ITALY
Background: OneViewTM enables
integration of in-office and remote device
follow-ups of CIED Patients in a common
format independently of device
manufacturers, whose operational
modality have different softwares and
communicating interfaces. It also
integrates with Electronic Health Records
via an HL-7 interface. We sought to
81
FREE PAPERS
CARDIAC ARRHYTHMIAS AND PACING MANAGEMENT
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CARDIAC ARRHYTHMIAS AND PACING MANAGEMENT
evaluate the improvement of our device
clinic workflow owing to the adoption of
OneViewTM .
Methods: Since January 2016 each CIED
patient presenting either at in-office or
remote device follow-up is progressively
entered into OneViewTM, that enables to
review, interpret, and produce reports of
device follow-ups, and also works as a
repository of EMRs to be reviewed at
subsequent patients’ follow-ups. Devicegenerated data are automatically imported
from programmers or Remote Monitoring
into OneViewTM, thus ensuring an errorfree database population while easing the
allied professional workflow. Being
capable to analyze discrete data,
OneViewTM offers customizable queries
that automatically update along time.
Results: 2145 patients were entered so
far: 1232 pacemaker and 913 ICD/CRTD
recipients. Based on queries, we observed
that 130/1232(10.6%) had an RV pacing
threshold above2Vat0.4ms, 67/920(7.3%)
had a RA threshold above2Vat0.4ms, and
165/920(18%) had AF episodes lasting >5
hours among DDD/R pacemaker
recipients. Moreover, among ICD/CRTD
recipients we could identify 178/920(19.5
%) living patients with a recalled RV lead,
58(6.4%) patients having received a
shock since the previous follow-up.
Conclusion: OneViewTM eases CIED
follow up by creating a repository with a
common format across manufacturers.
Owing to its database functions, it enables
82
relevant epidemiological studies of this
specific population at no additional cost.
SAFETY OF THE EXTRACTION OF
LEADS HAVING LONG (> 14Y) DWELL
TIME. ANALYSIS OF 271 AMONG 2036
TLE PROCEDURES
A. Kutarski 1, M. Czajkowski 2, A. Tomasik
3
, M. Polewczyk 4, A. Polewczyk 5, W.
Jachec 3
1
Department of Cardiology, Medical University
of Lublin, Lublin, POLAND, 2 Department of
Cardiac Surgery Medical University of Lublin,
Lublin, POLAND, 3 2nd Department of
Cardiology Silesian Medical University, Zabrze,
POLAND, 4 District Hospital, Intensive Cardiac
Care Unit, Kielce, POLAND, 5 The Jan
Kochanowski University, Department of
Medicine and Health Sciences, Kielce, POLAND
Introduction: Long lead body dwelling
time is a known risk factor of transvenous
lead extraction (TLE) but influence on
effectiveness and safety of TLE
procedures was examined occasionally. It
was not established which leads need
special safety TLE procedure regime.
Objective: The comparison of safety and
feasibility of TLE in three groups of
patients with different dwelling time of the
oldest lead in the system (division
according to Ch. Byrd).
Methods: Using standard mechanical
systems we have extracted ingrown
PM/ICD leads from 2036 pts within the
last 9 years. Statistic: Ch2 and “U” –
Mann-Withney tests.
Results are
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
presented in the table. Impression: Major
TLE complications may appear even
during extraction of a lead with short
dwelling time.
Conclusions: There is a visible relation
between lead body dwelling time and
effectiveness and safety of TLE procedure.
Higher number of leads, abandoned leads,
higher percentage of female patients
seem to be additional risk factors of
effectiveness of TLE in patients with long
lead body dwelling time and therefore their
significance should also be considered.
RESULTS OF A NEW CARDIOLOGY
TRIAGE SERVICE, BASED WITHIN A
SECONDARY CARE SETTING, RUN BY A
PRIMARY CARE PHYSICIAN WITH A
SPECIAL INTEREST IN CARDIOLOGY
A. Alasadi 1,2, M. Sabar 1, V. Thapar 2, R.A.
Kaba 1,3,4
1
Department of Cardiology, Ashford & St
Peter’s Hospitals NHS Trust, Chertsey, UNITED
KINGDOM, 2 North West Surrey Clinical
Commisioning Group, Weybridge, UNITED
KINGDOM, 3 Department of Cardiology, St.
George’s University Hospitals NHS Trust,
London, UNITED KINGDOM, 4 Royal Holloway
University of London, Egham, UNITED
KINGDOM
Objective: To evaluate the effectiveness of
a Primary Care Physician (General
Practitioner (GP)) led new, proactive
cardiology triage service within a
secondary care setting to streamline
cardiology referrals.
Methods: Between June-August 2016, GP
referrals to a secondary care cardiology
service were assessed by a specifically
trained GP with a Specialist Interest
(GPwSI) in cardiology, with appropriate
support from cardiologists. A decision was
then made for each referral, either to
accept or reject, and to provide
appropriate advice accordingly. In addition,
results of routine cardiac diagnostic
investigations were reviewed and actioned
by the GPwSI.
Results: Out of 362 referrals, 272 (75.1%)
were accepted for secondary care
assessment. Among the remaining 90
cases, investigations were requested for
62 patients and only 6 (1.7%) patients
required
subsequent
out-patient
appointment (OPA) in secondary care. The
remaining 84 (23.2%) referrals were
returned to the referring GP with
appropriate advice, without the need for
OPA.
Of the routine cardiac diagnostic
investigations, out of 324 ambulatory
ECGs and 117 echocardiogram
investigations, OPAs were offered to 60
83
FREE PAPERS
CARDIAC ARRHYTHMIAS AND PACING MANAGEMENT
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
CARDIAC ARRHYTHMIAS AND PACING MANAGEMENT
(18.5%) and 22 (18.8%) patients,
respectively. Advice, without need for OPA,
was provided for 134 (41.4%) and 63
(53.8%) cases, respectively, while no
action was necessary for 130 (40.1%) and
32 (27.4%) cases, respectively.
Conclusion: A well-defined and suitably
resourced cardiology triage service can
substantially reduce the burden of
cardiology referrals to secondary care.
Consequently, this model may be effective
in alleviating some of the financial costs
of providing cardiology services in the
healthcare sector.
FREE PAPERS
WEDNESDAY, NOVEMBER 30, 17.30-19.00 [Leptis magna 1]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
84
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
TRANSESOPHAGEAL
ECHOCARDIOGRAPHIC ASSESSMENT
OF LEFT ATRIAL APPENDAGE: SEARCH
FOR PREDICTORS OF RECURRENCE OF
ATRIAL FIBRILLATION IN PATIENTS
TREATED WITH RADIO-FREQUENCY
M. Scarcia 1, N.D. Brunetti 1, M. Grimaldi 2,
G. Cecere 2, F. Troisi 2, A. Di Monaco 2, F.
Quadrini 2, M. Di Biase 1
1
Azienda Ospedaliero Universitaria OO.RR U.O.C. Cardiologia e Utic, Università degli Studi
di Foggia, Foggia, ITALY, 2 Ente Ecclesiastico
Ospedale Generale Regionale F. Miulli, UOC
Cardiologia e Utic, Acquaviva delle Fonti, ITALY
Objectives: We aimed to identify a left
atrial appendage transesophageal
echocardiographic parameters able to
predict recurrence in patients with atrial
fibrillation (AF) treated by radio-frequency
catheter ablation (RFA).
Methods: 80 consecutive patients with
indication to (RFA) were enrolled in the
study and underwent transesophageal
echocardiography. In 15 patients left atrial
anatomy and high density voltage map
with CARTO 3 system was reconstructed.
A myocardium with low voltage was
identified from a bipolar amplitude voltage
<0,8 mV, a very low voltage area <0,1 mV.
Results: 60% patients had paroxysmal AF
and 40% persistent. We found a
statistically significant correlation between
left atrial appendage emptying velocity
and recurrence of AF after RFA (36±13 vs
49±16 cm/s, p=0,0007). Velocity value
predicted recurrence with a relative risk of
0,96 (95% C.I. 0,94-0,99, p: 0,02) also at
the multivariate analysis corrected for age
and gender. Evaluation of electroanatomic voltage maps with the extension
of very low voltage areas showed an
inverse correlation, in the subgroup with
persistent AF, between left atrial
appendage emptying velocity and
percentage of very low voltage areas (r=
-0,77; p: 0,024).
Conclusions: Low left atrial appendage
emptying velocity can predict recurrence
of AF after RFA and can be an indirect
index of damaged atrial tissue.
PERCUTANEOUS LEFT ATRIAL
APPENDAGE OCCLUSION IN HIGH-RISK
PATIENTS: LONG-TERM FOLLOW UP
B. Pezzulich, E. Brscic, S. De Salvo
Maria Pia Hospital, GVM Care & Research,
Turin, ITALY
Percutaneous left atrial appendage
occlusion may be considered for stroke
prophylaxis in patients with non-valvular
atrial fibrillation believed to be at high
thromboembolic risk and with relative or
absolute contraindications to oral
anticoagulant therapy . Data on safety of
device implantation and long term follow
up are presented.
Percutaneous left atrial appendage
occlusion was performed using mainly
Amplatzer Cardiac Plug and Amulet device
in 149 consecutive patients, with mean
CHADS2-VASC2 score of 4,63 ± 1,43 and
85
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TECHNICAL PROGRESS IN IMPLANTABLE ENDOCARDIAL TOOLS
THURSDAY, DECEMBER 1, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
TECHNICAL PROGRESS IN IMPLANTABLE ENDOCARDIAL TOOLS
HAS-BLED score of 3,88 ±1,37. Follow up
data were collected over a mean follow up
period of 712 ± 142 days, comprising a
total implant experience of 267 patientyears. Device implantation was successful
in 96,6% of the procedures. The rate of
major peri-procedural complications was
4.7%, with no reported mortality. All
patients received life long therapy with
aspirin 100 mg/die and clopidogrel 75 mg
for the first three months. We observed
one ischemic stroke, two minor bleedings
and two major bleedings. The relative risk
reduction of observed ischemic stroke
related to expected events in warfarin
therapy was 0,20 (I.C. 95% 0.024-1.7; P
value 0.21) and the relative risk reduction
of major and minor bleedings was 0,15
(I.C. 95% 0.035-0.67; P value 0.006). Left
atrial appendage occlusion is safe and
effective in preventing ischemic stroke in
a high-risk of non-valvular atrial fibrillation
cohort of patients , both at implantation
and during a long follow up period. Risk of
bleeding seems to be reduced when
compared to oral anticoagulant therapy
86
PERCUTANEOUS LEFT ATRIAL
APPENDAGE CLOSURE WITH
WATCHMAN DEVICE: RESULTS FROM
THE TRAPS REGISTRY
P. Mazzone 1, G. D’Angelo 1, D. Regazzoli 1,
G. Molon 2, G. Senatore 3, S. Saccà 4, G.
Canali 2, C. Amellone 3, R. Turri 4, P. Della
Bella 1
1
San Raffaele Hospital, Milan, ITALY, 2 Sacro
Cuore Hospital, Negrar (VR), ITALY, 3 P.O.
Riunito-Ospedale Civile, Ciriè (TO), ITALY, 4
Mirano Hospital, Mirano (VE), ITALY
Introduction: The WATCHMAN device for
Left Atrial Appendage occlusion (LAAO) is
effective and non-inferior to oral
anticoagulation (OAC) in patients with
atrial fibrillation, and is now adopted in
clinical practice.
Purpose: The study aim was to evaluate
success implantation rate, peri-procedural
complications and mid-term follow-up
events.
Methods: The TRAPS registry is
observational, multicenter involving 4
Italian centers, enrolling patients
undergone LAAO with WATCHMAN device:
clinical-demographic procedural and
follow-up data were collected.
Results: This analysis included 151
patients. Mean age 73±8 years, 58%
male, 21% had heart failure, 10% history
of transient ischemic attack, 23% history
of ischemic stroke, 73% history of
bleeding. The baseline CHADS2 score =
2.3±1.2, the CHADsVASc score =
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
3.9±2.7,the HAS-BLED score =3.3±1.06;
33% of the patients were on OAC at the
time of implantation. The implantation of
the device was successful in 150/151
patients with no or minimal (< 5mm)
leakage, assessed by peri-procedural
transesophageal-echo:
device
embolization was reported in 1 patient
early after the implantation, the device
was successfully snared in the iliac
bifurcation. Following intra-procedural
complications were reported: 2 pericardial
effusions treated with pericardiocentesis,
1 device-associated thrombus formation
treated with aspiration, 1 vascular access
dissection. The adverse events rate within7-days was (5/148=3.3%). During a
median follow-up of 16 months, 5 patients
died for any cause and 19 adverse events
were totally observed. The annual rate of
all-cause death was 2.2%, all-stroke
2.2%, TIA 1.3%, major bleeding 0.4%.
Conclusion: The success rate in LAAO
with WATCHMAN was high and the
adverse events rate was low.
COMBINED LEFT ATRIAL APPENDAGE
PERCUTANEOUS CLOSURE AND ATRIAL
FIBRILLATION ABLATION: A SINGLE
CENTRE EXPERIENCE.
E. Pelissero, C. Amellone, M. Giuggia, G.
Trapani, B. Giordano, G. Senatore
Ospedale Civile di Ciriè, Ciriè, ITALY
Background: We evaluated long term
safety and efficacy of concomitant left
atrial appendage (LAA) closure and atrial
fibrillation ablation (AFTCA).
Methods: Patients referred for AFTCA and
LAA closure (group 1) were compared to a
control group in which only AFTCA was
performed (group 2). LAA was occluded
with Watchman or Amplatzer Cardiac Plug
(ACP)
devices.
Transesophageal
echocardiography and clinical visits were
performed 2 , 6 and 12 months after
procedure.
Results: We enrolled 19 patients in each
group . Mean age was 66,86 ± 10,35
years in group 1 and 68.42 ± 10.61 in
group 2, respectively (p: n.s.); mean
CHADSVASc score 2,8 ± 1,22 and 2.01 ±
0,93 (p: n.s.), mean HASBLED score 2.2
± 0,83 and 1.6 ± 0.95, (p: n.s.); persistent
AF was present in 80% and in 83% of
patients, respectively. LAA closure was
always successful(15 Watchman, 4 ACP).
Procedural and fluoroscopy time were
68,93 ± 17,78 vs 47, 52 ± 15.31 minutes,
p < 0.05 and 22.23 ± 3,45 vs 15.02 ±
1.24 minutes, p < 0.05. One case of selfterminating pericardial effusion and one
arteriovenous fistula were observed in
group 1. After 14,93 ± 10,05 months
follow-up complete seal of LAA was
documented in all patients, without
thromboembolic/hemorrhagic
complications. Maintenance of sinus
rhythm was similar: AF burden of 35,3 ±
15 % in group 1 vs 38,5 ± 12% in group
2 (p : n.s.).
Conclusions: Combined LAA percutaneous
87
FREE PAPERS
TECHNICAL PROGRESS IN IMPLANTABLE ENDOCARDIAL TOOLS
THURSDAY, DECEMBER 1, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
TECHNICAL PROGRESS IN IMPLANTABLE ENDOCARDIAL TOOLS
closure and AF ablation appears to be
feasible in high risk patients.
IS TRANSCATHETER LEADLESS
PACEMAKER SUITABLE FOR RARE
ANATOMIES? A CASE REPORT OF A
PATIENT SUFFERING OF
DESTROCARDIA
P. Filannino 1,2, P. Artale 1,3, A. Caragliano 1,
A. Petretta 1, R.A. Farulla 1, G. Speziale 2,
S. Iacopino 1,2,3
1
Maria Cecilia Hospital, Cotignola, ITALY, 2
Anthea Hospital, Bari, ITALY, 3 Città di Lecce
Hospital, Lecce, ITALY
Background: Permanent cardiac pacing
delivered by conventional pacemaker is
the corner stone in the treatment of
bradycardia. Occasionally, complications
related to the pacing lead and pocket
could prevent in delivering pacing by
traditional pacemaker. In recent years,
major advancements have been achieved
using Transcatheter Pacemaker System
(TPS).
Methods: NA
Results: We report a case of a 36 years-old
man suffering of situs-viscerum-inversus
underwent permanent VVI pacemaker
implantation in 1998, and PM replacement
in 2006. In 2007, due to a pacemaker
failure, the PM was extracted and a dualchamber pacemaker was implanted with
an epicardial ventricular lead and an atrial
lead intravenously implanted via left
subclavian vein. The follow-up was
88
complicated by three surgical pocket
revisions for decubitus. In May 2016 the
patients was hospitalized for a devicerelated infection. After pacemaker
extraction, a TPS was performed via the
right femoral vein. The device was firstly
deployed on the low-interventricular septum with unacceptable electrical value.
The electrical measurements were tested
at least 10 times in different positions in
order to reach the best one. After the some
attempts, despite the continuous cleaning
with Heparinized saline drip, the TPS
delivering system was almost completely
obstructed by a clot so we decided to use
a new TPS system. The TPS was
successfully positioned in the anteroseptal
region with optimal electrical values (Fig.
1). On 3-month examination, the electrical
measurements was stable and the TPS
position was confirmed by chest X-ray.
Conclusions: TPS seems to be a valuable
solution in case of rare anatomies.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
EXPERIENCE WITH LEADLESS
PACEMAKERS IN AN SPANISH REGION
E. Garcia Cuenca 1, J.G. Martinez 1, J.L.
Ibañez 1, J. Osca 2, O. Cano 2, A. Andres 2,
P. Alonso 2, M.J. Sancho Tello 2, R. Ruiz 3,
L. Bondanza 3, C. Nuñez 3, A. Ibañez 1, A.
Garcia 1
1
Hospital General Universitario, Alicante,
SPAIN, 2 Hospital Universitario y Politecnico La
Fe, Valencia, SPAIN, 3 Hospital Clinico
Universitario, Valencia, SPAIN
Methods: Leadless pacemakers were
recently developed as alternative to
conventional pacemakers.
We expose our preliminary results with
Micra MC1VR01, Medtronic in 3
hospitals from Eastern Spain.
We have enrolled the implants
performed in Hospital General
Universitario
Alicante,
Hospital
Universitario y Politecnico la Fe and
Hospital Clinico Universitario Valencia.
Results: From December 2015 to
September 2016, 24 patients were
included. Mean age of the patient cohort
was 79.8 +/-6.7 years and 50% of the
patients were males. Main indications
were 16 cases of AF with slow ventricular
rate, 4 patients with sick sinus syndrome
and 4 individuals with atrial
tachyarrhytmia with fast ventricular rate;
3 of those underwent AVN ablation
(through the Micra introducer sheath). 4
patients had mechanical prosthesis and 2
had previous pacemaker leads.
Mean procedure duration was 38.35 (+/-
14.11) minutes and fluoroscopy time 3.55
(+/-2.29) minutes.
Mean pacing theresold was 0.71V (+/0.49V), detection was 8.99mV (+/4.31mV) and impedance was 751.08Ohm
(+/-184.07Ohm).
3 patients had an acute pacing theresold
higher than 1V (1.25, 1.5 and 2.38 V), that
decreased the following day in all the
cases.
There
were
no
life-threatening
complications. One of the patients suffered
from a vasovagal episode while we were
introducing the sheath. A different individual
had significative bleeding, but he didn’t
require blood transfusion.
Conclusions: Implant of leadless
pacemakers is a safe technique, low time
consuming and with electrical measures
similar to conventional pacemakers.
Feasible procedure in patients with
mechanical prosthesis.
The system allows doing AVN ablation
through the Micra introducer sheath.
89
FREE PAPERS
TECHNICAL PROGRESS IN IMPLANTABLE ENDOCARDIAL TOOLS
THURSDAY, DECEMBER 1, 12.30-14.00 [Tarragona]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
RESPONSE TO CARDIAC
RESYNCHRONIZATION THERAPY WITH
QUADRIPOLAR LEAD: PRELIMINARY
RESULTS OF RESQ-CRT PROSPECTIVE
STUDY
A. Ferraro 1, A. Vado 2, M. Giammaria 3, P.
Notarstefano 4, T. Giovannini 5, V. Zacà 6, G.
Senatore 7, M. Giuggia 8, F. Rametta 9, F.
Pizzetti 10
1
Degli Infermi Hospital, Rivoli, ITALY, 2 Santa
Croce e Carle Hospital, Cuneo, ITALY, 3 Maria
Vittoria Hospital, Turin, ITALY, 4 San Donato
Hospital, Arezzo, ITALY, 5 Santo Stefano
Hospital, Prato, ITALY, 6 Santa Maria alle Scotte
Hospital, Siena, ITALY, 7 Civil Hospital, Ivrea,
ITALY, 8 Civil Hospital, Ciriè, ITALY, 9 Sant’Andrea
Hospital, Vercelli, ITALY, 10 Santo Spirito
Hospital, Casale Monferrato, ITALY
Introduction: Left ventricle (LV)
quadripolar leads offer the chance to
overcome implant difficulties (phrenic
nerve
stimulation,
unsatisfactory
thresholds or pacing site) and potentially
to reduce the need for reoperation, but few
prospective data are available about
effects on patient’s response with different
pacing configurations.
Methods: A total of 152 patients in 15
Italian hospitals were enrolled between
November 2012 and May 2015.
[(Average±SD): Age(y) 69.4±9; 76.3%
Man; 42% Ischemic; 68% NYHA III; LV
EF(%) 27.6±5.5]. The CRT-D device was
programmed with LV pacing from a distal
cathode. The clinical outcome was
evaluated at 6 months (6M) and 12
90
months (12M) follow-up (FU). Patients with
both an improvement of HF Clinical
Composite Index and echocardiographic
parameters (EF or LVESV) were considered
responders. At 6M FU, in patients nonresponders (NR), the change in LV pacing
configuration from distal dipoles to
proximal was taken into account.
Results: At this time, 12M FU data are
available in 103 patients: 77/103 (75%)
patients were classified as Responder.
Analyzing 27 patients considered NR at
6M FU: 10/17 (59%), with distal to
proximal configuration change, have
become responders. In 30/103 patients
with proximal LV configuration, LV EF
absolute increase, respect to baseline, is
significantly higher at 12M than at 6M FU
(10.9±9.5% vs. 5.2±6.5%; P<0.001.
Conclusions: Changing from distal to
proximal LV quadripolar pacing has
produced an increase in the number of
patients responding to CRT. Follow-up
data at 12 months, though preliminary,
show the potential benefit of quadripolar
LV lead availability on this population’s
outcome.
CARDIAC RESYNCHRONIZATION
THERAPY BY MEANS OF MULTIPOINT
VERSUS BIPOLAR LEFT VENTRICULAR
PACING: MULTIPOINT PACING ITALIAN
MULTICENTER (MPP-IMC) STUDY
DESIGN
P.G. Golzio 1, C. Budano 1, D. Castagno 1, P.
Palmisano 2, R. Mantovan 3, F. Solimene 4,
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
1
Divisione di Cardiologia, AOU Città Della
Salute e della Scienza “Molinette”, Turin, ITALY,
2
Ospedale Card. G. Panico, Tricase (LE), ITALY,
3
Ospedale Bufalini, Cesena, ITALY, 4 Casa di
Cura Montevergine, Mercogliano (AV), ITALY, 5
Ospedale Treviglio-Caravaggio, Treviglio (BG),
ITALY, 6 Ospedale degli Infermi, Rivoli (TO),
ITALY, 7 Ospedale SS. Trinità, Borgomanero
(NO), ITALY, 8 Ospedale Vito Fazzi, Lecce, ITALY,
9
Ospedale SS. Annunziata, Savigliano (CN),
ITALY, 10 St. Jude Medical Italia, Agrate Brianza
(MI), ITALY
Introduction: Cardiac resynchronization
therapy (CRT) by means of pacemaker or
ICD is well-established for patients with
chronic heart failure. Unfortunately about
one third of patients do not receive the
expected benefits from the implant. Left
ventricle (LV) quadripolar leads and multipoint pacing (MPP = two sequential stimuli
from different LV cathodes) offer the
chance to overcome the issues that affect
the patient response to CRT, like phrenic
nerve
stimulation,
unsatisfactory
thresholds or pacing site and myocardial
scars.
Methods: The MPP-IMC study is a
prospective, crossover, randomized,
single-blinded, multicenter clinical trial
designed for comparison between the
optimized (BP-Opt) standard biventricular
(BIV) stimulation and the MPP. Patients
implanted with a CRT device and LV
quadripolar lead will be randomized (1:1)
to receive either BP-Opt or MPP. In BP-Opt
group, the BIV stimulation will be
optimized through the QuickOpt algorithm
together with an echocardiographic
(ECHO) or electrocardiographic (ECG)
method. In MPP group, the optimal
configuration will be selected using ECHO
or ECG method. After 6 months, the
patient’s outcome will be assessed for
combined primary endpoint by means of
clinical (cardiac death, HF hospitalization)
and ECHO parameters (EF, LVESV). In the
same visit will be implemented the
crossover between BP-Opt and MPP or
vice versa. The configurations will be
optimized as above, whereupon the
patient’s response will be revalued after 6
months.
Conclusion: This study aims to evaluate a
new CRT strategy (MPP) for patients at
high risk of hospitalization and death,
because the current ones have outcomes
not fully satisfactory (30% non-responder).
MULTI-POINT PACING IN CARDIAC
RESYNCHRONIZATION THERAPY:
FEASIBILITY FROM A MULTICENTER
EXPERIENCE
D. Ricciardi 1, G. Forleo 2, E. De Ruvo 3, B.
Bolzan 4, G. Di Stolfo 5, F. Zanon 6, C.
Pignalberi 7, M. Giammaria 8, A. Curnis 9, L.
Santini 10
1
Policlinico Universitario Campus Biomedico,
Rome, ITALY, 2 Policlinico Tor Vergata, Rome,
91
FREE PAPERS
G. Belotti 5, A. Mazza 6, P. Paffoni 7, E.
Pisanò 8, A. Coppolino 9, I. Meynet 1, A.
Bissolino 1, M.J. Kapiris 10, F. Di Lorenzo 10,
V. Cutrona 10, F. Gaita 1
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
ITALY, 3 Policlinico Casilino, Rome, ITALY, 4
Azienda Ospedaliera Universitaria di Verona,
Verona, ITALY, 5 Ospedale Casa Sollievo della
Sofferenza, S. Giovanni Rotondo, ITALY, 6
Ospedale S. Maria della Misericordia, Rovigo,
ITALY, 7 Ospedale S. Filippo Neri, Rome, ITALY,
8
Ospedale Maria Vittoria, Turin, ITALY, 9 Spedali
Civili di Brescia, Brescia, ITALY, 10 Presidio
Ospedaliero Giovan Battista Grassi, Ostia (RM),
ITALY
The novel MultiPoint™ Pacing (MPP)
feature allows delivery of Cardiac
Resynchronization Therapy (CRT) by two
sequential stimuli from different cathodes.
The aim of this Survey is to verify, in the
real clinical practice, the feasibility of MPP.
Methods: During CRT implantation,
Cardiac Thresholds (CTs) were measured,
and the presence of phrenic nerve
stimulation (PNS) was determined.
Results: Data were collected from 518
patients (pts) in 76 Italian hospitals.
In all pts the LV CTs were measured in at
least 2 out of 10 available configurations
with different cathodes.
The MPP was programmable in 89%
(463/518) of the pts with CT <=3,5V for
both cathodes, and without PNS issues.
In 363/518 (70%) pts the electrical delays
were measured with an automatic CRT
toolkit, in Right Ventricle (RV)-sensed
mode or in RV-paced mode; whilst in
431/518 (83%) pts it was possible to
consider an optimization based on the
geometrical distance among the cathodes.
The MPP feature was programmable in
92
93% (339/363) of the pts by selecting the
cathodes through the electrical delays
method, being LV1 the earlier electrode
and LV2 the latest one (or vice-versa).
When a method based on the anatomical
distance was analyzed ( LV1: most distal
vectors, LV2: most proximal vectorLV1Cathode-LV2Cathode:
D1-M3/D1-P4/M2- P4), it was possible to
program MPP in 82% (352/431) of the pts.
Conclusion: The MPP is programmable
considering
different
optimization
methods, based on the maximum
anatomical distance or the electrical
conduction time. Overall, in our series, the
MPP may be activated in 89% of the pts
TRIPLE-SITE PACING CARDIAC
RESYNCHRONIZATION THERAPY IN
PATIENTS WITH PERMANENT ATRIAL
FIBRILLATION: RESULTS FROM A
PROSPECTIVE OBSERVATIONAL STUDY
G. Lima Da Silva 1, P. Marques, T.
Guimarães, M. Nobre Menezes, A.
Bernardes, N. Cortez-Dias, L. Carpinteiro,
J. De Sousa, F.J. Pinto
Cardiology Department, Santa Maria University
Hospital, LMAC, Lisbon, PORTUGAL
Purpose: Assess the effectiveness of
triple-site ventricular pacing (Tri-V) cardiac
resynchronization therapy (CRT) in
pattients with permanent AF.
Methods: Single-center prospective
observational study of pts with permanent
AF, NYHA class higher than II and ejection
fraction < 35% who underwent CRT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
pts with permanent AF who are candidates
for CRT, or as an upgrade option in nonresponders.
TRI-VENTRICULAR PACING
A. Tordini 1, G. Zingarini 2, A. Mengoni 1, F.
Notaristefano 1, G. Ambrosio 1, C. Cavallini 2
1
Division of Cardiology and Cardiovascular
Pathophysiology, Department of Medicine
University of Perugia, Perugia, ITALY, 2 Division
of Cardiology, Perugia, ITALY
A 78- year-old man was admitted for heart
failure.
He had an ischemic heart disease, treated
with CABG, in hypokinetic and dilated
evolution (EF 15%).
In 2014 the patient was undergoing
implant of a pacemaker DDD for AV
block 2:1. The upgrading to CRT-D failed.
In 2015 the device was reprogrammed to
VVI because patient showed a permanent
atrial fibrillation.
The electrocardiogram showed atrial
fibrillation and QRS complex stimulated
(260 msec) . Fig.1
Evaluating the cardiopathy (EF 15 %),
associated with very wide QRS (260
msec), derived from the stimulation from
the apex of the right ventricle (the patient
was pacemaker dependent), we
performed the up-grading to CRT - D.
We placed a new pacing and defibrillation
lead in the right ventricle at the level of
medium - basal septum (the old
defibrillation lead was rested) and we
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implantation. Two leads were implanted in
the right ventricle (apex and outflow tract
septal wall). A left ventricle lead was
implanted as usual in a conventional CRT
– Figure 1. All pts underwent minimally
invasive hemodynamic assessment using
the
Vigileo
Flotrac®
(Edwards
Lifesciences). The final mode (Tri-V vs
Biventricular pacing) was programmed
according to the hemodynamic
performance. Follow-up assessment was
performed at 6 and 12 months.
Results: We included 40 pts (93% male,
72 ± 10 years). Thirty-three (82.5%) were
programmed in Tri-V based on the
hemodynamic test results. The following
results pertain to this subgroup. At
baseline, 58% of pts were in NYHA class
III and 42% NYHA class II, with a mean
ejection fraction of 28% ± 5. At 1-year
follow-up, the event-free survival was
88%, the responder rate 76% and the
super-responder rate 24%. Mean QoL and
6MWT distance significantly improved
(31±21 vs. 15±18, p=0,017; 416±104 vs.
465±107, p=0,005, respectively). Also,
mean ejection fraction increased (28±5
vs. 41±10; p < 0,001 at 12 months).
Conclusion: These results may warrant
considering Tri-V as a first line therapy in
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
placed two leads for the left ventricular
(one lead was positioned inside the lateral
vein of LV in the middle position and the
other one was positioned in the posterior
vein of LV in basal position).
The electrocardiogram after implantation
showed atrial fibrillation and paced QRS
complexes (150 msec ) much narrower
than the previous QRS complexes (fig.2).
The ejection fraction improved from 15%
to 30% and NYHA class improved from III
to II after three months from implantation.
The studies showed that Tri-V displayed
had similar safety profile compared with
Bi-V and was associated with long-term
benefits.
ARE ACUTE PHASE QRS AND CARDIAC
OUTPUT MEASUREMENTS GOOD
PREDICTORS OF TRIPLE-SITE PACING
CARDIAC RESYNCHRONIZATION
THERAPY IN PERMANENT ATRIAL
FIBRILLATION?
T. Guimarães, P. Marques, G. Lima Da
Silva, M. Nobre Menezes, I. Gonçalves, J.
Agostinho, A. Bernardes, N. Cortez-Dias ,
L. Carpinteiro, J. De Sousa, F.J. Pinto
94
Santa Maria University Hospital- Department
of Cardiology, Lisbon, PORTUGAL
Triple-site pacing (Tri-V) is a new method
of cardiac resynchronization therapy
(CRT).
Purpose: To evaluate whether acute
phase QRS and cardiac output (CO)
measurements are helpful in predicting
CRT response in patients with permanent
AF (pAF) undergoing Tri-V CRT.
Methods: Single-center prospective
observational study of patients with pAF,
NYHA class greater than I and ejection
fraction less than 35% who underwent
CRT implantation. Two leads were
implanted in the right ventricle (apex and
outflow tract septal wall). Left ventricle
lead was implanted as usual. Patients
underwent
minimally
invasive
hemodynamic assessment using the
Vigileo Flotrac®. Final mode (Tri-V vs
Biventricular pacing) was programmed
according to the hemodynamic
performance.
Results: We included 40 patients (93%
male, aged 72±10 years). 80% had
superior hemodynamic performance in TriV. In this group, 12-month response rate
was 76%; mean CO increase from RV
apical pacing to Tri-V pacing at baseline
was 0,34 ± 0,26 L/min (4,47 to 4,81
L/min); mean QRS duration reduction from
pre-implantation to Tri-V at baseline was
44 ± 33 mseg (170 to 123 ms); CO
increase was not different between non-
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
THURSDAY, DECEMBER 1, 12.30-14.00 [Spalato]
MULTISITE AND MULTIPOINT CRT
FREE PAPERS
responders and responders (0,25 [0,125
– 0,45] L/min vs. (0,30 [0,20-0,60] L/min,
p=NS), nor was the magnitude of QRS
duration reduction (-46 [-67 - 18] vs. –69
[-75 -22], p=NS).
Conclusion: Acute phase hemodynamic
and QRS results could not differentiate
between responders and non-responders
in patients with pAF undergoing Tri-V.
These surrogates do not seem to be
predictors of response in this subgroup of
patients, this type of CRT, or both.
95
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Pola]
CATHETER ABLATION OF VENTRICULAR TACHYCARDIA
UTILITY OF AUTOMATED PACEMAP
TEMPLATE MATCHING TO GUIDE
ABLATION OF UNSTABLE OR
UNSUSTAINED POST-INFARCTION
VENTRICULAR TACHYCARDIA
E. Cronin 1, F. Krainski 1,2, E. Crespo 1,2
1
Hartford Hospital, Division of Cardiology,
Hartford, CT, USA, 2 University of Connecticut
School of Medicine, Farmington, CT, USA
Introduction: Sinus rhythm pacemapping
with manual comparison to ventricular
tachycardia (VT) QRS morphology is of
limited value in post-infarction VT due to
antidromic and orthodromic capture of the
circuit and poor spatial resolution.
Automated template matching may
provide improved resolution.
Methods: We examined the utility of an
automated pacemap template matching
algorithm (PaSo module, Biosense
Webster) to identify the presumed VT exit
site of unstable or unsustained postinfarction VT. Ablation was targeted initially
at the exit site as defined by the highest
pacemap correlations, combined with
substrate modification.
Results: Six clinical VTs which were
unstable (4) or unsustained (2) were
mapped in five patients (4 male, age
59±19 years; LVEF 26±12%). A mean of
20.6±9.4 pacemaps were acquired per
patient. The mean maximum correlation
was 94.8±5.3%, range 85.4-99.3%. StimQRS did not correlate with correlation %.
The site of maximum correlation was
96
located in scar border zone (bipolar
voltage 0.5-1.5 mV) in all cases. Ablation
was acutely successful, with 4/5 patients
free of any recurrent VT after mean followup of 10.0±5.8 months. The only
recurrence was of the clinical VT which
was unstable and had been non-inducible
post ablation.
Conclusions: Automated pacemap
matching provides reasonably high
correlation with the clinical VT morphology
in post-infarction VT. This may provide a
useful indication of the exit site of unstable
or unsustained VT.
ADDED VALUE OF HIGH-DENSITY
SUBSTRATE MAPPING WITH
MULTIPOLAR MAPPING CATHETER AND
AUTOMATIC ANNOTATION IN ISCHEMIC
VENTRICULAR TACHYCARDIA
ABLATION
G. Lima Da Silva, N. Cortez-Dias, T.
Guimarães, I. Gonçalves, A. Bernardes, S.
Sobral, L. Carpinteiro, J. De Sousa, F.J. Pinto
Cardiology Department, Santa Maria University
Hospital, LMAC, Lisbon, PORTUGAL
Purpose: Assess the efficiency and
reliability of high-density substrate
mapping with multipolar mapping
catheters and automatic annotation for
ischemic ventricular tachycardia (isVT)
ablation.
Methods: Single-center retrospective
study of consecutive patients submitted to
isVT ablation using high-density substrate
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Conclusion: The enhanced efficiency and
high substrate map detail may be critical
to improve ablation techniques.
PREDICTORS OF OUTCOME AFTER
RADIOFREQUENCY ABLATION OF
PREMATURE VENTRICULAR
COMPLEXES
M. Al-Housari , B. Harbieh , M. Refaat, M.
Khouri, B. Abi-Saleh
American University of Beirut Medical Center,
Department of Internal Medicine-Cardiology,
Beirut, LEBANON
Introduction: Radiofrequency catheter
ablation(RFA) improves or prevents
deterioration of left ventricular function in
patients with frequent premature
ventricular contractions(PVCs). Currently
there is no sufficient data on predictors of
outcome of this procedure.
Methods: This is retrospective, single
center study of 48 patients with frequent
non ischemic PVCs who underwent RFA.
Medical charts were reviewed for initial
PVC burden, acute outcome (elimination of
predominant PVC(pPVC) and absence of
recurrence within 12 hours), and outcome
at 1 to 3 months. Multiple patient & PVC
related variables were analyzed to
correlate with outcome.
Results: The pPVC was acutely terminated
in 41 patients (85.4%), >80 % reduced at
1 to 3 months in 42 patients (89%), and
recurred at 1 month in one patient. The
presence or absence of the pPVC 12 hours
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mapping. A control group was selected
comprising
consecutive
patients
previously submitted to isVT using the
conventional technique. High-density
substrate mapping was performed using
the PentaRayTM multipolar mapping
catheter and automatic annotation was
performed using the CONFIDENSETM
module - CARTO® 3V4. Conventional
mapping was performed with the
SmartTouchTM ablation catheter with
manual acquisition and annotation using
CARTO ® 3V3. The duration of map
acquisition and the number of collected
EGMs was determined. All the EGMs were
revised in offline processing and the
proportion of EGMs rejected due to
inconsistency or noise was determined.
Results: A total of 18 patients (9 in each
group), aged 53±15 years, with ischemic
heart disease and reduced left ventricular
ejection fraction (35 ± 10%) were
enrolled. Clinical characteristics of both
groups were similar. High-density
substrate mapping and conventional
mapping did not differ in the duration of
map acquisition [92 (60-115) vs. 74 (6081) min; p=NS]. However, the number of
EGMs was significantly higher with highdensity substrate mapping [2171
(1174-3479) vs. 248 (144-360); p<0.001]
and the automatic algorithm was more
reliable than manual acquisition resulting
in a lower proportion of rejected EGMs
[4.5% (2.1-10.1) vs. 11.5% (7.9-16.4),
p=0.04].
THURSDAY, DECEMBER 1, 12.30-14.00 [Pola]
CATHETER ABLATION OF VENTRICULAR TACHYCARDIA
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
THURSDAY, DECEMBER 1, 12.30-14.00 [Pola]
CATHETER ABLATION OF VENTRICULAR TACHYCARDIA
post procedure was the single most
significant predictor of long term outcome
(P-valve <0.0001, sensitivity 95% positive
predictive value 97.6%). In 7/48 patients
(14.6%) the pPVC was not acutely
eliminated, 5(10.4%) had significant
reduction in PVC burden at 12 hours and
2(4.2%) were not ablated, 2/7 had >80%
reduction of PVC burden at 3 months. PVC
origin at coronary cusps (OR 0.2 {CI 0.031.52}, P-value 0.154) and PVC transition
from negative to positive at V3 (OR 0.33
{CI 0.05-2.23}, P-value 0.336) showed a
trend towards predicting failed outcome,
without
statistical
significance.
Conclusions: Acute outcome within 12
hours of non-ischemic PVC ablation is a
significant predictor of outcome at 1 to 3
months post procedure with high
sensitivity and positive predictive value
98
CLINICAL IMPACT OF CATHETER
ABLATION IN LEFT VENTRICULAR
CARDIOMYOPATHY ASSOCIATED WITH
RIGHT VENTRICULAR OUTFLOW TRACT
PREMATURE VENTRICULAR COMPLEX
L. Aguinaga, A. Bravo , J. Bonacina , P.
Gallardo , J. Dantur , R. Quintana
CPC, Tucuman, ARGENTINA
Purpose: The association between
premature ventricular complex originating
from right ventricular outflow tract (RVOTPVC) and the left ventricular dilated
cardiomyopathy is well known. We
investigated the clinical characteristics
and the impact of catheter ablation for the
treatment of RVOT-PVC associated left
ventricular dysfunction in a long term
follow up.
Methods: A total of 96 patients (45±8
years) who successfully underwent
catheter ablation for RVOT-PVC were
enrolled. After divided patients into those
with reduced (n=16) and normal (n=80)
left ventricular function (LVF), based on a
cutoff level of 40% ejection fraction (EF).
We compared the clinical and ECG
characteristics in them. After a mean
follow-up of 106±15 months, we also
evaluated the post-procedural changes in
LVF.
Results: EF in patients with reduced and
normal LVF was 38±6 and 59±9%. At
baseline, there were no differences
between patients with reduced and
normal LVF in age, sex, cicle length of
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
COMPARISON BETWEEN ROBOTIC AND
MANUAL APPROACH OF VENTRICULAR
ARRHYTHMIAS ABLATION: A SINGLE
CENTER EXPERIENCE
S. Grossi, M. Brunacci, C. De Rosa, F.
Bianchi, A. Sibona Masi, M.R. Conte
Mauriziano Hospital, Turin, ITALY
age: 65± 15years) with premature
ventricular contractions, sustained and
non sustained ventricular tachycardia,
electric storm were submitted to ablation
procedure with a 1:2 randomization
between remote magnetic navigation
(Epoch, Stereotaxis Inc., St Louis, MO,
USA) (group 1) and manual approach.
(group 2). There were no statistically
significant differences in age, gender, EF,
baseline cardiopathy between the two
groups. Acute success after the procedure
was defined as the absence of inducible
arrhythmia (A), the inducibility of not clinic
arrhythmia (B), the inducibility of same
arrhythmia (C). Acute, long term success,
complication rate, crossover between
group 1 and 2 were assessed.
Results: There was no statistically
significant difference in Type A results (93
vs. 97 %, P > 0.05), early recurrences
(13% VS 12%; P > 0,05), late recurrences
(11% VS 24 %, P > 0,05) . Neither groups
exhibited any major complications
Conclusion: Remote magnetic navigation
ventricular arrhythmias ablation is a safe
procedure with results comparable to
standard manual approach.
Background:
Remote
magnetic
navigation has proved to be effective in
ventricular arrhythmias ablation. We
compared procedural outcomes of
ventricular arrhythmias catheter ablation
guided by remote magnetic navigation
(RMN) versus manual approach.
Methods: A total of 129 patients (98 male,
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ventricular tachycardia and the origin of
VT/PVC. Only the total number of RVOTPVC on 24 hours Holter monitoring was
significantly greater in patients with
reduced LVF than in patients with normal
LVF (29850±10453 vs 13546±9234
beats/day P=0.006). The total number of
PVC demonstrated an inverse relation to
EF. At follow-up of patients with reduced
LVF, EF was significantly increased by 17%
(P=0.003.
Conclusions: Our results suggest the
association between the total number of
RVOT-PVC and the incidence of left
ventricular dysfunction. Catheter ablation
may have the clinical impact for the
treatment of RVOT-PVC associated left
ventricular dysfunction.
THURSDAY, DECEMBER 1, 12.30-14.00 [Pola]
CATHETER ABLATION OF VENTRICULAR TACHYCARDIA
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION: STRATEGIES
FOR A SAFE AND EFFECTIVE THERAPY
SECOND-GENERATION CRYOBALLOON
ABLATION OF ATRIAL FIBRILLATION:
BLANKING PERIOD ATRIAL
ARRHYTHMIAS ARE PREDICTIVE OF
LATE RECURRENCES WHEN DETECTED
BY INSERTABLE CARDIAC M
G. Sirico, S. Panigada, L. Ottaviano, G.
Pensa, D. Fanelli, V. De Sanctis, M. Mantica
Istituto Clinico S. Ambrogio-Unità di
Aritmologia clinica ed Elettrofisiologia, Milan,
ITALY
Introduction: Recent data showed that
early recurrence of atrial arrhythmias
(ERATs) occurring in blanking period are
strongly associated with late recurrence
(LRs) after paroxysmal atrial fibrillation
(AF) ablation using second-generation
cryoballoon (CB-2). There are limited data
on CB-2 efficacy based on continuous
monitoring. We here report 12 months
follow-up based on either non invasive or
insertable cardiac monitoring (ICM) after
AF ablation using CB-2.
Methods: From 2014 to 2016, 52 patients
(33 males, mean age 57.7 ±11.8 years)
affected by AF (92.3% paroxysmal)
underwent pulmonary vein isolation (PVI)
using CB-2. A Reveal Linq ICMTM was
implanted in 25 patients following ablation
(ICM
group),
while
Holter
electrocardiograms were used in the
remaining 27 patients (non ICM group).
Recurrences were defined as any episode
of AF, atrial flutter or atrial tachycardia
lasting at least 30 seconds.
100
Results: Overall, 99% of pulmonary veins
were successful isolated. At mean follow
up of 12 months, freedom from LRs was
achieved in 83.3% of patients in non ICM
group and in 69.6% in ICM group
(P=0.086). On overall population, LRs
occurred in 7 of 11 patients with ERATs
(63.6%) and in 5 of 41 patients without
ERATs (12.2%) (P<0.01). ICM data
reported the greatest number of ERATs (9
of 11, 81.8%).
Conclusions: In our population, ERATs
were strongly associated with LRs and
were better detected by ICM than non
invasive Holter electrocardiograms. If
routinely adopted, ICM helps in early
detection of patients at higher risk of LRs,
who might benefit from further ablations.
SAFETY AND NECESSITY OF THERMAL
ESOPHAGEAL PROBES DURING
RADIOFREQUENCY ABLATION FOR THE
TREATMENT OF ATRIAL FIBRILLATION
A. Fasano 1,2, L. Anfuso 2, S. Bozzi 2, C.
Pandozi 3
1
Dept. of Mathematics and Informatics U. Dini,
Univ. of Florence, Florence, ITALY, 2 FIAB Spa,
3
Florence,
ITALY,
Dipartimento
Cardiovascolare, San Filippo Neri Hospital,
Rome, ITALY
Background: Radiofrequency ablation is
used for the cure of atrial fibrillation.
Esophageal temperature can be monitored
by means of suitable probes. Aim To
compute the thermal field generated by
the ablation, to investigate the interaction
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
between the electromagnetic field and the
probe sensors, and to provide a safe
interpretation of the temperature detected
by the probe.
Methods: A mathematical model is
formulated and the thermal and
electromagnetic fields are computed.
Experiments have been performed to
assess the solution energy deposition rate
on the probe sensors. Clinical data have
been collected during radiofrequency
pulmonary veins isolation in patients with
atrial fibrillation and compared with the
computed predictions.
Results: The direct interaction between
the radiofrequency source and the probe
sensors was negligible. Numerical
simulations show that the outer
esophageal wall can be much warmer
than the lumen. The temperature in the
inner and external esophagus attains the
value of 39.5°C and 47°C respectively.
Theoretical heating curves are compared
with the clinical data selecting the
maximal slope as the reference quantity.
The clinical values range between
0.01°C/s and 0.15°C/s agree with the
computed predictions and demonstrate
that reducing the esophagus-atrium
distance by 1mm causes a slope increase
of 0.06°C/s.
Conclusion: The use of esophageal
thermal probes is safe and necessary in
order to avoid thermal lesions. The
external esophageal temperature can be
considerably higher than the luminal one.
The model is reliable, and describes
effectively the generated thermal field, as
confirmed by the results obtained during
radiofrequency circumferential isolation of
pulmonary veins.
PERSISTENT ATRIAL FIBRILLATION
ABLATION APPROACHES. COMPARISON
OF MATHEMATICAL SIMULATION DATA
AND CLINICAL RESULTS
E. Zhelyakov 1, A. Ardashev 1, M. Mazurov 2,
V. Finko 1
1
Lomonosov State University, Medical Centre,
Moscow, RUSSIA, 2 Economic and Statistic
Institute, Moscow, RUSSIA
Aims: 1) to estimate theoretical probability
of 6-waves re-entry elimination as a
results of simulation of linear vs. PVI
ablation in 2D mathematical modeling of
atrial fibrillation (AF). 2) to evaluate clinical
results of the both ablative techniques in
persistent AF patients.
Material and methods: The numeric
reconstruction of the autowave process in
excitable tissues of the LA and the
simulation of 6-wave re-entry AF was
performed using Fitzhugh-Nagumo
equation. A special scanning method was
used for calculating characteristics of
autowave processes in a 2D mathematical
model of the LA. Then ablation formatting
which corresponding all ablation lines was
performed.
We studied 20 consecutive pts (6 women,
58.2±10.6 years of age) with persistent
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ATRIAL FIBRILLATION: STRATEGIES
FOR A SAFE AND EFFECTIVE THERAPY
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION: STRATEGIES
FOR A SAFE AND EFFECTIVE THERAPY
AF during index ablation. The first step of
ablation was antral isolation of PVs, the
second and third steps included mitral
isthmus and roof ablation respectively. We
evaluated AF CL into the CS after each
step.
Results: Organization of AF CL (from
112±24 to 204±35 ms) was verified in 12
of 20 pts during ablation. SR was
effectively restored after cardioversion in
the end of procedure in all pts. Ablation
formatting (corresponding to linear
ablation) may transform 6-wave reentry to
4 wave re-entry. Following simulation of
cardioversion may effectively terminate 4wave reentry, whereas did not terminate
6-wave reentry.
Conclusion: Mathematical approach
using linear ablation may simulate clinical
impact suppressed 6-waves re-entry in
persistent AF pts. Our clinical results are
consistent with ablation formatting data
obtained by means of 6-waves re-entry
simulation in 2D mathematical modeling
of AF.
CRYOBALLOON ABLATION OF
PULMONARY VEINS FOR PAROXYSMAL
ATRIAL FIBRILLATION. ACUTE
EVALUATION BY VOLTAGE MAPPING
R. Robledo-Nolasco, R. Leal-Diaz, J.
Melgarejo-Murga, O. Torres-Jaimes, G.
Rodriguez-Diez, M. Ortiz Avalos
Centro Medico Nacional 20 De Noviembre.
Issste, Servicio de Hemodinamia y
Electrofisiologia, Mexico, MEXICO
102
Introduction: Cryoablation of pulmonary
veins (PVs) for paroxysmal atrial fibrillation
(PAF) has proven to be as effective as
catheter ablation. Corroboration insulation
is usually done by silence and lack of atrial
capture stimulation in the VPs. The
purpose of this study was to assess the
isolation of VPs by mapping voltage.
Methods: Patients with PAF and
underwent VPs isolation with usual
procedure cryoablation with balloon 28
were included. Mapping of VPs and left
atrium with EnsiteTM (St Jude Medical)
and Catheter Achieve mappingTM
(Medtronic Inc.) was made before and
after cryoablation. The isolation of the VPs
was first confirmed by electrical silence
and stimulation of VPs and subsequently
by mapping voltage. Ablation time and
temperature reached in each vein was
assessed, also the presence of gaps in the
ablation area immediately.
Results: Twelve patients were included,
6(50%) women, age 57+14 years. The
cryoablation time and the average of high
temperature vein was: 198.3+28.2
seconds (sec), 46.9+6.7 Celsius degrees
(CD); 188.0+21.1 sec, 41.6+6.5 CD;
182.9+37.6 sec, 46.4+5.3 CD;
186.6+19.4 sec, 46.0+6.7 CD for the
upper and lower left VPs and upper and
lower right VPs, respectively. In total 47
VPs was treated, the line of ablation was
very accurate (Fig. 1, left before, right
after). Gaps on mapping voltage were
found in 3(6.4%) VPs; two left superior
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
VPs and in one right inferior VP, so we went
back to finish the ablation.
Conclusions: Voltage mapping can
properly assess the isolation of the
pulmonary veins and could possibly
reduce the recurrence rate.
ATRIAL FIBRILLATION RE ABLATION:
EFFICACY IN A LARGE SERIES OF
PATIENTS
F. Moscoso Costa 1, N. Lopes 2, D. Cavaco 1,2,
L. Parreira 1, J. Mesquita 2, J. Carmo 2, P.
Carmo 1,2, S. Carvalho 2, F. Morgado 2, A.
Ferreira 1,2, P. Adragão 1,2, M. Mendes 2
1
Hospital da Luz, Lisbon, PORTUGAL, 2 Hospital
Santa Cruz, Lisbon, PORTUGAL
Aim: Atrial fibrillation recurrence after
ablation is often related to pulmonary vein
reconduction. A repeated procedure
targeting pulmonary vein re isolation is
thus a frequent strategy. Our goal was to
evaluate the efficacy of pulmonary of this
strategy in a large series of patients.
Methods and Results: In a registry of
1931 consecutive patients submitted to
pulmonary vein isolation (PVI) in two
centers, 245 (11.3%) were second
procedures due to AF recurrence (Average
59,7±11years old; 35,8% (87patients)
female; 69.2% (162patients) paroxysmal
AF). The second procedure was faster
(198.9±151minutes vs 201±107min;
p=0.013) with equivalent fluoroscopy time
(13,9 ±10,7 vs 13,9 ±10,8; p=NS). During
an average follow up of 2,4±1,9 years, AF
recurrence was similar when compared to
patients submitted to a single procedure,
20,4%
(50patients)
vs
19,2%
(370patients), p=0,34.
Conclusions: In this large series of
patients submitted to a repeated
procedure, pulmonary vein isolation was
feasible, with recurrence rates similar to a
first procedure, requiring similar
fluoroscopy time and with a significantly
lower procedure duration. Pulmonary vein
reisolation should be considered in
patients with recurrence after ablation.
REDUCTION OF XRAY EXPOSURE IN
ATRIAL FIBRILLATION ABLATION
PROCEDURES
S. Grossi , M. Bunacci , C. De Rosa , F.
Bianchi , A. Sibona Masi , M.R. Conte
Mauriziano Hospital, Turin, ITALY
Background: fluoroscopy remains the
cornerstone of imaging in most interventional
electrophysiological procedures: the
consequent excess in risk of cancer may be
103
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ATRIAL FIBRILLATION: STRATEGIES
FOR A SAFE AND EFFECTIVE THERAPY
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 4]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION: STRATEGIES
FOR A SAFE AND EFFECTIVE THERAPY
1 in 100 both for the long period exposed
operators and patients undergoing repetitive
complex procedures.
Methods: Between 2009 and 2015 we
evaluated 1216 consecutive procedures of
atrial fibrillation ablation, 803 male. The
xray exposure in terms of fluoroscopy time
and DAP (dose area product microGray/
m2) were considered over the time. At the
beginning of the period xray system was
set at 45 nanoGray per pulse with 7,5
pulses per second and wad used in
parallel with a CARTO XP system. The
physician reduced the fluoroscopy time as
much as possible. The xray system output
was reduced to 23 nanoGray per pulse
with 6 pulses per second and finally to 12
nanoGray per pulse with 4 pulses per
second. New non fluoroscopic CARTO 3
mapping system was introduced.
Results: In 2009 at the beginning of the
period mean fluoroscopy time for a single
AF ablation procedure was 9,5 min with
a mean DAP of 3800 microGray/m2. In
2015 at the end of the period mean
fluoroscopy time for a single AF ablation
procedure was 1,5 min ( 6,3 fold
reduction) with a mean DAP of 92
microGray/m2 (41 fold reduction).
Conclusion: Restraining the fluoroscopy
time, customizing of the X-ray system set
up and implementing non-fluoroscopic
guiding technologies enable to strikingly
reduce xray exposure in AF fibrillation
ablation procedures.
104
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
THE INTRACARDIAC ECG WITH WIDE
QRS: CAN IDIOVENTRICULAR ACTIVITY
BE DISCRIMINATED FROM
ATRIOVENTRICULAR CONDUCTION
WITH A BUNDLE-BRANCH BLOCK?
A. Capucci 1, M. Luzi 1, F. Guerra 1, L.
Marcantoni 2, G. Pastore 2, E. Baracca 2, F.
Di Gregorio 3, F. Zanon 2
1
Cardiology and Arrhythmology Dept.,
Ospedali Riuniti, Ancona, ITALY, 2 Cardiology
Dept., S. Maria della Misericordia General
Hospital, Rovigo, ITALY, 3 Clinical Research Unit,
Medico Spa, Rubano (PD), ITALY
The intracardiac ECG (iECG) is a nonconventional cardiac electrogram derived
by a dual-chamber pacing system. The
iQRS width closely reflects the duration of
the surface QRS and is suitable to
distinguish narrow from wide complexes.
A wide QRS, however, could represent
either idioventricular activity (IVA) or
atrioventricular conduction (AVC) with
LBBB or RBBB. Seeking for IVA recognition
criteria, the iECG was recorded by Eos or
Hera pacemakers (Medico, Italy) during or
after implantation. The device programmer
received the iECG signal by real-time
telemetry and simultaneously acquired the
surface ECG, which was used as the
standard
reference
for
activity
classification. All tracings were stored in
memory and analyzed off-line. A wide QRS
complex (duration > 120 ms on the
surface ECG) was detected in 30 patients
featuring LBBB (7 cases), RBBB (6),
idioventricular rhythm (5), PVCs (12). The
iQRS time-derivative was worked out and
its peak-peak amplitude was measured
within 50 ms from the signal onset as well
as along the whole waveform. The ratio
between early and total derivative change
averaged 0.42 ± 0.17 and 0.91 ± 0.09,
respectively, in case of IVA or AVC (P <
0.001). By setting a cut-off at 0.675, IVA
was properly recognized in all but 2 cases
(88% sensitivity; 95% c.l. 71–99). In
conclusion: a major early change in iQRS
speed is generally observed with LBBB or
RBBB, but not with IVA. This principle
might be applied in the interpretation of
the iECG tracing and be helpful in
discriminating
ventricular
and
supraventricular tachycardias.
ADDED VALUE OF PACEMAKER
RESPIRATORY MONITORING
ALGORITHM VERSUS CONVENTIONAL
POLISOMNOGRAPHY IN THE
DIAGNOSIS OF OBSTRUCTIVE SLEEP
APNOEA
T. Guimarães 1, P. Marques 1, G. Lima Da
Silva 1, M. Nobre Menezes 1, I. Gonçalves
1
, J. Agostinho 1, M. Dias 2, A. Bernardes 1,
N. Cortez Dias 1, P. Pinto 2, J. De Sousa 1,
F.J. Pinto 1
1
Santa Maria University Hospital- Department
of Cardiology, Lisbon, PORTUGAL, 2 Santa
Maria University Hospital- Department of
Pneumology, Lisbon, PORTUGAL
It has been suggested that 25% of
105
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CLINICAL ARRHYTHMOLOGY
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CLINICAL ARRHYTHMOLOGY
patients with sinus node disease or
atrioventricular node disease requiring
pacemaker implantation have obstructive
sleep apnoea (OSA). New generation
pacemakers have respiratory monitoring
algorithms that monitor the respiratory
distress index (RDI), identifying patients
with possible OSA.
Purpose: To compare the RDI obtained by
pacemaker monitoring algorithms (IDRPM) with the RDI obtained through
polisomnography (PSG).
Methods: Prospective study of
consecutive patients submitted to doublechamber pacemaker implantation or
generator replacement, using the Reply
200 TM device. Patients underwent a
clinical interview to access OSA symptoms
and PSG overnight study with RDI
determination. OSA was diagnosed
applying the American Academy of Sleep
Medicine criteria. RDI-PM during the PSG
study was registered.
Summary: 24 patients, aged 75±11
years, were submitted to pacemaker
implantation or generator replacement.
The RDI-PM during the PSG period was
found to be higher in patients with OSA
[32 (21-36) vs. 9.5 (5-20) p=0.008].
Although the correlation between the RDIPM and the definite RDI obtained through
PSG study has been moderate (Pearson
R=0.51; p=0.011), IDR-PM presented high
diagnostic accuracy for OSA diagnosis
[AUC: 0.813 (95% IC: 0.62-1.0); p=0.009].
Customer suggested threshold of 20
106
conferred diagnostic accuracy of 79%. In
this population, optimal RDI-PM cut-off
was 17.5 [sensitivity = 92%; specificity =
75%, overall diagnostic accuracy = 90%].
Conclusion: This prospective study
confirms the reliability of respiratory
monitoring algorithms available in
pacemakers for OSA diagnosis.
Respiratory monitoring algorithms
available in new generation pacemakers
can be valuable tools for timely detection
of OSA in clinical practice.
MAGNETIC RESONANCE IMAGE
INDICATION IN 456 CARRIERS OF
CARDIAC IMPLANTABLE DEVICES.
TWENTY YEARS FOLLOW UP FROM A
SINGLE MEDICAL CENTER IN LATIN
AMERICA
R. Robledo-Nolasco, J.A. Suarez-Cuenca,
P. Mondragon-Teran , F. FernandezSaldaña , J. Melgarejo-Murga
Centro Medico Nacional 20 De Noviembre.
Issste, Servicio de Hemodinamia y
Electrofisiologia, Mexico, MEXICO
Aims: To describe how often Latin
American patients carrying a cardiac
implantable device (CID) prospectively will
require a magnetic resonance image (MRI)
scan or surrogate study; as well as
characterizing such population. The use of
MRI-conditional CIDs represents potential
safety benefits; nevertheless, no data
regarding frequency of MRI indication or
associated clinical characteristics are
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
available in Mexico and Latin America.
Methods: Four hundred and fifty-six CID
carriers from a Cardiac Arrhythmia Clinic
in Mexico City were consecutively
included. Clinical information, as well as
data regarding CID and MRI or surrogate
study, were collected from medical
evaluation or digital records performed in
the last 20 years. Characteristics
associated to image study indication were
analyzed by T-test and x2.
Results: Study population showed a high
prevalence of hypertension, type 2
Diabetes Mellitus and most of the cases
were included within the first 5 years from
CID implantation, which was indicated due
to sick sinus syndrome, complete heart
block or ischemic heart disease. In 133
(29.1%) of CID carriers, a MRI or surrogate
study was indicated during the study
period, annual estimation of 9 cases / year
and CID-to-MRI mean time of 3.13±4.72
years. Comorbidities and the type of CID
implanted, being pacemaker the most
frequent, were significantly associated
with MRI indication, although they did not
affect the cumulative percentage of MRI
indication.
Conclusion: One third of patients carrying
a CID required a MRI or surrogate study
during a 20 years follow up. Comorbidity
and type of CID are likely associated
factors.
OUT OF HOSPITAL CARDIAC ARREST
SURVIVORS WITH INCONCLUSIVE
CORONARY ANGIOGRAM: IMPACT OF
CARDIOVASCULAR MAGNETIC
RESONANCE ON CLINICAL
MANAGEMENT AND DECISION-MAKING
A. Baritussio 1, A. Zorzi 2, A. Ghosh Dastidar 1,
A. Susana 2, G. Mattesi 2, J.C.L. Rodrigues
1
, G. Biglino 1, A. Scatteia 1, E. De Garate 1,
J. Strange 1, L. Cacciavillani 2, S. Iliceto 2,
G. Angelini 1, D. Corrado 2, M. PerazzoloMarra 2, C. Bucciarelli-Ducci 1
1
Bristol NIHR Cardiovascular Biomedical
Research Unit, Bristol Heart Institute, University
of Bristol, Bristol, UNITED KINGDOM, 2
Department of Cardiac, Thoracic and Vascular
Sciences, University of Padua, Padua, ITALY
Background: Non-traumatic out of
hospital cardiac arrest (OHCA) is the
leading cause of death worldwide, mainly
due to acute coronary syndromes. Urgent
angiography with view to primary
percutaneous coronary intervention is a
class IB recommendation. Diagnosis and
management of patients with inconclusive
coronary angiogram (unobstructed
coronaries or unidentified culprit lesion) is
challenging.
Objectives: We sought to assess the role
of Cardiovascular Magnetic Resonance
(CMR) in OHCA survivors with an
inconclusive coronary angiogram.
Methods: This is a retrospective
multicentre CMR registry analysis of
consecutive OHCA survivors undergoing
urgent coronary angiogram and CMR.
107
FREE PAPERS
CLINICAL ARRHYTHMOLOGY
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CLINICAL ARRHYTHMOLOGY
Clinical, ECG and multi-modality imaging
data from patients with an inconclusive
angiogram were analysed. Clinical impact
of CMR was defined either as a change in
diagnosis, compared to a multi-parametric
pre-CMR diagnosis, or a change in
management.
Results: We enrolled 110 OHCA survivors
(84 male, median age 58) with
inconclusive angiogram. CMR identified a
pathologic substrate in 76 patients (69%):
ischemic heart disease was found in 45
patients (41%) and non-ischemic heart
disease in 31 (28%). A structurally normal
heart was found in 25 patients (23%) and
non-specific findings were reported in 9
(8%). CMR proved to be superior to transthoracic echocardiogram in identifying a
substrate of the event (69% vs 54%,
p=0.018) and had a clinical impact in 70%
of patients (change in diagnosis 25%,
change in management 29%, change in
diagnosis and management 16%).
Conclusions: CMR showed a promising
role in the clinical-diagnostic work-up of
OHCA survivors with inconclusive
angiogram and its wider use should be
considered.
ECONOMIC IMPACT OF LONGER CRT-D
BATTERY LIFE IN SWEDEN
F. Gadler 1, Y. Ding 2, N. Verin 3, M. Bergius 4,
J.D. Miller 5, G.M. Lenhart 5, M.W. Russell 5
1
Department of Cardiology, Karolinska
University Hospital, Stockholm, SWEDEN, 2
Truven Health Analytics Inc., an IBM Company,
108
Bethesda, MD, USA, 3 Boston Scientific
Corporation, Hemel Hempstead, UNITED
KINGDOM, 4 Boston Scientific Nordic AB,
Helsingborg, SWEDEN, 5 Truven Health
Analytics Inc., an IBM Company, Cambridge,
USA,
Objectives: To quantify the impact that
longer battery life of cardiac
resynchronization therapy defibrillator
(CRT-D) devices has on reducing the
number of device replacements and
associated costs of those replacements
from a Swedish healthcare system
perspective.
Methods: An economic model based on
real-world published data was developed
to estimate cost savings and avoided
device replacements for CRT-Ds with
longer battery life compared with devices
with industry-standard battery life
expectancy. Base-case comparisons were
performed among CRT-Ds of three
manufacturers—Boston
Scientific
Corporation (BSC), St. Jude Medical (SJM),
and Medtronic (MDT)—over a 6-year time
horizon. A sensitivity analysis, evaluated
CRT-Ds as well as single-chamber (ICDVR) and dual-chamber implantable
cardioverter defibrillator (ICD-DR) devices
over a longer, 10-year period. All costs
were in 2015 Swedish Krona (SEK).
Results: Base-case analysis results show
that up to 603 replacements and up to
SEK 60.4 million cumulative-associated
costs could be avoided over 6 years by
using devices with extended battery life.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Savings are modest initially but they
increase rapidly beginning in the third year
of follow up. Evaluating CRT-D, ICD-VR,
and ICD-DR devices together over a longer
10-year period, the sensitivity analysis
showed 2,820 fewer replacement
procedures and associated cost savings of
SEK 249.3 million for all defibrillators with
extended battery life.
Conclusion: Extended battery life is likely
to reduce device replacements and
associated complications and costs, which
may result in important cost-savings and
a more efficient use of healthcare
resources as well as a better quality of life
for heart failure patients in Sweden.
LONG-TERM FAILURE RATE OF LINOX
AND VOLTA ICD LEADS, SINGLE
CANADIAN CENTER EXPERIENCE
A. Klein , M. Badra , C.H. Dussault , J.F.
Roux, A. Klein, F. Ayala Paredes
CIUSSS Université de Sherbrooke, Sherbrooke,
CANADA
Background: Some recent reports have
alerted that the failure rate of Biotronik ICD
leads is higher than expected, in the range
of 3.6 to 6.4% at five years.
Methods: All Linox and Volta ICD leads
implanted at our institution (three
operators) between 2006 and 2015 were
followed for at least one year. The patient
status was assigned as: 1) alive with a
functional lead, 2) alive with a confirmed
broken lead, 3) alive with a lead changed
for other reason, 4) dead not related to the
lead status.
Results: 524 leads were implanted (in 513
patients) between December 2006 and
may 2015: 57 Volta leads; 70 Linox Smart
Dx, 9 Linox Smart ProMRI, 25 Linox SD,
and 363 Linox Smart leads; they were
implanted with 167 single chamber, 199
dual chamber and 158 Biventricular
devices. Mean follow up was 1404 days
(SD 747 days, median 1385 days). Eight
leads presented with failure (electrical)
requiring either extraction or a new lead
(1.53%), median time to fail: 1300 days
(range 532-3289 days), all had short VV
intervals. Seventeen leads were changed
or extracted (3.24%) six due to lead
dislodgment and the others mostly
because infection. A hundred patients died
(19%) after a median of 746 days (range
41-3357 days). Finally 399 patients were
alive and with a functional lead after a
median of 1565 days (range 393-3564
days)
Conclusion: Failure rate of Linox and Volta
leads is low at our institution. We did not
found any specific characteristic related to
lead failure.
109
FREE PAPERS
CLINICAL ARRHYTHMOLOGY
FRIDAY, DECEMBER 2, 11.00-12.30 [Leptis magna 2]
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
DIAGNOSTIC APPROACH TO PATIENTS
WITH SUSPECTED ARRHYTHMIAS BY
EXTERNAL LOOP RECORDER
G. Boggian, F. Serafini, S. Saccà, R.
Vandelli, R. Parlangeli, A.C. Musuraca, E.
Mazzoni, F. Lai, A. Lombardi, L.G. Pancaldi
ASL Bologna, Ospedale Civile di Bentivoglio
(BO), Bologna, ITALY
Background: external loop recorders
(ELRs) allow higher arrhytmias yeld than
multilead Holter monitoring. We evaluated
since January 2015 until august 2016 53
patients with symptoms from possible
arrhytmias or known heart disease who
needed a risk stratification by ELR
(Spiderflash-SORIN).
Results: Age of our population ranged
from 7 to 77 years old; main indication for
ELR positioning was palpitations (25/53
pts, 47 %), other other were: previous
AIT/ischaemic events (7%) or Brugada
Syndrome (5%), previous AVNRT (7%),
vertigo/syncope (13%) or pastAF (9%),
ARVD or previous Ventricular tachycardia
or previous atrial tachycardia (1/53, 1,9%
each one); valvular heart disease (2/53,
3,7%). A global amount of 73 diagnostic
ecg strips were isolated. The mean
recording time was 17,9±4,3 days. Events
recorded have been acquired after
patients’ activation or automatically by
ELR; than the ratio between events revised
by technician and physician to the whole
events recorded was calculated
110
Automated records had a mean reliability
ratio higher than events triggered by
symptoms: 0,27 vs 0,08 respectively,
p=0,00074; Fig1. The amount of events
detected according to clinical status
showed that patients prone to ventricular
arrhythmias had less probablity of
supraventricular rhythms than patients
with history of supraventricular
arrhythmias or former AIT/thromboembolic
event or valvular heart disease (p=0,01
Chi squared for tables “true values” and
“expected values”, DistXsq for probability
calculation), Tab1, Fig 2.
Conclusions: ELR-Spiderflash is useful in
detection of supraventricular tachycardias
and ventricular rhythms patients with
palpitations, previous ischaemic event and
is useful in risk stratification in patients
prome to ventricular events.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Santa Maria del Carmine Hospital, Rovereto,
ITALY
Background: the Insertable cardiac
monitor (ILR) Medtronic LinQ® is a
leadless subcutaneous device that
continuously monitor the heart rhythm and
record events over three years, allowing
for recording of infrequent rhythm
abnormalities. The device can be remotely
monitored with a wireless system which
may potentially reduce the time from
arrhythmia onset to diagnosis and therapy.
The aim of our study was to evaluate the
ability of this system to provide a
diagnostic response in a short term
follow-up. Materials and methods: we
111
FREE PAPERS
THE BENEFIT OF A REMOTELY
MONITORED IMPLANTABLE LOOP
RECORDER
M. Maines, A. Zorzi, G. Tomasi, D.
Catanzariti, C. Angheben, M. Del Greco
evaluated 154 consecutive patients(pts)
who received a LinQ from August 2014 to
May 2016 and were provided the remote
monitoring system MyCarelink®. We
calculated the diagnostic rates in relation
to the implantation indication and the
average time from arrhythmia onset to.
Results: Indications for implantation
included: evaluation of atrial fibrillation(AF)
burden(N=37,24%),
palpitations(N=15,10%),
recurrent
syncope(N=52,34%),
ventricular
arrhythmias(VT)(N=26,17%)
and
criptogenetic stroke(N=24,15%). During a
mean follow-up of 12.1±6.7 months, 117
automatically recorded arrhythmic events
(48 symptomatic and 59 asymptomatic)
from different categories occurred in
92(60%)pts. In addition, 30(19%) pts
manually recorded symptomatic events
that were not automatically recorded by
the device and that corresponded to sinus
rhythm or premature ventricular beats.
Overall, a diagnosis was made in
99(64%)pts. In 60(39%)pts a therapy was
established following recording of
arrhythmias. In 26pts the device recorded
asymptomatic arrhythmic events that
prompted therapeutic intervention.
Conclusion: the Linq plus MyCarelink
system allowed to make a diagnosis in
64% of pts after about one year of followup and to reduce the time from arrhythmia
onset to therapy.
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
EARLY DETECTION OF ATRIAL
FIBRILLATION IN PATIENTS WITH
HYPERTROPHIC CARDIOMYOPATHY
AND IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR. THE IMPORTANCE OF
REMOTE MONITORING
R. Morgagni, A. Sanniti, G.B. Forleo, L.
Santini, F. Marchetti, F. Romeo
Fondazione Policlinico Tor Vergata, Rome, ITALY
Introduction: Hypertrophic Cardiomyopathy
(HCM) is an inherited myocardial disease
characterized by inappropriate ventricular
hypertrophy and increased risk of sudden
cardiac death. Implantable cardioverter
defibrillator (ICD) has changed the natural
history of the disease, having a significant
mortality benefit. Atrial fibrillation (AF) is the
most common supraventricular arrhythmia
in HCM.
Aim of the study: Early detection of AF in
older patients with HCM and ICD.
Matherials and Methods: We have
studied 26 patients with familial HCM
(echocardiographic diagnosis confirmed
by genetic study) and ICD implanted for
primary prevention of SCD, aged > 44. The
duration of follow up was 24 months. All
ICDs had home monitoring.
Results: On 26 patients 11 (42,3%) had at
least one episode of atrial fibrillation: 6 on
11 had one or more episode of paroxysmal
AF, 1 of them had an inappropriate shock
due to ventricular rate response. 5 patients
on 11 (45,4%) had a persistent AF and were
hospitalized in 48 hours for cardioversion.
112
2 of them were completely asymptomatic.
Only 1 patient had a pulmonary edema due
to AF and was hospitalized. We decided to
put them on oral anticoagulation. No
embolics events were documented. No
patients had sustained ventricular
arrhythmias during FU.
Conclusions: AF seems to be very
frequent in older HCM patients. ICDs with
home monitoring can identify atrial
tachyarrhythmias in symptomatic or
asymptomatic HCM patients with no prior
history allowing an earlier hospitalization
as well as early optimization of
pharmacological therapy and ICD
programming.
SAFETY AND EFFICACY OF ANTITACHYCARDIA PACING IN PATIENTS
WITH HYPERTROPHIC
CARDIOMYOPATHY IMPLANTED WITH
A CARDIOVERTER-DEFIBRILLATOR
C. Adduci, F. Palano, L. Semprini, B.
Musumeci, D. Santini, L. Zezza, M. Volpe,
C. Autore , P. Francia
Cardiology, Department of Clinical and
Molecular Medicine, St. Andrea Hospital,
Sapienza University, Rome, ITALY
Introduction: Anti-tachycardia pacing
(ATP) is an effective treatment for
ventricular tachycardia in patients
implanted with an ICD. Safety and efficacy
of ATP in hypertrophic cardiomyopathy
(HCM) have never been assessed. In a
retrospective analysis of a cohort of HCM
patients implanted with an ICD we aimed
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
patients could safely reduce unnecessary
therapies.
TECHNICAL FEASIBILITY FOR APPBASED REMOTE MONITORING AND
PATIENT’S ACCEPTANCE: A MULTICENTER EXPERIENCE
L. Rossi 1, R.P. Ricci 2, L. Morichelli 2, G.
Augello 3, G. Belotti 4, C. Parmigiani 4, G.
Guenzati 5, A. Personi 5, M.S. Bacillieri 6, F.
Badessa 7, C. Marino 7, G.Q. Villani 1
1
Ospedale G. Da Saliceto, Piacenza, ITALY, 2
Ospedale San Filippo Neri, Rome, ITALY, 3
Istituto Clinico Città Studi, Milan, ITALY, 4
Ospedale Treviglio-Caravaggio, Bergamo,
ITALY, 5 Ospedale San Carlo Borromeo, Milan,
ITALY, 6 P.O. Camposampiero, Camposampiero
(PD), ITALY, 7 P.O. “Giuseppe Fogliani”, Milazzo
(ME), ITALY
Introduction: Until today, all remote
monitoring systems (RMS) used
worldwide consist of a patient monitor and
a secure website for accessing data.
Patient monitor was a new tool for
patients. The aim of this project was to
evaluate patients’ acceptance and
satisfaction of the new remote control
system Medtronic MyCareLink Smart
(MyClSm).
Methods: The project interested 7
Hospitals over all Italy and involves 70
pacemaker patients provided by MyClSm.
This type of RMS uses a portable reader
that communicates via Bluetooth with
smartphone or tablet using the free
MyClSm app. The system is connected to
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FREE PAPERS
to (a) assess the burden and
characteristics of ventricular arrhythmia
(VA) suitable for ATP; (b) evaluate ATP
safety and efficacy.
Methods and Results: HCM patients
implanted with an ICD in our Centre were
assessed for VA requiring device
intervention. 77 patients (44 males; mean
age: 46±16y) were followed for
64±37months from ICD implantation. 24
patients (31%) had 51 VT/VF, 44 of which
(86%) treated with at least 1 ATP.
ATP (1 or more attempts) was successful in
24 (55%) VTs, unsuccessful in 11 (25%) and
inappropriate (ATP for self-terminating VTs)
in 9 (20%). Among VTs treated ineffectively
or inappropriately (n=20), 9 self-terminated
and 11 (25%) were accelerated (8 requiring
DC-shock). Successfully ATP-treated VTs
had mean HR 200±28 bpm and were
terminated within 11±3 s; ineffectively
treated self-terminating VTs had
comparable HR (202±39bpm) and longer
duration (20±14 s).
As compared with successfully treated
VTs, those ATP-accelerated had
comparable HR (202±39bpm) and ATP
rate (85±3% vs 83±6% of the VT-CL;
p=0.33).
Conclusions: In this cohort of HCM
patients, ATP was only moderately
effective and frequently induced VT
acceleration. When successful, ATP
terminated most VTs within few seconds,
leaving unanswered the question whether
less aggressive ICD programming in HCM
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
the hospital through CareLink Website.
Each patient fulfills a questionnaire at
enrollment and after one month, to
evaluate the acceptance and the easy of
use of new monitor.
Results: 66/70 patients accept the
system, resulting in a 93% rate of
acceptance of the technology. 60% of this
patients use the app on a relative’s
smartphone/tablet. Android was the
operating system more used with respect
to IOS (66% vs 34%) and no one of this
patients did call Medtronic Directo for
technical problems or troubleshooting. 6%
decline the service, we’ve found most
commonly reason is that patient isn’t
comfortable enough with the smart
technology or rather do in office checks.
96% of patients say it was easy or very
easy to use and it took less than 10
minutes for app download & send 1st
transmission. Is surprising that 80% of
patients are more than 60 years old.
Conclusion: MyClSm showed no change
in patient compliance and proves the
simplicity of the system, because for the
first time patient manage something
which is already friendly for him or for
caregivers: smartphone or tablet.
LONG TERM SURVEY OF ENERGY
DRINK CONSUMPTION IN YOUNG
PEOPLE IN HIGHT SCHOOL
M. Santomauro 1, L. Matarazzo 1, G.
Castellano 1, G. Palma 1, C. Riganti 2, A.
Ferro 3, C. Vosa 1
114
1
Department of Cardiology, Cardiac Surgery
and Cardiovascular Emergency, Federico II
University, Naples, ITALY, 2 Direzione Sanitaria,
Azienda Ospedaliera Universitaria Federico II,
Naples, ITALY, 3 Istituto di Biostrutture e
Bioimmagini, Consiglio nazionale delle
Ricerche, CNR, Naples, ITALY
The purpose of this survey was to
determine ED consumption pattern among
students, prevalence and frequency of ED
use for 7 situations, namely for insufficient
sleep, to increase energy, driving long
periods of time, drinking with alcohol while
partying, drinking with Italian coffee,
prevalence of ED use before and during
sport practice and prevalence of adverse
side effects. Based on the responses from
a 4 member Hight School students focus
group and a filed test, a 10 item
questionnaire survey was used to assess
ED consumption pattern of 478 randomly
students ( 250 m and 228 f, mean age
16±2 years) attending the School of
Naples.
Approximately 68% of 14 to 19 year old
adolescents consume EDs regularly
(consuming greater than one ED each
month in an average month for the current
semester). The majority of user consumed
ED for insufficient sleep (70%), to increase
energy (65%). The majority of users
consumed one ED to treat most situations
although using three or more was a
common practice to drink with alcohol
while partying (52%) and before or during
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 1]
CARDIAC ARRHYTHMIAS: PREVENTION AND TREATMENT
FREE PAPERS
sport practice (66%) . 20% reported ever
having headaches and 15% heart
palpitations from consuming ED. There
were no significant differences in use of
ED for the 7 situation assessed by sex.
It is important for physicians to understand
the lack of regulation in caffeine content
and other ingredients of these high-energy
beverages and their complications so that
parents and children can be educated
about the risk of cardiac arrhythmias.
115
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
REDUCING EXPOSURE TO RADIATIONS
IN THE EP LAB, FROM THEORY TO
PRACTICE: THE MONTREAL HEART
INSTITUTE EXPERIENCE
B. Thibault, B. Mondesert, M. Dubuc, K.
Dyrda, P. Guerra, P. Khairy, L. Rivard, D.
Roy, M. Talajic , L. Macle
Montreal Heart Institute, Montreal, CANADA
It is important to reduce exposure to
ionizing radiations (IR) during EP
procedures. Our objective is to report our
experience to reduce IR exposure in the EP
lab over the last 4 years.
Methods: Data on IR exposure performed
between 2012 and 2015 were collected.
Measures to reduce IR were introduced
from 2013: 1st with mandatory training
and IR dose reporting in EP reports, 2nd
with
optimal
usage
of
3-D
mapping/tracking systems and from 2015,
by optimizing the fluoro settings (reducing
from 6 to 3 fps and 40 to 23 pGy/pulse).
Results: An 85% reduction in IR exposure
was observed: DAP decreased from a
median of 6.8 in 2012 to 1.0 Gy.cm2 in
2015 (P<0.001). This was true for ablation
and devices procedures. In ablations, the
benefits came from shorter IR exposure
times (14.6 to 8.5 min) and lower DAP/min
(1.5 to 0.3 Gy.cm2/min). Benefits in
devices procedures came mainly from
116
lower DAP/min: IR time went from 3.3 to
2.5 minutes while DAP/min decreased
from 1.6 to 0.3 Gy.cm2/min. Importantly,
reducing IR doses reflected on the
dosimeter readings of the staff: in 2012,
the average quarterly reading was 0.72
mSv, as of 2015, it went down to 0.14
mSv (P<0.001).
Conclusions: Minimizing IR in the EP lab
is doable and the benefits are significant.
It comes from a multi-aspect strategy,
where teaching and awareness play an
important part. It is hard and continuous
work, with progressive implementation of
the adequate habits and technologies.
FROM NEAR ZERO TO ZERO
FLUOROSCOPY CATHETER ABLATION
PROCEDURES. DOUBLE CENTRES
EXPERIENCES WITH
ELECTROANATOMIC MAPPING SYSTEM
WITHOUT THE USE OF FLUOROSCOPY
A. Santoro 1, F. Lamberti 1, V. Zacà 2, C.
Baiocchi 2, F. Di Clemente 1, C. Bianchi 1,
C. Bellini 1, R. Maggi 1, F. Piccolo 3, M.
Mercurio 3, R. Favilli 2, A. Gaspardone 1
1
Department of Medicine, Cardiovascular
Section, San Eugenio Hospital, Rome, ITALY, 2
Department of cardiovascular disease,
Cardiology section, Le Scotte Hospital, Siena,
ITALY, 3 Biosense Webster Johnson and
Johnson, Italy
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
and ventricular tachycardia (VT)
completely without FL, guided by CARTO
system, are safe, feasible and effective.
After an adequate learning curve CA can
be performed completely without FL.
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Aims: The use of electroanatomical
mapping system (EAM) can reduce
fluoroscopy (FL) exposure and it can
completely eliminate the use of FL.
Radiation exposure related to conventional
RF (RF) ablation procedures carries a
stochastic and deterministic effect on
health. The main findings of this study
were to evaluate the safety and feasibility
of a completely non fluoroscopic approach
to catheter ablation (CA) using EAM
CARTO3.
Methods: In 2011 we started a FL
minimization program in all procedures
using CARTO system with the deliberate
intention not to resort to the aid of FL
unless strictly necessary. We divided
procedures in two groups (group 1: from
2011 to 2013; group 2: from 2014 to
2016). The only exclusion criterion was the
need for trans-septal puncture and
ischemic ventricular tachycardia.
Results: In 181 procedures out of 268 we
performed CA without FL, 68%. From
2011 to 2013 we performed 35.9 % of CA
without FL; from 2014 to 2016 we
performed 91.4 % of cases with zero FL.
The use of FL was significantly reduced in
Group 2 (Group2: 1.76±12.6 seconds
versus Group1: 556.92±520.76 seconds;
p<0.001). These differences were
irrespective of arrhythmia treatment.
There were no differences between two
groups about acute success (95% vs
97.2%;p=0.4), complications, duration of
procedures (group 1: 137,1±57.7 min vs.
group 2: 137.1±70.9 min; p=0.6).
Conclusions: CA of supraventricular (SVT)
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
ZERO FLUOROSCOPY DIRECTION:
GOING BACK TO 3D MAPPING SYSTEM
ORIGIN
A. Pani 1, G. Rovaris 2, L. Rossi 3, P. Vergara 4,
S. Negroni 5, N. Bottoni 9, G. Viola 7, S.
Ocello 8, S. De Ceglia 2, R. Brambilla 1, A.
Scopinaro 6, G. Belotti 10, D. Penela Maceda
3
, M.G. Bongiorni 11, D. Malaspina 12, F.
Zoppo 13, S. Pedretti 14, C. Bonanno 15, C.
Pandozzi 16, V. Zacà17
1
A. Manzoni, Lecco, ITALY, 2 S. Gerardo, Monza,
ITALY, 3 G. da Saliceto, Piacenza, ITALY, 4 S.
Raffaele, Milan, ITALY, 5 S. Paolo, Milan, ITALY,
6
SS Antonio e Biagio e Cesare Arrigo,
Alessandria, ITALY, 7 S. Francesco, Nuoro, ITALY,
8
SS Trinità, Cagliari, ITALY, 9 Arcispedale S.
Maria Nuova, Reggio Emilia, ITALY, 10 Treviglio
e Caravaggio, Treviglio, ITALY, 11 Pisa, ITALY,
12
Milan, ITALY, 13 Mirano, ITALY, 14 Milan, ITALY,
15
Vicenza, ITALY, 16 Rome, ITALY, 17 Siena, ITALY
Introduction: radiofrequency catheter
ablation (RFCA) is currently a firstline
therapy for the treatment of arrhythmias.
Operators need to develop a procedural
workflow for reducing the fluoroscopy use,
using 3D mapping system: the aim of our
multicenter, prospective and obervational
study is to demonstrate feasibility, efficacy
and safety of a
specific flow-chart
using the CARTO®3
(Biosense Webster,
Johnson & Johnson
Medical S.p.A., CA,
USA)
mapping
system as the sole
118
or prevailing imaging modality to guide
RFCA.
Methods: 430 patients (age 55±22) with
supraventricular arrhythmias underwent
electrophysiological study. Of these, 392
(92%) patients proceeded to RFCA guided
by the CARTO®3 mapping system and in
38 cases no arrhythmia could be induced
during the EP study. The flow-chart
provides cannulation of the right femoral
vein to insert NAVISTAR® catheter,
creation of right atrial geometry, His
bundle region tag, CS ostium and the
tricuspid valve tags acquisition, diagnostic
catheters advancement, EP study and
RFCA.
Results: In 289/430 (68%) of cases 3D
mapping avoided fluoroscopy entirely and
in the remaining 141/430(32%) cases, in
relation with a mean procedure time of
93,3±41,2 min, the mean fluoroscopy
time was 0,37±0,9 min. Conclusion: RFCA
was acutely successful in all 59 patients.
There was no complication in all flowchart
steps described. An homogeneity and
complete adherence to the workflow
adopted lead to an immediately reduction
or absence of fluoroscopy use. We noticed
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
NON-FLUOROSCOPIC 3D MAPPING
SYSTEM FOR CATHETER ABLATION
LEADS TO A SENSITIVE REDUCTION OF
THE EFFECTIVE DOSE ABSORBED BY
ELECTROPHYSIOLOGISTS
L. Duro, G. Tola, A. Scalone, A. Pollastrelli,
B. Schintu, A. Setzu, M. Porcu
Azienda Ospedaliera G. Brotzu, Cagliari, ITALY
Background: Traditionally EP procedures
are performed under fluoroscopicguidance causing radiation exposure for
both patients and operators. Fluoroscopy
is an efficient way to navigate catheters
but requires ionizing radiation, which even
in low doses may be harmful. Recently it
has been introduced a non-fluoroscopic3D-mapping system for catheter ablation
through a minimally fluoroscopic (MF)
approach and several trials have showed
its feasibility and safety in terms of
reduction in x-ray exposure for patient,
while the effect on the operators has still
to be investigated.
Aim of this study was to compare ionizing
radiation exposure during MF catheter
ablation with conventional fluoroscopyguided ablation for supraventricular
tachycardias.
Methods: From 2012 to 2015 data on EP
procedures
performed
were
retrospectively evaluated, together with
their impact on radiation exposure of the
two EP operators through dosimeters.
1157 patients have been implanted with
implantable cardiac devices and 342 EP
procedures have been performed. Since
2014, most of EP procedures were done
with non-fluoroscopy mapping, using the
SJM Ensite NavX.
Results: The dosimeters analysis showed
a sensitive reduction of the effective dose
absorbed by electrophysiologists. The
number of procedures/year, procedural
time and total ionizing radiation exposure
dose were analyzed. A significant
reduction
in
ionizing
exposure
(p<0.00001) was observed at the
statistical analysis of data trends (carried
with T-Test) from conventional fluoroscopy
period (2012-2013) to actual nonfluoroscopy time (2014-2015).
Conclusion:
The
non-fluoroscopy
mapping system in catheter ablation of
supraventricular arrhythmias represents a
first line strategy in terms of efficacy,
safety and total benefit from ionizing
radiation exposure reduction, for both
patients and operators.
ZERO FLUOROSCOPY APPROACH FOR
INTERVENTIONAL ELECTROPHYSIOLOGY.
SINGLE CENTRE EXPERIENCE ON MORE
THAN 860 PATIENTS
E. Kropotkin, E. Ivanitskiy , V. Sakovitch
Federal Centre For Cardiovascular Surgery,
Department of Cardiac Surgery Unit 2,
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a progressive diagnostic catheters number
reduction: learning curve in taking
confidence with CARTO®3 mapping
system accuracy and potentialities to
guide RFCA.
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
Krasnoyarsk, Russia
Aim of the study: to assess safety and
effectiveness of totally non fluoroscopic
approach for interventional electrophysiology.
Methods and patients: 863 consecutive
patients with indications for catheter
ablation or anti arrhythmic device
implantation were enrolled in the study
(including children - 134 patients) and
pregnant women (10 patients). All patients
signed informed consent. All procedures
were performed by using 3D navigation
system CARTO 3, or NaviX and under
intracardiac echo guidance (Acu Nav,
Sound Star). All types of arrhythmias were
included in the study. All devices
implantations
(except
cardiac
resynchronization
devices)
were
performed under the intracardiac echo
guidance. Control group of patients was
studied for every type of arrhythmia (total
number of patients in control group was
914).
Results: Complication rate and
effectiveness in totally non fluoroscopic
group of patients and in control group
were comparable. In six patients we had
to switch from non fluoroscopic approach
to fluoroscopic due to different reasons.
Procedure time for different types of
arrhythmias became comparable after
learning curve.
Conclusion: zero fluoroscopic approach is
safe and as effective as a standard. In
sone cases safety of this method could be
120
higher when compared to standard
approach. It could be a variant of choice
in selected groups of patients such as
children and pregnant women.
CRT IMPLANTATION USING AN
ELECTROMAGNETIC NAVIGATION
SYSTEM (MEDI GUIDE): TOWARD ZERO
IN X-RAY EXPOSURE
P.G. Golzio 1, C. Budano 1, D. Castagno 1, U.
Barbero 1, I. Meynet 1, M. Bisi 1, A. Bissolino 1,
M.J. Kapiris 2, F. Di Lorenzo 2, V. Cutrona 2, F.
Gaita 1
1
Divisione di Cardiologia, AOU Città della
Salute e della Scienza di Torino, “Molinette”,
Turin, ITALY, 2 St. Jude Medical Italia, Agrate
Brianza (MI), ITALY
Introduction: Implantation of cardiac
resynchronization therapy (CRT) devices
can be challenging, time consuming, and
fluoroscopy intense. To reduce X-Ray
exposure during CRT implantation a novel
electromagnetic navigation system
(MediGuideTM, St. Jude Medical, St. Paul,
MN, USA) (MG) has been developed,
displaying real-time location of sensorembedded tools superimposed on a
three-dimensional electro-anatomical
map (3D-EAM).
Methods: Non-fluoroscopic coronary
sinus (CS) cannulation and location of the
sensor-driven guidewire into the target
vein on the 3D-EAM was performed using
MG, with short sequences of live
fluoroscopy to confirm the position of the
tools.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FRIDAY, DECEMBER 2, 11.00-12.30 [Orange 2]
ZERO FLUOROSCOPY ABLATION
FREE PAPERS
Results: Between April 2014 and
December 2014, 10 patients (69 ± 11
years, 7 males) were implanted with a CRT
device using the new electromagnetic
tracking system.
LV lead implantation was successfully
achieved in all patients without severe
adverse events.
Median total fluoroscopy time (skin-toskin) was 20 ± 17 (2-57) minutes with a
median dose-area-product of 16311 ±
15239 (1690-52581) microGy*m2 (Table
I). Over the time fluoroscopy and X-Ray
exposure were significantly reduced (Fig
1 and 2).
Conclusions: after gaining the necessary
operator’s experience, fluoroscopy time
resulted even lesser than the usually
observed in a conventional pacemaker
implant.
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XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Tarragona]
ATRIAL FIBRILLATION:
CLINICAL EVALUATION AND MANAGEMENT
ATRIAL FIBRILLATION IN ELDERLY
PATIENTS - MODERN CONCEPT OF
COMPLEX MANAGEMENT
I. Skigin, K. Shorokhov, E. Voitkovskaya, N.
Lepakhina, A. Abramov, I. Pyaterichenko
Municipal Cardiac Surgery Center, Hospital 2,
Saint-Petersburg, RUSSIA
Despite the evolution in RFA of paroxysmal
atrial fibrillation (PAF) important cohort of
elderly patients with PAF and bradycardia
remains.
Goal: To demonstrate modern oportunities
of hybrid therapy in elderly patients with
PAF.
In the study enrolled 73 patients with PAF
and sinus node disease at the age 61-97
years-old. All the patients has received DR
pacemakers (PM): 36 patients-ReplyDR,
13-EspritDR (Sorin), 21-E60DR (Vitatron),
7-AdaptaDR (Medtronic). PM programmed
to the basic rate 70 bpm, ATP and
algorithms for reducing RV pacing
switched on. All patients has received
antiarrhythmic drug therapy (Class III).
Specific subgroup consist of patients, who
underwent RFA PAF; in 5 cases as start of
hybrid management (group 1), in 8 cases
(group 2)–after PM implantation (6-18
months) because of lack of antiarrhythmic
drugs efficacy and high PAF symptomatic
classes (EHRA).
We used Carto3 System; there were no
complications. An AcuNav ultrasound
catheter was used for ICE.
During the first post-op day, the PAF
122
burden was 15,1±1,7 hours, on the 5-th
day PAF burden was 2,3±0,2 hours. After
1-year follow-up PAF burden was
0,5±0,06 hours/day. In RFA subgroup in
group 1 after 3 months of follow-up all the
patients were free from PAF;
antiarrhythmic therapy was discontinued
as well as in 4 cases from group 2. In 4
patients from group 2 we observed a rare
and unstable PAF, antiarrhythmic therapy
continues.
More aggressive approach in PAF
management is effective modern concept
in elderly patients. ICE-assisted RFA
significantly increase effectiveness and
safety, reduce the recurrence of PAF.
OUTCOMES AFTER ELECTIVE
ELECTRICAL CARDIOVERSION FOR
PERSISTENT ATRIAL FIBRILLATION:
COMPARISON OF PATIENTS AT THEIR
FIRST ARRHYTHMIC EPISODE VS
RELAPSES
S. Cattarin 2, E. Causin 2, L. De Mattia 1, V.
Calzolari 1, M. Crosato 1, P.A.M. Squasi 1,
R. Razzolini 2, Z. Olivari 1
1
OC Ca’ Foncello - UOC Cardiologia, Treviso,
ITALY, 2 Clinica Universitaria di Padova Dipartimento di Scienze Cardio-toracovascolari, Padua, ITALY
Background:
Elective
electrical
cardioversion (ECV) for persistent atrial
fibrillation (AF) is highly effective, but sinus
rhythm (SR) maintenance rates are low.
ECV efficacy and SR maintenance in
patients at their first AF episode compared
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Results: Population characteristics:
Overall, 93,3% of the patients were
successfuly cardioverted, 63,7% were in
SR after one month and 38,6% after one
year.
Rates of acute ECV success and SR
persistence after one month were similar
between the three groups (Table 1).
After one year, SR was significantly less
present in Group C (25%) than in Group A
(45.3%, p < 0,05) and Group B (40.8%, p
< 0,05) (Group A VS Group B p = ns).
Conclusion: Acute success rate of ECV is
high even in patients with recurrent AF, but
recurrences are frequent.
Patients with multiple AF episodes have
lower chances to mantain SR after one
year, even when anti-arrhythmic therapy
is provided.
IS ADVERSE CHILDHOOD EXPERIENCES
A POSSIBLE CAUSE OF LONE ATRIAL
FIBRILLATION IN THE YOUNG?
B. Stefano 1, P. Rossi 1, F. Drago 2, F. Cauti 1,
A.M. Speranza 3, F. Farina 4
1
Osp. Fatebenefratelli, Rome, ITALY, 2 Osp.
Pediatrico Bambin Gesu’, Roma, ITALY, 3
Università La Sapienza, Rome, ITALY, 4
Università Europea, Rome, ITALY
Purpose: Autonomic nervous system
(ANS) activation may induce significant
and heterogeneous changes of atrial
electrophysiology and may trigger atrial
fibrillation (AF). In young population, AF is
often characterized by the absence of any
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FREE PAPERS
with patients with recurrent AF episodes
has never been previously investigated.
Study aim: To compare the different
acute, mid and long-term success rates of
ECV in patients, according to the number
of previous AF episodes (Group A= first AF
episode; Group B= first AF recurrence;
Group C= > 1 AF recurrences).
Methods: Data from 402 consecutive
patients referred to the Cardiology unit at
the “Santa Maria dei Battuti” Hospital in
Treviso between January 2011 and
December 2012 for elective ECV of
persistent AF were collected. The acute,
one-month and one-year success rates
were registered during follow-up visits.
FRIDAY, DECEMBER 2, 11.00-12.30 [Tarragona]
ATRIAL FIBRILLATION:
CLINICAL EVALUATION AND MANAGEMENT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Tarragona]
ATRIAL FIBRILLATION:
CLINICAL EVALUATION AND MANAGEMENT
cardiovascular disorder and seems to be
vagally mediated. Recent data suggest
that adverse childhood experiences (ACE)
with caregivers lead to abnormal
development of endocrine and behavioral
response to stress and hamper autonomic
balance.
The aim of the present study was to
assess the incidence of ACE among young
patients with lone AF.
Methods:, All patients with <65 years of
age and lone AF who were candidates to
pulmonary veins isolation ablation were
screened for inclusion into the study.
Presence of ACE was assessed by AAI (a
semistructured interview retrieving
childhood emotional and relational
memories of past attachment experiences
with caregivers), DERS (self administered
questionnaire on emotional dysregulation),
CTQ (self administered Childhood Trauma
Questionnaire) and IES (self administered
Impact of Event Scale). All questionnaires
were validated with prespecified
qualitative or quantitative cutoff values.
Results: Fifteen consecutives patients (14
males, mean age: 42±5 years) were
included into the study. All patients had
identifiable gastro-intestinal triggers for AF
episodes. Six patients (40%) reported ACE
in the AAI, 7 (47%) exceeded cut-off at
DERS, 8 (53%) presented values higher
than cut-off at emotional neglect subscale
of CTQ, and 8 (53%) at IES.
Conclusions: ACE are frequently present
among young patients with lone AF. These
124
preliminary results suggest that ACE might
be a trigger for AF development in the
young.
LARGE SCALE PROSPECTIVE STUDY
TO DETECT ATRIAL FIBRILLATION BY
USING A NOVEL 6-LEAD DEVICE AND
ALGORITHM
M. Sabar 1, A. Henderson 1, F. Ara 1,3, I.
John 1,3, C. Crockford 4, R. Yanez 3, R.A.
Kaba 1,2,3
1
Research & Development Department,
Ashford & St. Peter’s Hospitals NHS Trust,
Chertsey, UNITED KINGDOM, 2 Department of
Cardiology, St. George’s University Hospitals
NHS Trust, London, UNITED KINGDOM, 3 Royal
Holloway University of London, Egham, UNITED
KINGDOM, 4 Cardiocity UK Ltd., Lancaster,
UNITED KINGDOM
Objective: To evaluate the effectiveness of
a novel 6-lead ECG device and software
algorithm (RhythmPad II) in accurately
detecting atrial fibrillation (AF).
Methods: A large prospective study was
carried out involving 752 patients. A
standard 12-lead ECG was obtained
immediately followed by a 6-lead ECG
with updated RhythmPad II software
algorithm. Patients were provided
questionnaires to rate their preference.
12-lead and 6-lead ECGs were separately
analysed by two cardiologists blinded to
the automated reports. The analyses were
compared with the automated reports
generated by the RhythmPad II.
Results: The novel 6-lead ECG system
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION IN CARDIOLOGY
PRACTICE: A PROSPECTIVE
MONOCENTRIC REGISTRY ANALYSIS
AND A 3-YEARS OUTCOME
EVALUATION RELATED TO STANDARD
ECHOCARDIOGRAPHIC PARAMETERS
R. Mei 1, L. Bianchini 1, C. Martignani 1, M.
Biffi 1, M. Ziacchi 1, G. Massaro 1, S.
Lorenzetti 1, M. Gallucci 1, J. Frisoni 1, G.
Boriani 2, I. Diemberger 1
1
Policlinico S.Orsola-Malpighi, Bologna, ITALY,
Policlinico di Modena e Reggio Emilia,
Modena, ITALY
2
Overview: Atrial fibrillation (AF) is wellknown associated to an increased risk of
death and cardiovascular events; however
the relation between echocardiographic
left atrium enlargement and outcome in
patients with AF remains unexplored.
Methods: In this observational prospective
monocentric study 520 not-selected
patients with AF were enrolled between
July 2012 and April 2016 with a 3 years
follow-up. Echocardiographic parameters
related to antero-posterior left atrium (LA),
left ventricular ejection fraction (EF), left
ventricular end-systolic (LVESD) and enddiastolic dimensions (LVEDD) were
collected at baseline.
Clinic instrumental and laboratoristic
parameters were associated with relative
risk of death and cardiovascular
hospitalization.
Kaplan-Meier curves were used for
univariated
analysis
significative
parameters. ROC curve were performed to
identify echocardiographic cut-offs.
Multivariate analysis was performed for
significative univariate analysis.
Results: 503 of 520 patients had
completely followed-up; 123 patients
(24%) died, mostly (45%) for
cardiovascular reason. Recidive of AF was
the main cardiovascular reason of
readmission (37,7%). At multivariate
analysis significative echocardiographic
125
FREE PAPERS
was very well tolerated by all patients,
with >95% of patients preferring 6-lead
system over standard 12-lead ECG.
Comparison of blinded analyses of 6-lead
ECGs vs 12-lead ECGs by the cardiologists
revealed an accuracy of 97% for
identifying AF by RhythmPad II, with
sensitivity and specificity being 93% and
98% respectively. The positive and
negative predictive values were 83% and
99% respectively. The accuracy of the
automated reports by RhythmPad II in
correctly diagnosing AF was 95%, with
sensitivity and specificity of 87% and 96%,
respectively, when compared with 6-lead
cardiologist reports. Analysis of automated
reports of 6-lead ECGs vs 12-lead
cardiologist reports conceded an accuracy
of 93%, with sensitivity and specificity of
82% and 94%, respectively.
Conclusion: The RhythmPad II is capable
of identifying AF with a high degree
(>90%) of accuracy, sensitivity and
specificity. It is a quick, simple and very
well tolerated device, which can safely be
employed for mass AF screening.
FRIDAY, DECEMBER 2, 11.00-12.30 [Tarragona]
ATRIAL FIBRILLATION:
CLINICAL EVALUATION AND MANAGEMENT
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Tarragona]
ATRIAL FIBRILLATION:
CLINICAL EVALUATION AND MANAGEMENT
predictors of mortality were: LA (HR =
1,035; 95%CI:1,016-1,055; p< 0,001), EF
(HR=0,979; 95%CI:0,967-0,992; p=0,001).
Significative predictors of mortality or
cardiovascular hospitalization were: LA
(HR=1,020; 95%CI:1,006-1,034; p<0,001),
EF (HR=0,980; 95%CI:0,972-0,988;
p<0,001)
Conclusions: Left atrium diameter
standardly
collected
with
echocardiography is an independent
predictor of mortality and/or cardiovascular
hospitalization. This is independent on
therapy, type and duration of FA, left
ventricular volumes and functionality.
These results may prompt a possible
benefit for patients with AF who
undertakes pharmacologic or surgical
therapy focused on reducing left atrial size.
PACEMAKER-DETECTED SEVERE
SLEEP APNEA PREDICTS NEW-ONSET
ATRIAL FIBRILLATION
A. Mazza 1, M.G. Bendini 1, R. De Cristofaro 1,
C. Franchin 2, M. Lovecchio 2, S. Valsecchi 2,
G. Boriani 3
1
S. Maria Della Stella Hospital, Orvieto (TR),
ITALY, 2 Boston Scientific Italia, Milan, ITALY, 3
University of Modena and Reggio Emilia,
Policlinico di Modena, Modena, ITALY
Aim: Sleep apnea (SA) diagnosed on
overnight polysomnography is a risk factor
for atrial fibrillation (AF). Advanced
pacemakers are now able to monitor
intrathoracic impedance for automatic
detection of SA events.
126
Methods: We enrolled 160 consecutive
recipients of a dual-chamber pacemaker
with the ApneaScan algorithm (Boston
Scientific). Severe-SA was defined as
pacemaker-measured
Respiratory
Disturbance Index>=30 episodes/h for at
least one night during the first week after
implantation. A cumulative AF burden>=6
hours in a day detected by the device was
considered as AF episode.
Results: Sixteen patients in AF at the time
of implantation were excluded from
analysis. During follow-up, AF episodes
were documented in 35(24%) of the
patients in analysis and in 12(13%) of the
96 with no history of AF. Severe-SA was
detected in 89 patients during the first
week after implantation; 58 of these had
no history of AF. Severe-SA at baseline
was associated with a higher risk of AF
both in the whole population (log-rank
test, HR:2.38; 95%CI: 1.21 to 4.66;
p=0.025) and among patients with no
history of AF (log-rank test, HR:2.80;
95%CI: 1.10 to 7.10; p=0.047). Moreover,
severe-SA at the time of follow-up device
interrogation predicted AF occurrence
within the next 3 months (log-rank test,
HR:2.13; 95%CI: 1.11 to 4.08; p=0.036).
Conclusions: In pacemaker patients,
device-diagnosed
severe-SA
was
independently associated with a higher
risk of AF and new-onset AF. In particular,
severe-SA on follow-up data review
identified patients who were about twofold more likely to experience an AF
episode in the next 3 months.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CPC, Tucuman, ARGENTINA
Purpose: To compare the use of a minimal
(SIN) with a conventional (CON) catheter
approach for the mapping and ablation of
regular supraventricular tachycardias
(SVT) in the setting of a randomizedcontrolled trial.
Methods: Two hundred patients (age
48.3+-11.2 years, 87 male) were
randomized to a SIN or CON group. The
SIN approach involved using a maximum
of two catheters for SVT (ablation
catheter included), whereas the CON
approach involved more than two
catheters, respectively
Results: Acute procedural success was
similar between the two groups.
There was significant difference in overall
procedure times (63±11vs 85±5min )
(P<0.01) and fluoroscopy times (20 ±8 vs
35±15 min)(P<0.01).
Procedural costs were significantly lower
in SIN compared with CON (P <0.0001).
Follow up: At 12 month follow-up, five
patients in MIN (5,5%) and six patients in
CON (5,4%) had documented recurrence
of the index arrhythmia. There were no
major complications in both groups.
Conclusions: The use of a SIN approach
in the treatment of SVT is as effective and
safe as using a CON approach.
The SIN approach is faster and more costeffective.
HIGH DENSITY MAPPING TO KOCH
TRIANGLE IN AVNRT ABLATION: NEW
INSIGHT
C. Pandozi 1, C. Lavalle 1, M. Russo 1, M.
Galeazzi 1, C. Franchin 2, F. Piergentili 2, F.
Colivicchi 1
1
San Filippo Neri Hospital, Rome, ITALY,
Boston Scientific, Milan, ITALY
2
This report details a successful slow
pathway (SP) ablation of atrioventricular
nodal reentrant tachycardia (AVNRT) by
using a novel high-density mapping
system. A 3-dimensional propagation map
of the RA was created during sinus rhythm
using the OrionTM multipolar basket
catheter and RhythmiaTM mapping
system (Boston Scientific). The
propagation map confirmed dual pathway
physiology and the presence of collision
between different wave-fronts inside the
Koch Triangle (KT). The collision points,
joined by the line of collision (LOC), were
tagged on the map. The high number of
points recorded during sinus rhythm
allowed to clearly define the conduction
path and the switch between the slow and
the fast pathway. The basket catheter was
then positioned at the site of LOC and the
distribution and timing of all SP potentials
127
FREE PAPERS
ABLATION OF SUPRAVENTRICULAR
TACHYCARDIAS. A RANDOMIZED TRIAL
ON CATHETER ABLATION: SIMPLIFIED
TECHNIQUE VERSUS CONVENTIONAL
TECHNIQUE
L. Aguinaga , A. Bravo , J. Bonacina , P.
Gallardo , E. Hasbani, J. Dantur
FRIDAY, DECEMBER 2, 11.00-12.30 [Spalato]
CATHETER ABLATION OF ATRIAL FLUTTER
AND AV NODE TACHYCARDIA
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Spalato]
CATHETER ABLATION OF ATRIAL FLUTTER
AND AV NODE TACHYCARDIA
in the KT were collected. After two RF
ablations we obtained the abolition of the
SP. The successful ablation was confirmed
by looking at the junctional beats during
RF delivery and performing additional
conventional pacing maneuvers at the end
of ablation.
Interestingly, the remap with the OrionTM
catheter during sinus rhythm showed an
altered conduction path induced by the RF
lesion with the LOC between the wavefronts outside the KT.
This case could have practical
implications for improving the traditional
anatomy-guided approach within the
triangle of Koch. The use of a propagation
map-guided ablation technique for AVNRT
ablation may result in faster selection of
ablation site, reduction of RF delivery and
shorter fluoroscopy time.
FEASIBILITY OF DUAL CATHETER
CRYOTHERAPY FOR ACCESSORY
PATHWAYS RESISTANT TO
RADIOFREQUENCY ABLATION
J. Gomes, I. Harding, H. Gonna, H. Raju, A.
Angelozzi, M. Norman, M. Gallagher
St George’s Hospital, London, UNITED
KINGDOM
Background: We have recently described
the use of two cryotherapy generators
simultaneously to improve efficiency in
cryoablation for atrial fibrillation and
flutter. We hypothesised that simultaneous
cryotherapy from two generators might be
128
effective in ablating accessory pathways
resistant to standard methods.
Methods: We used cryotherapy delivered
simultaneously from two cryo-consoles
via two Freezor Max cryoablation
catheters in consecutive cases of preexcitation
syndromes
in
which
radiofrequency ablation failed to
accomplish permanent block of accessory
pathway conduction.
Results: In the 2 years to the end of
August 2015, we treated 6 patients who
had undergone 1-3 (mean 1.8) failed
attempts at ablation of an accessory
pathway using radiofrequency energy.
Pathway location was septal in 4 cases,
left lateral in 1 right lateral in 1. In all cases
we achieved block of the accessory
pathway using dual catheter cryotherapy.
Procedure duration was 202 ± 64
minutes; fluoroscopy duration was 35±14
minutes. Procedure duration fell
significantly in the second half of the
series (153 ± 26 minutes) compared to
the first half (253 ± 45 minutes, p=0.03,
t-test). In the second patient treated, preexcitation recurred at 1.2 months after the
procedure, but there was no recurrence of
the previous tachycardia episodes. After
9.7 ± 5.6 months, all other patients
remained free of pre-excitation and all
remained asymptomatic.
Conclusion: Dual catheter cryotherapy
can provide lasting block of accessory
pathways that have not responded to
standard radiofrequency ablation.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
ATRIAL FIBRILLATION UNMASKING
ACCESSORY PATHWAY: CASE REPORT
S. Ferretto, L. Leoni
pre-excitation (fig. 2). The administration
of adenosine, revealed the presence of a
left-posterior AP (Fig. 3). In the
electrophysiological study the AERP of the
AP resulted high (390 ms, fig.4). After
administration of isoprenaline, the AERP of
the AP was 270 ms.
Conclusion.
During
AF
the
inhomogeneous origin of atrial impulses
and the increase in sympathetic tone
altered
the
electrophysiological
conduction properties, disturbing the
Department of Cardiac, Thoracic and Vascular
Sciences, Padua University, Padua, ITALY
FREE PAPERS
Background: Atrial fibrillation (AF) can
become a dangerous arrhythmia in Wolff
Parkinson White (WPW) syndrome. The
anterograde effective refractory period
(AERP) of accessory pathway (AP)
generally correlates with the shortest preexcited R-R interval (SPERRI) during
documented AF. Classically patients who
develop pre-excited AF have overt preexcitation on the resting 12 lead ECG. We
report a case of latent asymptomatic AP
unmasked by a pre-excited AF episode.
Case report: A 50 years old woman
presented to the Emergency Department
for a first episode of palpitations; previous
routine ECGs were normal. The ECG during
palpitation showed pre-excited AF with a
SPERRI of 280 ms (fig.1). The patient was
treated with electric cardioversion which
restored sinus rhythm without evidence of
FRIDAY, DECEMBER 2, 11.00-12.30 [Spalato]
CATHETER ABLATION OF ATRIAL FLUTTER
AND AV NODE TACHYCARDIA
129
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Spalato]
CATHETER ABLATION OF ATRIAL FLUTTER
AND AV NODE TACHYCARDIA
balance between nodal and AP
anterograde conduction and revealing a
latent left-sided AP. In our case report
during AF the SPERRI was similar to the
AERP obtained with isoprenaline infusion.
HIGH DENSITY MAPPING OF RIGHT
ATRIUM IN PATIENTS WITH AVNRT
C. Pandozi, S. Ficili, M. Galeazzi, C. Lavalle,
M. Russo, F. Colivicchi
UOC Cardiologia, san Filippo Neri Hospital,
Rome, ITALY
This report details a successful slow
pathway (SP) ablation of atrioventricular
nodal reentrant tachycardia (AVNRT) by
using a novel high-density mapping
system. A 3-dimensional propagation map
of the RA was created during sinus rhythm
using the OrionTM multipolar basket
catheter and RhythmiaTM mapping
system (Boston Scientific). The
propagation map confirmed dual pathway
physiology and the presence of collision
between different wave-fronts inside the
Koch Triangle (KT). [Figure1] The collision
points, joined by the line of collision (LOC),
were tagged on the map. The high number
of points recorded during sinus rhythm
allowed to clearly define the conduction
path and the switch between the slow and
the fast pathway. The basket catheter was
then positioned at the site of LOC and the
distribution and timing of all SP potentials
in the KT were collected.[Figure2] After
two RF ablations we obtained the abolition
130
of the SP. The successful ablation was
confirmed by looking at the junctional
beats during RF delivery and performing
additional conventional pacing maneuvers
at the end of ablation.[Figure3]
Interestingly, the remap with the OrionTM
catheter during sinus rhythm showed an
altered conduction path induced by the RF
lesion with the LOC between the wavefronts outside the KT.
This case could have practical
implications for improving the traditional
anatomy-guided approach within the
triangle of Koch. The use of a propagation
map-guided ablation technique for AVNRT
ablation may result in faster selection of
ablation site, reduction of RF delivery and
shorter fluoroscopy time.
CONCEALED JUNCTIONAL
TACHYCARDIA
A. Tordini 1, G. Zingarini 2, F. Notaristefano 1,
A. Mengoni 1, G. Ambrosio 1, C. Cavallini 2
1
Division of Cardiology and Cardiovascular
Pathophysiology, Department of Medicine
University of Perugia, Perugia, ITALY, 2 Division
of Cardiology, Perugia, ITALY
A 79- year-old man was admitted for a left
ventricular failure.
This electrocardiogram was recorded
when the patient was asymptomatic
(Fig.1).
The intervals between the P waves ( green
stars) are irregolar. Also the P - QRS and
QRS - P intervals are irregular , therefore
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
CATHETER ABLATION OF ATRIAL FLUTTER
AND AV NODE TACHYCARDIA
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Spalato]
we can rule out the possibility that it is a
reentrant tachycardia or a parasystole. In
the first part of ECG there are wide QRS
similar to those recorded in the baseline
electrocardiogram. The intervals between
QRS complexes (yellow stars) are
alternately 580 msec. and 1160 msec.
(580 x 2). The dominant rhythm in the
first half of ECG is a junctional rhythm at
100 HR. The automatic junctional focus
sometimes produces conceled beats whit
periodic trend. So at the surfacing ECG
there are not the P waves and the QRS
complexes.
There are P waves (green stars)
representing blocked atrial extrasystoles ,
because the AV junction is in the refractory
period after automatic junctional beat
(which is sometimes counceled).
The interruption of the automatic
junctional focus permits the emergence
of sinus rhythm with HR 52 bpm (blue
stars). In the last part of the ECG there is
a low atrial rhythm HR 67 bpm (red stars).
The last beat, originated by a low atrial
focus (red star), makes a fusion P wave,
because the low atrial focus is preceded
by a PAC (green star).
The presence of counceled junctional
beats is deductible from the regular
activation of the automatic focus .
131
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Pola]
CLINICAL CASE-REPORTS
PACEMAKER IMPLANT WITH
MAGNETIC POSITIONING OF THE
LEADS: A FEASIBILITY CASE
G. Viola, F. Amadori, G. Motta, G. Casu
Ospedale S. Francesco, Nuoro, ITALY
Introduction: Pacemakers’ implants are
commonly performed with the aid of
fluoroscopy, despite at a low dose. The
MediGuide System was developed to
provide
support
both
during
electrophysiology
procedures
and
implants of cardiac resynchronization
therapy (CRT-left ventricular lead) devices
using sensor-equipped delivery tools,
including sheaths, sub-selectors, and
guidewires, allowing the drastic reduction
of the X-rays.
We report our experience of a pacemaker
implantation procedure using this tool.
Methods: A 72 years male, with a Sick
sinus syndrome. The right lead positioning
was carried out using the MediGuide
Technology, in particular with the CPS
Excel™,
MediGuide
Enabled™
Guidewires Extra Support used as stylet e
identified by the magnetic system.
Results: After inserting the lead in the
venous system, a Mediguide Guidewire
(Extra Support) was inserted in the active
lead. A miniaturized sensor on the tip of
the magnetic guidewire allows the
positioning and orientation of the device
to be visualized in a pre-recorded
fluoroscopy/cine-loop frame.
The lead was positioned in the right
132
appendage without additional exposure of
the patient and the operator to the ionizing
radiation (fig.1) in 1 minutes.
The time of the procedure didn’t exceed
the normal pacemaker implantation time.
Furthermore, the total fluoroscopy time
was 58,3 s.
Conclusions: This case report underlines
the efficacy of the MediGuide Technology
in pacemaker implantation and it shows
the reliability of the system in obtaining a
reduction of the x-ray exposure.
MAGNETIC POSITIONING SYSTEM FOR
INTRACORONARY NAVIGATION
APPROACH: A FIRST-IN-MAN (FIM)
PROSPECTIVE EXPERIENCE
P. Merella, G. Casu
Ospedale S. Francesco, Nuoro, ITALY
Introduction: The MediGuide System was
developed to provide support both during
electrophysiology
procedures
and
implants of cardiac resynchronization
therapy (CRT) devices using sensorequipped delivery tools, including sheaths,
sub-selectors, and guidewires.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
IMPROVEMENT OF PACING-INDUCED
DYSSYNCHRONY BY RIGHT
VENTRICULAR SEPTAL STIMULATION
IN A CHILD WITH TETRALOGY OF
FALLOT
M. Cabrera Ortega, D.B Benítez Ramos
Department of Arrhythmia and Cardiac Pacing,
Cardiocentro Pediatrico William Soler, La
Havana, CUBA
The harmful effects of ventricular pacing
are most pronounced during right
ventricular (RV) stimulation, nevertheless,
RV pacing sites have been determinated
as optimal in some patients with and
without congenital heart disease
A 4-year-old boy with a history of
surgically repaired tetralogy of Fallot had
a single-chamber pacemaker implanted in
left ventricular (LV) epicardium for a
postoperative complete atrioventricular
block. During
LV
pacing
the
electrocardiogram (ECG) demonstrated an
133
FREE PAPERS
We report the first-in-man experience of
coronary artery stent placement using this
tool.
Methods: A 77 years male, with a known
history of cardiovascular disease and
ischemic cardiomyopathy was diagnosed
with inferior myocardial infarction and
underwent coronary angiography which
evidenced the need for stenting the right
coronary artery. After selectively cannulate
the right coronary artery using fluoroscopy
and radiographic contrast, we decided to
use a Magnetic Medical Position System
(MPS) as the primary guide to place the
0,014 inch guidewire over the lesion.
Results: Two coronary angiography views
of the right coronary artery were obtained
in LAO (18°) and RAO (23°) projections,
with a cranial orientation of 27° and 2°,
respectively (see fig.1). We navigated with
the sensor enabled guidewire only on the
MDG pre-registered cine loop (see fig.2),
and we used the X-rays just to acquire the
baseline cines and as a control for right
guidewire location and movement. This
resulted in a successful placement of the
guidewire using MDG prospectively with a
minimal fluoroscopy usage (70 sec) over
a 180 sec total duration of guidewire
navigation, with a 60% save compared to
the standard approach.
Conclusions: The use of this technology
is safe and effective with a drastic
fluoroscopy reduction in the central phase
of the procedure.
FRIDAY, DECEMBER 2, 11.00-12.30 [Pola]
CLINICAL CASE-REPORTS
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Pola]
CLINICAL CASE-REPORTS
increase of QRS complex duration and
exaggerated right bundle branch block
(RBBB) pattern with negative paced QRS
complexes in inferior leads. Subsequently
echocardiographic evaluations showed
interventricular and right intraventricular
dyssynchrony, which was associated with
progressive RV dilatation. After one year of
ventricular pacing he developed RV
dysfunction with a fractional area change
(FAC) of 28% and tricuspid annular plane
systolic excursion (TAPSE) of 12 mm.
Furthermore, two-dimensional strain
reflected a RV dyssynchrony index of 56
msec with the worse QS´ delay at RV
midseptum (195 msec). Considering the
beneficial effects of septal stimulation the
patient underwent lead and pacemaker
replacement. An active ventricular lead
was fixed in RV midseptum, obtaining
appropriate sensing and pacing
thresholds. Since single- site RV midseptal
pacing, twelve-lead surface ECG revealed
lower duration of QRS complex and left
bundle branch block pattern with positive
paced QRS complexes in inferior lead.
Furthermore, interventricular assynchrony
diminished to 31 msec and RV
dyssynchrony index decreased to 27
msec, immediately. Echocardiographic
assessment showed an increase of FAC
(39%) and TAPSE (15 mm) with reduction
of RV diameters three months after the
therapy.
134
ST-SEGMENT DEPRESSION WITH
CONCAVE-UPWARD CURVE: A NEW
HIGH RISK PATTERN OF INHERITED
ARRHYTHMIA SYNDROME?
C. Lavalle 1, D. Della Rocca 2, G.B. Forleo 2,
L. Santini 3, R. Mango 2, L. Duro 2, M. Russo 1,
M. Galeazzi 1, C. Pandozi 1, F. Colivicchi 1
1
Cardiology Department University of Rome
“Tor Vergata”, Rome, ITALY, 2 Cardiology
Department of San Filippo Neri Hospital, Rome,
ITALY, 3 Cardiology Department, G.B. Grassi
Hospital, Rome, ITALY
A 60-year old woman (patient 1) was
successfully resuscitated and hospitalized
after out-of-hospital cardiac arrest due to
torsade de pointes. She subsequently died
due to severe neurological damage one
month later. A family history of
unexplained sudden death in otherwise
healthy close-blood relatives was present
in four generations. Electrocardiogram on
admission showed sinus rhythm and a
pattern of concave-upward ST segment
depression in the lateral leads. Three
adult patients from the same family, two
males and one female aged 30-65 years,
were evaluated. All of them had a history
of palpitations and dizziness and two of
them of atrial fibrillation. Their baseline
ECG showed a similar pattern of STsegment
depression
with
a
concave-upward curve in at least 2
contiguous inferior and/or lateral leads.
Concomitant flat T waves were present in
all the patients.
No evidence of
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
RUNAWAY PHENOMENON IN A PATIENT
IMPLANTED WITH MEDTRONIC
ADAPTA ADDR01 PACE MAKER
M. Pala, D. Malaspina, G. Guenzati, A.
Mafrici
Ospedale San Carlo Borromeo, Milan, ITALY
The runaway phenomenon of a
pacemaker (PM) is considered impossible
to occur in the new pacemaker with the
upper rate control function. In recent
years have been described cases of
runaway only in special circumstances:
exposition to electric fields, radiation
therapy, extreme battery discharge. We
describe a case of spontaneous runaway.
On July 30, 2012 a 75 year old patient (pt)
arrived in the emergency room for
syncope and third-degree AV block and
ventricular escape rhythm of 32 bpm. He
was implanted with PM Medtronic Adapta
ADDR01 without any complication. A
month later the ambulatory monitoring
showed normal device function and no
arrhythmias. On October 20 2012 the pt at
home in absence of external causes felt
sudden palpitations, chest pain and
syncope. He reached our emergency room
in 30 minutes from the onset of
symptoms. The electrocardiogram showed
a continuous inappropriate atrial and
ventricular stimulation at 191 bpm. When
the programming head was placed on the
PM stopped the stimulation and appeared
an atrial driven rhythm to 60 bpm. The
patient immediately feels good and did not
have any damage. The next interrogation
of the pacemaker showed an abnormal
selfreprogramming at high stimulation
rate than the programmed upper rate of
130 bpm The engineering analysis of the
device made by manufacturer confirmed
the presence of a fault of high frequency
circuit limitation. This case shows that
even in the new devices may occur for
intrinsic circuit defects the phenomenon
of runaway pace maker potentially fatal to
patients.
135
FREE PAPERS
intraventricular conduction and QT interval
abnormalities was observed. Extensive
noninvasive and invasive evaluation,
including physical examination, serial
ECGs,
24-h
ECG
monitoring,
echocardiogram, exercise testing, cardiac
MRI and coronary angiography were
performed. Structural heart disease was
ruled out in all patients.
Additionally, two patients underwent a
commercially available clinical genetic test
to identify the principal cardiac
channelopathies. No evidence of common
genetic mutations were found.
Two years later, the 32-year-old son of
patient1 was found dead at his home.
Structural heart disease was ruled out by
autopsy. In consideration of the strong
family history of sudden death, an ICD was
implanted prophylactically in the two
patients with the similar distinctive pattern
of ST-segment depression.
FRIDAY, DECEMBER 2, 11.00-12.30 [Pola]
CLINICAL CASE-REPORTS
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
FREE PAPERS
FRIDAY, DECEMBER 2, 11.00-12.30 [Pola]
CLINICAL CASE-REPORTS
A CASE OF ABORTED SUDDEN DEATH
IN A YOUNG PATIENT
C. Ruperto, G. Ricca, G. Busacca, L.
Cassaniti, A.A. Arcidiacono, G. Licciardello
Cardiology Department, E. Muscatello Hospital,
Augusta (SR), ITALY
We reported a 23-year-old man with fever
since 2 days. He suddenly collapsed and
recovered spontaneously. At the arrival in
the emergency room, he was alert and
conscious, still febrile (39 °C), in normal
sinus rhythm. While monitoring, he
suddenly went in ventricular fibrillation
(VF), successfully converted by external
DC-shock (Fig.1A). His family history was
unremarkable and negative for sudden
death in relatives. The physical
examination was normal. A 12-lead
electrocardiogram
(ECG)
showed
characteristic right bundle branch block
and ST segment elevations in leads V1-V3
(Fig.1B), so diagnosis of Brugada
syndrome with ECG type 1 pattern was
done. Laboratory tests were normal except
hypokaliemia (3,2 mEq/L) and toxicology
screen was negative. Echocardiogram
ruled out structural heart disease. We
stabilized the patient with antipiretics and
potassium replacement. A subcutaneousICD (S-ICD) was implanted. Two months
ago his mother was performed an ECG
that had been reported as normal, but that
showed the same pattern. During
electrophysiological
study
she
experienced a monomorphic ventricular
136
tachicardia (VT), so she was implanted,
too.
In this case, a documented VF and ECG
type 1 pattern in both had allowed us to
make definitive diagnosis of Brugada
syndrome.The first syncope was likely due
to a self-terminating polimorphic VT or VF
interrupted by spontaneous defibrillation.
The true mechanisms of this process are
unknown and may provide newer
therapeutic options for treatment of this
otherwise fatal arrhythmia
In this subset of patients, considering
young age and underlying mechanisms of
this genetic arrhythmogenic syndrome, SICD represents an optimal therapeutic
option.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
- December 2, 2016 Ergife Palace Hotel
Rome, Italy November 29
POSTERS
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
1 - DIAGNOSTIC YIELD OF DETAILED
TRANS-OESOPHAGEAL
ECHOCARDIOGRAPHY IN PATIENTS
UNDERGOING ATRIAL FIBRILLATION
ABLATION
D. Smith, H. Gonna, J. Gomes, I. Harding,
R. Ray, A. Marciniak, M. Gallagher, R.
Sharma
POSTER SESSION
St. George’s Hospital, London, UNITED
KINGDOM
Introduction: Patients undergoing atrial
fibrillation (AF) ablation often undergo a
cursory and very focal transoesophageal
echocardiogram (TEE) to assess for left
atrial appendage thrombus and guide
transeptal puncture. Our study aim was to
perform a more detailed TEE study to
determine prevalence of potentially
important coexistent valve
disease
in
patients
undergoing AF ablation.
Methods:
Consecutive
patients who underwent AF
ablation at a single tertiary
centre by the same
electrophysiologist over a
15 month period from April 2013 to July
2014 were included. Patients with artificial
valve prostheses were excluded. All
qualifying patients who had their ablation
under general anaesthesia underwent a
detailed TEE study by a cardiologist expert
in the performance of TEE while the
electrophysiologist was cannulating the
femoral vein and positioning the
diagnostic catheters.
Results: 176 patients underwent AF
ablation over the 15 month period of
which 97 (57% of patients) met entry
138
criteria and were enrolled. Of the 97
patients
who
underwent
echocardiography, the mean age was 61.6
+/- 11.6 years and 64.9% were male. 53
patients (54.6%) had no valve disease, 23
patients (23.7%) had mild single valve
disease, 8 patients (8.2%) had mild to
moderate disease and 10 patients (10.3%)
had moderate valve disease. In 3 patients
(3.1) we found moderate to severe valvular
disease. The most common valvular
abnormalities were mitral regurgitation
noted in 39 patients (40.2%) and aortic
regurgitation in 16 patients (16.5%) of
which the majority were categorised as
mild.
Conclusion: Clinically significant valve
disease is uncommon in this AF ablation
population
2 - LONG-TERM MOBILITY OF THE
ESOPHAGUS IN PATIENTS
UNDERGOING CATHETER ABLATION OF
ATRIAL FIBRILLATION. A COMPARISON
OF DATA FROM CT AND 3D ROTATION
ATRIOGRAPHY
T. Kulik 1,2,3, A. Kulikova 1,2, Z. Starek 1,2,3, F. Lehar
1,2
, J. Jez 1,2,3, J. Wolf 1,2,3, Z. Svanovska 1,2
1
St. Anne’s University Hospital Brno, Brno,
CZECH REPUBLIC, 2 International Clinical Research Center, Brno, CZECH REPUBLIC, 3 Masaryk University, Faculty of Medicine, Brno,
CZECH REPUBLIC
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
3 - DETAILED ANALYSIS OF ANATOMIC
RELATIONSHIP OF THE ESOPHAGUS
AND THE LEFT ATRIUM FROM CT SCAN
ENHANCING SAFETY OF
RADIOFREQUENCY CATHETER
ABLATION OF CARDIAC ARRHYTHMIAS
A. Kulikova 1,2, T. Kulik 1,2,3, Z. Starek 1,2,3,
F. Lehar 1,2, J. Jez 1,2,3, J. Wolf 1,2,3, Z.
Svanovska 1,2
1
St. Anne’s University Hospital Brno, Brno,
CZECH REPUBLIC, 2 International Clinical Research Center, Brno, CZECH REPUBLIC, 3 Masaryk University, Faculty of Medicine, Brno,
CZECH REPUBLIC
Atrio-esophageal fistula is a complication
of ablation on the posterior wall (PW) of
the left atrium (LA). This damage may be
prevented by understanding the spatial
relations between the esophagus and the
PW of the LA.
The study enrolled 56 patients who
underwent the CT scan of the heart before
the ablation. The course, location and
width of esophagus and its distance from
the PW of the LA were evaluated. The
contact of the esophagus with the PW and
the length of the fat pad between the
esophagus and the LA were evaluated. We
measured the “roundness index” and
statistically evaluated an influence of the
shape of the LA on the observed
parameters.
The width of the esophagus was 16.0±4.1
mm and the distance between the PW and
esophagus was 4.8±1.6 mm. The length
of the PW was 75.3±8.9 mm and 50.4±11
mm of that was in contact with the
esophagus. The length of the fat pad was
9.1±5.5 mm in the upper part and
139
POSTER SESSION
Atrio-esophageal fistula is a rare (0.1%)
complication and it is caused by ablation
on the posterior wall of the left atrium (LA).
At ICRC and St. Anne’s University Hospital,
Brno, CT scans of the heart were
performed in a total number of 56
patients.
These
same
patients
subsequently underwent also 3D
rotational atriography (3DRA) of the LA
with simultaneously imaging of the
esophagus (during the EP study). The
posterior wall of the LA was divided into
the 5 segments (A-E). Subsequently, we
made a statistical comparison between
the positions of the esophagus in CT and
the 3DRA.
The position of the esophagus in CT and
3DRA was identical in a total number of 20
patients (35.7 %). The average shift
between the CT and the 3DRA was 0.86
width of 1 position (9.6 mm). The greatest
shift was observed via 3 positions (33.6
mm). Shift via 1 position was observed in
44.6 %, via 2 positions in 17.9 % and via
3 positions in 1.8 % of cases. The most
common position of the esophagus in CT
imaging was B (46.4 %), in case of the
3DRA it was C (37.5 %). In the averaged
time horizon of 20 days, statistically
significant difference (p=0.001) was found
between the position of the esophagus in
CT and 3DRA for individual patients.
The accurate knowledge of the
esophageal position in the shortest
possible
timeframe
before
the
electrophysiological procedure, or even
during the procedure, belongs among the
main strategies for avoidance of atrioesophageal fistula.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
15.8±7.3 mm in the lower part of LA. We
didn´t reveal any effect of the left atrial
shape on the contact of the esophagus
with the PW and the length of the superior
and inferior fat pad. The esophagus
descended behind the left PV´s in 75 %,
medially in 18 % and behind the right PV´s
in 7 %.
Knowledge of esophageal position and
understanding the spatial relations
between the esophagus and the PW of LA,
may be effective way to avoid the thermal
injury.
4 - THREE-DIMENSIONAL ROTATIONAL
ANGIOGRAPHY OF THE LEFT ATRIUM
AND ESOPHAGUS: SHORT-TERM
MOBILITY OF THE ESOPHAGUS AND
STABILITY OF THE FUSED 3D MODEL
OF THE LEFT ATRIUM AND ESOPHAGUS
DURING CATHETER ABLATION FOR
ATRIAL FIBRILLATION
Z. Starek 1, F. Lehar 1,2, J. Jez 1,2, J. Wolf 1,2,
T. Kulik 1,2, A. Zbankova 1,2
1
International Clinical Research Center
(FNUSA-ICRC), St. Anne’s University Hospital
Brno, Brno, CZECH REPUBLIC, 2 I. Internal Cardiovascular department, St. Anne’s University
Hospital Brno, Brno, CZECH REPUBLIC
Introduction: Atrioesophageal fistula is a
rare,
serious
complication
of
radiofrequency ablation for atrial
fibrillation due to the close proximity of the
esophagus and left atrium (LA). The
objective of this study was to evaluate the
mobility of the esophagus and the stability
of the 3D model of the esophagus using
3D rotational angiography (3DRA) of the
LA and esophagus during live fluoroscopy
during procedure.
140
Methods: From 10/2011 to 9/2015,
3DRA of the LA and esophaguswas
performed in 33 consecutive patients
before catheter ablation for atrial
fibrillation using the Philips Allura FD 10
X-ray system.. The 3D model of the
esophagus was automatically merged
with live fluoroscopy. Control contrast
esophagography was performed every 30
minutes.The
positions
of
the
esophagograms and the 3D model of the
LA and esophagus were repeatedly
measured against the spine and
statistically compared.
Results: The average shift of the
esophagus during the examination was
3.4 ± 2.6 mm. A shift of the esophagus >
3 mm was present in 44.8% of patients,
and a shift > 8 mm was present in 5% of
patients. The average shift of the 3D
model of LA was 2.4 ± 2.5 mm (left-right
direction) and 1.6 ± 1.5 mm (craniocaudal
direction).
Conclusion: During catheter ablation for
atrial fibrillation, there is no significant
change in the position of the esophagus
and no significant shift in the 3D model of
the left atrium and the esophagus. The 3D
model of the esophagus reliably depicts
the position of the esophagus during the
entire procedure.
5 - COMPARISON OF PARAMETERS OF
THE CATHETER ABLATION OF ATRIAL
FIBRILLATION USING CATHETER WITH
CONTACT FORCE MEASURING AND
STANDARD COOL-TIP CATHETER
F. Lehar, Z. Starek, J. Jez, Z Svanovska,
J. Wolf, T. Kulik, A. Zbankova
6ICRC - Department of Cardiovascular Disea-
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Introduction: Contact force of the ablation
catheter to the tissue is an important
factor affecting the success and safety of
ablation of atrial fibrillation. In our work we
focus on the comparison parameters
ablation procedure using a catheter with
contact force measurement compared to
a standard catheter.
Methodology: This is retrospective
analysis of data of 173 consecutive
patients undergoing ablation for atrial
fibrillation (paroxysmal and persistent AF).
The investigated parameters were the
length of the procedure, fluoroscopy time,
radiation exposure, the number of RFA
(radiofrequency ablation), total RFA time.
Results: There were 173 patients included
(72 contact force catheter group, 101
patients standard catheter group).
Paroxysmal AF: there was the statistically
significant reduction of the length of the
procedure and RFA (133 vs. 179 min and
39 vs. 54min,), reduction of the
fluoroscopy time (10 vs. 8min), decrease
radiation exposure (5401 vs. 8802
mGycm2) and the number of RFA (47 vs.
59) in contact force group, p <0.05.
Persistent atrial fibrillation group: there
was a statistically significant reduction in
the length of the procedure and RFA and
number of RFA aplications (p<0.05), and
trend to shortening the fluoroscopy time
and radiation exposure.
Conclusion: Using a catheter with contact
force measurement during the ablation of
atrial fibrillation leads to a significant
reduction in the total time of the
procedrue, number and time of RFA. There
is a trend to shorter fluoroscopy, reducing
the radiation exposure, for ablation of
paroxysmal atrial fibrillation is this
reduction also statistically significance.
6 - ROBOTIC ABLATION OF ATRIAL
FIBRILLATION: IMPACT OF LESION
EFFICACY AND BIOMARKERS ON
RECURRENCES
G. Pinnacchio, M.L. Narducci, G. Pelargonio,
S. Noviello, F. Perna, G. Bencardino, T. Rio,
F. Cavaliere, M. Massetti, F. Crea
Catholic University of the Sacred Heart,
Policlinico A. Gemelli, Rome, ITALY
Background: We aimed to investigate the
mid-term outcome after pulmonary vein
isolation (PVI) with the Sensei X™ robotic
navigation system (RNS), with particular
regard to different markers of lesion
efficacy, including electrical coupling index
(ECI) and biomarkers.
Methods: Twenty-nine patients (20 males,
age 57±10), with lone paroxysmal AF
(75%) and persistent AF (25%) were
enrolled in this study. All procedures were
performed with the Sensei RNS. ECI, Creactive protein (CRP) and TnI-Ultra were
measured before and after PVI. All patients
were followed-up by 24h-Holter ECG at 2,
6 and 12 months.
Results: AF ablation with RNS was
performed successfully in all patients
without major complications, with
established RNS contact force (10-40 g
range). In all PVs, ECI was significantly
reduced after PVI (from 123±3 to 99±2;
p<0.001). CRP and TnI-ultra increased in
all patients after PVI (from 2.5 to 12.7
141
POSTER SESSION
ses, St Anne’s University Hospital, Brno, CZECH
REPUBLIC
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
mg/L and from 0.006 to 3.5 ng/ml,
respectively). After a median follow-up of
11 (range 1-20) months, 90% of patients
were free from AF>30 seconds. ECI
reduction after right inferior PVI (RIPVI) was
lower in patients with vs those without AF
recurrence (14% vs.18%, p=0.006). No
significant association was observed
between biomarker levels and AF
recurrences.
Conclusion: During robotic ablation of AF,
ECI reduction but not biomarkers appears
to be an important contact tissue marker
for the prediction of AF recurrence at midterm follow-up. In patients with AF
recurrence, the lower ECI reduction after
RIPVI could reveal a lower tissue lesion
depth during ablation and a consequent
late RIPV reconnection.
7 - HIGHER AMOUNT OF
RADIOFREQUENCY ENERGY
INCREASED THE RECURRENCE OF
ATRIAL FIBRILLATION AFTER
PULMONARY VEIN ISOLATION
K. Yokoyama, M, Tokuda, S. Matsuo,
R. Isogai, K. Tokutake, M. Kato, R. Narui,
S. Tanigawa, S. Yamashita, K. Inada,
M. Yoshimura, T. Yamane
Jikei University school of medicine Department
of Cardiology, Tokyo, JAPAN
Backgrounds: It has been already known
that ERAF is not rare after pulmonary vein
isolation (PVI) and is associated with AF
recurrence during a long-term follow-up.
Some studies reported that ERAF was
associated with inflammatory response
caused by radiofrequency application. We
hypothesized that longer duration and
142
higher amount of radiofrequency energy
delivery can create severer inflammation,
causing ERAF.
Methods: A total of 532 patients with
paroxysmal AF who underwent the initial
PVI targeting all four PVs were included.
ERAF was defined as AF appearance
within the 90 days after ablation
procedure. The patients were divided into
two groups according to the presence or
absence of ERAF and clinical
characteristics were compared between
two groups.
Results: All PVs were successfully
isolated. ERAF was observed in 174
patients (32.7%) and it was associated
with AF recurrence during a long-term
follow-up. On univariate analysis, higher
amount of radiofrequency energy
(53.5±23.0 vs 48.0±20.2kJ, p<0.001),
longer duration of energy delivery
(37.4±16.0 vs 33.6±13.8minutes,
p<0.001) were well associated with the
appearance of ERAF as well as AF
recurrence beyond the blanking period.
Conclusion: Higher amount of RF energy
is associated with more true AF
recurrence. Unreasonably excessive RF
ablation might make ablation outcome
worse, rather than better.
8 - ATRIAL FIBRILLATION ABLATION:
EFFICACY AND SAFETY IN ACUTE AND
LONG-TERM FOLLOW UP OF NMARQ™
AND THERMOCOOLR CATHETERS
A. Di Monaco, N. Vitulano, F. Quadrini, G.
Cecere, T. Langialonga, M. Grimaldi
Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti (Bari), ITALY
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
9 - LONG TERM RESULTS OF CATHETER
ABLATION AFTER SURGICAL
TREATMENT OF ATRIAL FIBRILLATION:
ELECTROPHYSIOLOGICAL ANALYSIS
AND ABLATION STRATEGIES
R. Krausova, D. Wichterle, P. Peichl, J.
Kautzner, J. Pirk
IKEM, Prague, CZECH REPUBLIC
We analyze regular atrial tachycardia (AT)
occurring after surgical ablation of atrial
fibrillation (AF).
Methods: Total of 980 pts underwent
surgical ablation for AF as a standalone
or concomitant procedure. Subjects with
symptomatic regular AT resistant to
repeated
cardioversions
and
antiarrhythmic (AA) drugs underwent
catheter ablation.
Results : AT occurred during follow up (FU)
in 190 pts (20% of all patients)
Fourty six subjects (4.5% of all pts, 16
female, mean age 63±12 years)
underwent catheter ablation. Mean left
atrium (LA) diameter was 49 ± 6 mm.
Ablation was performed 31 ± 14 months
after surgery. Pulmonary veins (PVs)
reconduction was demonstrated in
majority of pts , the most common
arrhythmia was perimitral flutter.
Reisolation of PVs and additional linear
lesions in LA were performed in 37 pts, in
22 of them ablation in both LA and RA was
necessary. In remaining 9 pts was
performed ablation for typical RA flutter.
Mean number of procedures per pt was
1.4. During a mean FU of 48 ± 22 months,
41 pts (90%) remained in sinus rhythm, in
subgroup of pts with ablation in both atria
sinus rhythm was achieved in 92% of pts.
143
POSTER SESSION
Introduction: The circular nMARQ™
ablation catheter is an useful tool for
pulmonary vein isolation (PVI). We
assessed acute and long-term efficacy of
NMARQ™ ablation catheter for PVI in
paroxysmal and persistent AF.
Methods and results: We report a case
series of 200 patients (mean age 56±9
years; 73% male) referred to our center to
perform PVI. One hundred patients (group
1) underwent PVI with the nMARQTM and
100 patients (group 2) with the single tip
ThermocoolR ablation catheters.
All patients performed 24 months of FU.
AF recurrences were documented in 13
patients of group 1 (13%) and 32 patients
of group 2 (32%) (p=0.003). Regarding the
patients with paroxysmal AF, 8 patients in
group 1 (11%) and 20 patients in group 2
(26%) had AF recurrences at clinical FU
(p=0.02). In patients with persistent AF, 8
patients in group 1 (33%) and 12 patients
in group 2 (59%) had AF recurrences at
clinical FU (p=0.06). A trivial pericardial
effusion not requiring any pharmacological
or interventional correction appeared in 10
patients of group 1 (10%) and 6 patients
of group 2 (6%); two patients reported a
groin haematoma. No other procedurerelated complications occurred in any
patient.
Conclusion: The use of nMARQ™
ablation catheter for PVI is feasible and
safe. Compared to standard single tip
approach, we found a significant higher
success rate in the nMARQ™ group at
long term FU.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
Seventy percent of pts were on AA drugs.
No significant complications were noted.
Conclusions: Regular ATs after surgical
ablation of AF are not uncommon. In
symptomatic pts, catheter ablation is
effective and safe procedure. Most
common arrhythmia is perimitral flutter.
Mapping and ablation in both atria seemed
to be necessary for successful prevention
of arrhythmia recurrences.
10 - CATHETER ABLATION FOR ATRIAL
FIBRILLATION MAY PRECLUDE AN
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR FOR PRIMARY
PREVENTION IN PATIENTS WITH
CONGESTIVE HEART FAILURE
A. Yagishita 1, M. Arruda 2, J. Rod Gimbel 2,
S. De Oliveira 2, H. Manyam 2, D. Sparano 2,
I. Cakulev 2, J. Mackall 2, K. Hirao 1
1
Heart Rhythm Center, Tokyo Medical and
Dental University, Tokyo, JAPAN, 2 University
Hospitals Harrington Heart and Vascular
Institute, Case Western Reserve University,
Cleveland, USA
Introduction: Catheter ablation for atrial
fibrillation (AF) has been shown to improve
left ventricular ejection fraction (LVEF). We
investigated the value of catheter ablation
in patients, presenting congestive heart
failure (HF) with low LVEF and AF,
who meet criteria for an
implantable
cardioverter
defibrillator (ICD) as primary
prevention.
Methods: Sixty-one patients with
AF (80% persistent) and HF (LVEF
< 35%), who underwent catheter
ablation, were retrospectively
144
assessed: 19 ischemic cardiomyopathy
(ICM)
and
42
non-ischemic
cardiomyopathy (NICM). LVEF and NYHA
class were reassessed at 3-6 months after
the catheter ablation.
Results: Among the 61 patients, 37 (61%)
did not meet criteria for an ICD after the
catheter ablation. Patient with NICM had
higher freedom from ICD indication than
those with ICM (74% vs. 32%, P = 0.004).
Patients with NICM free from AF or atrial
tachycardia (AT) recurrence had significant
improvement in LVEF (33 ± 4 vs. 26 ± 8, P
= 0.001) and NYHA class (-0.4 ± 0.6 vs. 1.0 ± 0.6, P = 0.002) compared to those
with recurrence, whereas there was no
difference in patients with ICM. During a
median follow up of 3.5 years, LVEF
improvement was associated with longterm freedom from AF / AT recurrence
(Log-rank P = 0.012), and lack of LVEF
improvement was an independent
predictor (HR 2.443; CI, 1.191-5.011; P =
0.015).
Conclusions: Catheter ablation of AF
rendered 61% of patients with HF non
applicable for an ICD as primary
prevention. Early LVEF improvement had
favorable impact on the long-term ablation
outcomes.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
11 - THERMAL FIELD IN
CRYOABLATION PROCEDURES FOR
PULMONARY VEINS ISOLATION:
IMPORTANCE OF ESOPHAGEAL
TEMPERATURE MONITORING
A. Fasano 1,2, L. Anfuso 2, G. Arena 3, C.
Pandozi 4
1
Dept. of Mathematics and Informatics U. Dini,
Univ. of Florence, Florence, ITALY, 2 FIAB, Florence, Italy, Florence, ITALY, 3 Coronary Unit,
Apuane Hospital, Massa, ITALY, 4 Cardiovascular Department, San Filippo Neri Hospital,
Rome, ITALY
Background: Cryoablation procedures for
pulmonary veins isolation have proved to
be a successful treatment of atrial
fibrillation, but exposure of surrounding
organs to excessively low temperatures is
potentially dangerous. Hence the
importance of monitoring esophageal
temperature and at the same time
predicting the thermal field induced by the
procedure
Methods: We formulate a mathematical
model for computing the esophageal
temperature using numerical simulations
to interpret recorded clinical data. Clinical
data have been collected during cryoablation procedures performed with a
cryo-balloon Arctic Front Advance
(Medtronic, Inc, Minneapolis, MN, USA).
Luminal esophageal temperature was
recorded by means of the Esotherm
catheter (FIAB SpA, Vicchio, Italy).
Results: Numerical simulations show that
during cryo-energy application the outer
esophageal wall can be much cold than
the lumen. The model indicates that the
difference between internal and external
esophageal temperature turns out to be as
large as 16°C. There is a clear correlation
between the steepness of the
transesophageal thermal gradient and its
expected evolution later during cryoenergy
application. Theoretical cooling curves
have been compared with the clinical data
showing agreement with the computed
predictions. In fact all the cryo-energy
applications showing a fast cooling rate
showed a marked esophageal cooling.
Conclusion: Monitoring the time evolution
of luminal esophageal temperature is of
fundamental importance not only to realize
but also to predict well in advance critical
developments of the procedure. The model
predictions fit remarkably well the data
recorded during cryo-ablation procedures
as well as the results found in the
literature.
12 - MINIMIZING PATIENT RADIATION
DOSE DURING CT OF THE LEFT ATRIUM
TO GUIDE ATRIAL FIBRILLATION
ABLATION; PILOT CLINICAL TRIAL
J. Wolf 1,2, Z. Starek 1,2, J. Jez 1,2, F. Lehar 1,
A. Novak 1, T. Kulik 1,2, A. Zbankova 1, Z.
Svanovska 1, P. Ourednicek 1
1
St. Anne’s University Hospital Brno, International Clinical Research Center, Brno, CZECH
REPUBLIC, 2 Masaryk University Brno, Faculty
of Medicine, Brno, CZECH REPUBLIC
Introduction: Computed tomography (CT)
of the heart has long been used as a
standard imaging modality to guide
catheter ablation of complex atrial
arrhythmias. However, using this method
exposes the patient to high radiation dose.
Our aim is to demonstrate that we are able
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Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
to achieve a significant reduction in
radiation dose with using of our optimized
CT scan protocol.
Methods: In the period 10/2015 to 1/2016
we conducted on the Philips Brilliance iCT
scanner a CT scan of the heart in 10
patients prior to catheter ablation of atrial
fibrillation. Patients were randomized into
two optimized protocols with lower
radiation dose - protocol A (5 pts.,
adjustable anode voltage of 80-120 kV
according to the patient’s weight, current
135 mAs) and Protocol B (5 pts.,
adjustable anode voltage of 80-120 kV
according to the patient’s weight, current
67 mAs). In both protocols target region of
interest (left atrium and surroundings) was
precisely focused before starting own
scan. The success of this imaging
procedure was defined as creation of
high-quality 3D model of the left atrium.
Results: The overall success rate was the
same for both protocols - 100%. We have
achieved an average effective radiation
dose of 2.24 mSv for protocol A and 0.82
mSv for protocol B. Lowest achieved
effective dose of radiation was 0.43 mSv.
Conclusion: Our innovative protocol for CT
examination of the heart reduced the
average patient radiation dose below 1
mSv. Based on this results the nextgeneration of our protocol is currently
under development.
13 - ANAESTHESIA AT THE
RADIOFREQUENCY ABLATION OF
ATRIAL FIBRILLATION: ASSESSMENT
OF EFFECTIVENESS
I. Skigin, K. Shorokhov, E. Voitkovskaya, N.
Lepakhina, A. Boyarkin, I. Pyaterichenko,
146
I. Chistyakova
Municipal Cardiac Surgery Center, Hospital 2,
Saint-Petersburg, RUSSIA
The literature origins where the various
outlines of anaesthetic management at
RFA AFib are analysed.
The most common outline - midasolam
(0.3-0.5 mg/kg per hour) and phentanyl
(1.0 µg/kg per hour) or propofol (2.0-4.0
mg/kg/ per hour) and phentanyl (0.5-1,0
µg/kg per hour) combined anaesthesia is
searched. The technique of injection of
phetanyl next to ablation (syringe in hand)
is also observed. The basic levels of
sedation intensity at RFA AFib are
surveyed. There are the superficial
sedation (level III-IV by the Ramsay scale),
the deep sedation (level V) and the total
anaesthesia (level VI).
The propofol and phentanyl combined
anaesthesia with continious infusion is the
most preferable technique at RFA AFib. It
provides to keep on the sought-for level of
sedation and to change intensity of the
conciousness depression fluently. It is
more convenient to manage the intensity
of sedation by propofol because it has
shorter period of action than midasolam
has. Furthermore propofol has good
patients’ tolerance and don’t provoke the
aftereffect phenomenon. The superficial
sedation saves the protective reactions,
spontaneous breathing and keeps verbal
contact with patient. This type of sedation
(level III-IV) is the most preferable. The
speed of infusion of propofol varies from
1.2+0.5 µg/kg per hour to 4.2+0.18 µg/kg
per hour. It is rationally to keep the level III
and the target concentration of propofol is
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
2-3 µg/ml. After the sheeths are removed
the infusion stops. This technique provides
quick and comfortable recovery of
conciousness at the end of procedure.
14 - IN AND OUT
A. Scopinaro, R. Massa, E. Gandolfi, M.
Brunacci, M. Giglio, G. Pistis
A 31 years old man presented to EP lab
with an incessant atrial tachicardia, HR
130 BPM and mild left ventricular
impairment.
The 3D electro-anatomical mapping of the
right atria evidenced a wide area of
moderate prematurity along the inferior
part of tricuspid annulus and in the
proximal part of the coronary sinus. The
absence of a clear target suggested an
epicardial focus of the arrhythmia (Fig1A).
A venography of the coronary sinus was
performed finding an abnormal accessory
branch that, specularly of vena cardiaca
magna, runs around the tricuspid valve.
Using a 3,5 mm irrigated catheter, this
accessory CS brach was cannulated via
right giugular vein (Fig 1B). An electroanatomical mapping was performed and
a focal anticipated target signal was
found. RF was delivered (25 watt, 43C°)
obtaining interruption of the arrhythmia in
4 second.
15 - INCIDENCE AND PREDICTORS OF
RECURRENT ATRIO-VENTRICULAR
NODAL REENTRANT TACHYCARDIA
(AVNRT) AFTER SUCCESSFUL
ABLATION: A > 10-YEAR, SINGLE
CENTER STUDY
M. Pintea, K. Ramkissoon, G. Turitto
Cornell Heart Center and Department of Medicine, New York Methodist Hospital, Brooklyn,
NY, USA
Between January 2005 and December
2014, a single operator performed ablation
for
documented
or
suspected
supraventricular tachycardia secondary to
AVNRT in 150 patients with long-term
follow-up data available for review. During
a mean follow-up of 57 months, 9 patients
experienced recurrent palpitations
requiring ER visits (n=4), or had a repeat
ablation (n=5) for recurrent AVNRT. The
overall arrhythmia recurrence rate was
6%. The mean time interval between the
first procedure and the recurrence of
symptoms and/or the repeat procedure
147
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Cardiology unit – Osp. S.S Antonio e Biagio,
Alessandria, ITALY
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
was 52 ± 46 months (range: 23-132).
Table I shows the clinical and
electrophysiological characteristics of
patients with AVNRT with or without
recurrent arrhythmias after ablation.
On multivariate analysis, female gender
remained significantly correlated to
recurrence rates (p<0.03), while the
presence of multiple slow AVN pathways
and inducibility of >1 type of AVNRT had
marginal p values (0.06 and 0.054,
respectively).
Our study showed that recurrence rates
after AVNRT ablation are low during a very
long term follow-up; surprisingly, patients
may experience recurrences even >10
years after the initial procedure. Female
gender may predispose to recurrent
AVNRT, while procedural variables are less
predictive of this phenomenon; complete
abolition of slow pathway conduction may
not be necessary to achieve satisfactory
long-term results.
16 - TRANSCATHETER ABLATION OF
ARRHYTHMIAS IN PATIENTS WITH
ANOMALOUS VENA CAVA
A. Di Monaco, F. Quadrini, N. Vitulano, F.
Troisi, G. Cecere, T. Langialonga, M. Grimaldi
148
1
Ospedale Generale Regionale F. Miulli,
Acquaviva delle Fonti (Bari), ITALY
Background: We reported 3 cases of
patients with anomalous inferior vena
cava (IVC) who underwent transcatheter
ablation (TA).
Methods: 3 female patients (age 45, 48
and 65 years) were enrolled to perform TA
for symptomatic atrial fibrillation and
ventricular ectopies. All the procedures
were performed using the CARTO3
system.
Results: The first patient had ventricular
ectopies and an atresia of IVC. The
ablation catheter entered into the right
heart through the azygos and superior
vena cava. The ectopies were localized
and ablated successfully into the right
ventricular efflux trai. The second patient
had symptomatic atrial fibrillation and,
again, an atresia of IVC. The azygos
entered in a big superior vena cava. In this
patient we localized continuous and
fragmented potentials on the distal region
of the enlarged superior vena cava and we
delivered energy on these potentials
obtaining arrhythmia cardioversion and no
further inducibility. The third patient had
symptomatic atrial fibrillation and a
persistent left superior vena cava. We
delivered energy on the fragmented
potential located into the left superior vena
cava and in the distal coronary sinus
obtaining arrhythmia cardioversion and no
further inducibility. In the second patient
we did not performed pulmonary vein
isolation. In the third patient the
pulmonary veins had been isolated in a
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International Symposium
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2016
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previous surgery ablation. After 24 month
of FU the patients were in good clinical
conditions
without
arrhythmia
recurrences.
Conclusion: The transcatheter ablation in
patients with anomalous vena cava is
feasible and safe. In these patients the
arrhythmogenesis was related to
anatomical anomalies.
17 - CARDIAC MAGNETIC RESONANCE
IMAGING IN PATIENTS WITH
COMPLETE ATRIOVENTRICULAR BLOCK
FOR RISK STRATIFICATION FOR HEART
FAILURE AND VENTRICULAR
TACHYCARDIA
N. Matsushita, K. Soejima, Y. Katsume,
Y. Momose, M. Nagaoka, S. Takeuchi,
K. Hoshida, Y. Miwa, I. Togashi, A. Ueda,
T. Sato, H. Yoshino
Kyorin University Hospital, Department of
Cardiology, Mitaka, JAPAN
Background: Atrioventricular block (AVB)
in elderly patients is usually due to fibrosis
of conduction system. In younger patients,
potential causes include cardiomyopathy
or cardiac sarcoidosis (CS). Cardiac
magnetic resonance (CMRI) with
gadolinium enhancement is used for
detection of the scar. MRI conditional
pacemaker (MR-PM) yields to evaluate
late gadolinium enhancement (LGE) in
patients with PM. We aimed to clarify the
presence of LGE and clinical course of
patients with MR-PM due to AVB.
Methods and results: 33 patients (64±9
y/o, 16 males) with AVB who underwent
MR-PM implant and CMR, pre or post
implant, were included (post implant: 22
patients). We compared the CMR findings,
underlying heart disease, and clinical
course between 8 patients with LGE
(LGE+) and 25 patients without LGE (LGE).
Ventricular pacing ratio and the incidence
of non-sustained ventricular tachycardia
were similar (95 vs 76%, p=N.S, 63 vs
27%, p=N.S, respectively).
In LGE+, 5 patients were diagnosed as CS,
1 patient as old inferior myocardial
infarction, and 2 patients with unknown
etiology. All patients with CS had multiple
LGE, including the area close to the AV
node. In LGE+, 1 CS patient had CRT
upgrade for heart failure, and other had
ICD upgrade and catheter ablation for VT
episodes.
Although 2 patients had CS in LGE-, none
developed heart failure or sustained VT
(figure).
Conclusion: In AVB patients, LGE can be
useful as risk stratification for future
development of heart failure or ventricular
tachycardia.
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Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
18 - EARLY INTRAVENOUS LOW/HIGH
DOSES OF METOPROLOL IN
MYOCARDIAL INFARCTION DOGS ON
THE EFFECTS OF CARDIAC
SYMPATHETIC ACTIVITY AND
ELECTROPHYSIOLOGICAL PROPERTIES
D. Wang, H. Ying, D. Liao
POSTER SESSION
Department of Cardiology Changzheng
Hospital Second Military Medical University,
Shanghai, CHINA
Objective: To observe the effects of early
intravenous low/high doses of Metoprolol
In myocardial infarction dogs on cardiac
sympathetic
activity
and
electrophysiological properties
Materials And Methods: 32 mongrel
dogs were randomly divided into three
groups, the low-dose group (n = 12),highdose group (n = 12) and control group (n
= 8). Three groups were all ligating the
first diagonal branch of the left anterior
descending coronary artery (LAD) to
establish the canine model of acute
myocardial infarction. After ligation the
low-dose group was given metoprolol 0.6
mg / kg immediately by intravenous
injection, the high-dose group was given
1.6 mg / kg, while the control group was
injected with same dose normal saline.
Norepinephrine (NE) and epinephrine(E)
levels in the coronary sinus blood , the
ventricular ERP ,the incidence of VA were
all measured during the experiments. The
pathological detection of infarction and
infarct area were also performed then.
Results: The low-dose and high-dose
group
performs
no
significant
difference(p> 0.05);The low-dose group
and high dose group shortened ERP
150
approximately, there was no statistically
significance(p>0.05); Three groups all
exhibited uneven shortness of ERP among
different regions, infarct area was
significantly shortened (p<0.05);There
was no significant difference among all
groups in VA incidence (p >0.05);
Conclusions: Low and high dose of
metoprolol performed similarly in reducing
the catecholamine concentrations in dogs
with anterior myocardial infarction, the
same effects also observed in the
reduction of regional ERP, but there was
no differences in induced arrhythmias.
19 - LEFT VENTRICULAR TRANSMURAL
REPOLARIZATION GRADIENT IN
HUMANS
B. Nguyen, L. Iannetta, A. Persi, G. Piccirillo,
S. Poggi, I. Maraschi, N. Alessandri,
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Sapienza University of Rome, Rome, ITALY
Introduction: Transmural dispersion and
increased variability of repolarization are
associated with ventricular arrhythmias
(VAs). Left ventricular (LV) transmural
repolarization gradient has been
demonstrated in animals. Such gradient
has not been demonstrated in vivo in
humans. We aimed to record endocardial
and epicardial QT intervals in patients
undergoing a percutaneous left-sided
atrial ablation procedure.
Methods: A total of 12 patients (7 men,
mean age 56.4±18.9 years) were enrolled
in the study. All patients underwent an
ablation procedure (8 atrial fibrillation, 4
atrio-ventricular reentrant tachycardia).
Endocardial
and
epicardial
LV
electrograms (EGMs) were recorded using
a standard bipolar ablation catheter. LV
endocardial EGMs were obtained by the
ablation catheter positioned at the
posterior-lateral basal LV; LV epicardial
EGMs of the same segment were obtained
by the ablation catheter positioned in the
left inferior pulmonary vein.
Results: Mean was QTc 438.4±36.9ms.
Unlike the animal setting, the epicardial QT
interval was longer (309.7±38.1ms), and
the endocardial QT interval was shorter
(231.8±42.6ms), with a LV repolarization
gradient of 77.8±37.0ms. Significant
relationships between QTc and
repolarization gradient (r=0.032, 95% CI 0.01-0.086, p<0.05) and between
endocardial QT and repolarization gradient
(r=0.3, 95% CI -0.85-0.04, p<0.05) were
present.
Conclusions: A
LV
transmural
repolarization gradient has been
demonstrated also in humans, however,
unlike animal models, the epicardial APD
was longer compared to the endocardial
APD. LV transmural repolarization gradient
relates to QTc. Analysis of the transmural
ventricular
repolarization
gradient
variability could be helpful in finding new
markers of VAs and in stratifying the risk
for sudden cardiac death regardless of EF.
20 - VENTRICULAR ARRHYTHMIAS
INDUCTION BY PROGRAMMED
ELECTRICAL STIMULATION OF THE
RIGHT VENTRICULAR OUTFLOW TRACT
ONLY DURING TYPE 1 BRUGADA ECG
MAXIMIZATION
B. Nguyen, R. Sergiacomi, F. Tersigni,
F. Tufano, N. Alessandri
Sapienza University of Rome, Polo Pontino,
Latina, ITALY
Introduction: Sudden cardiac death (SCD)
risk-stratification in Brugada syndrome
(BS) depends on its phenotypic
expression. Electrophysiology study (EPS)
with programmed ventricular stimulation
(PES) is a class IIB recommendation due
to protocols low reproducibility. We report
a BS patient who experienced different
ventricular arrhythmias (VAs) inducibility
depending on RVOT PES with/without type
1 BS ECG unmasked by ajmaline, in order
to better understand the dynamic
mechanisms, and the wide spectrum of
clinical presentations. Methods: NA
Results: A 68-year-old man with syncope,
151
POSTER SESSION
E. Rauseo, E. Indolfi, C. Gaudio, P. Puddu
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
episodes of persistent atrial fibrillation,
and family history of SCD had a type 1-2
BS ECG. During type 2 BS ECG, PES was
perfomed from the right ventricular apex
(RVA) and RVOT by double extrastimuli up
to ventricular effective refractory period
(VERP) without VAs induction. PES was
repeated after restoration of type 1 BS
ECG by ajmaline. RVA PES induced
ventricular couples, and RVOT PES
induced a reproducible self-terminated
symptomatic ventricular fibrillation, CL
260ms, HR 230bpm. An ICD was
implanted, per international guidelines. Conclusions: RVOT PES during BS
channelopathy maximization induces VAs.
Fatal events in BS happen when 2 factors
are combined: ventricular extrastimuli or
ectopies, and the greatest expression of
the
channelopathy.
EPS
poor
reproducibility is due to different protocols
used in various centers. BS phenotypic
heterogeneity and wide spectrum of
clinical presentations are due to the
underlying mechanisms and require
standardized SCD risk-stratification
protocols, to improve patient selection and
timing for ICD implantation when no
history of cardiac arrest is present, and
may return EPS its deserved prognostic
value.
21 - NONSUSTAINED REPETITIVE
UPPER SEPTAL IDIOPATHIC
FASCICULAR LEFT VENTRICULAR
TACHYCARDIA: A RARE TYPE OF VT
G. Aksan 1, R. Sarikaya 2, A. Elitok 2, A.K.
Bilge 2, K. Adalet 2
1
Department of Cardiology, Sisli Hamidiye Etfal
Research and Training Hospital, Istanbul,
152
TURKEY, 2 Department of Cardiology, Istanbul
Faculty of Medicine, Istanbul University,
Istanbul, TURKEY
Idiopathic
fascicular
ventricular
tachycardia (VT) of the left ventricle is a
rare type of VT. A very rare form affecting
the septal fascicle, known as upper septal
fascicular VT, has narrow QRS morphology
and normal or right axis deviation. A 46year-old female patient was admitted to
the cardiology outpatient clinic with
symptoms of intermittent attacks of
palpitations and discomfort. An initial
electrocardiogram (ECG) revealed that she
had sinus rhythm with repetitive
nonsustained 185-190 bpm narrow QRS
complex tachycardia without an axis
deviation. We offered a diagnostic
electrophysiological study and planned an
ablation
procedure.
In
the
electrophysiological study, AH-HV intervals
were normal. Simultaneously with the
catheter manipulations, a sustained 187
bpm narrow QRS tachycardia with normal
axis that was almost identical to the
clinical tachycardia was induced.
Atrioventricular dissociation (AV) was
observed during tachycardia. During VT,
retrograde activation of the His bundle
was recorded before the onset of the QRS
complex with a His-ventricular interval
that was shorter during VT than that during
sinus rhythm (26 msn vs. 51 msn
respectively). Early Purkinje potentials
before the onset of QRS were detected by
an activation mapping technique during
tachycardia. At the upper ventricular
septum activation mapping during
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
tachycardia, at the level od distal His
bundle or proximal left bundle branch,
early Purkinje potential was observed 23
msn before the onset of QRS. ). During
tachycardia, RF ablations were performed
to the site of earliest Purkinje potential
Following the procedure, a twelve-lead
ECG revealed no AV complete block and
left bundle branch block
22 - VALIDATION OF THREE DIFFERENT
ANNOTATION TECHNIQUES FOR
ELECTROANATOMIC MAPPING OF
PREMATURE VENTRICULAR BEATS
M. Baroni, S. Pedretti, S. Vargiu, M. Paolucci,
M. Lunati
De’ Gasperis Cardio Center- ASST Grande
Ospedale Metropolitano Niguarda Ca’ Granda,
Milan, ITALY
Background:
Reliability
of
electroanatomic mapping (EAM) systems
depends on precise annotation of local
activation time (LAT). To date, there is no
standard methodology for LAT annotation
and evidence is lacking about precision
and accuracy of available techniques. We
compared three largely used techniques
(maximum unipolar downslope [UniSlope],
bipolar onset [BipOn] and bipolar
maximum voltage [BipMaxV]) in terms of
precision and accuracy for activation
mapping of focal premature ventricular
beats (PVC) with Biosense Carto 3 EAM
system.
Methods: We retrospectively analyzed all
effective PVC ablation procedures
performed in Niguarda Hospital (Milan,
Italy) from 2013 to 2015 with efficacy
point annotated on map. For every
included study, three activation maps were
rebuilt offline and re-annotated with
UniSlope, BipOn and BipMaxV technique
respectively. The area of 5ms isochronal
(Iso5) was used as accuracy surrogate
whereas the distance between the
isochronal centre and the efficacy point
(Dist) was taken as precision surrogate.
Results: Over 350 ablations performed in
the considered time frame, 12 (8 males,
64±13years) met the inclusion criteria.
Mean ejection fraction was 52±13%, PVC
originated from right ventricle in 8/12
cases. A mean of 56±18 points were
considered per exam. Iso5 area was
0.16±0.09cm2, 0.42±0.38cm2, 0.94
±0.52 cm2 for UniSlope, BipOn and
BipMaxV respectively (p<0.01). Dist was
3.58±2.96mm for SlopeUni, 5.16±5.43
mm for BipOn and 7.08±3.60 mm for
MaxV (p<0.01).
Conclusions: Our data suggest that
annotation on UniSlope is superior to
BipOn and BipMaxV in terms of precision
and accuracy. Systematic adoption of this
153
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
technique could improve procedural
efficacy and patients’ outcome.
23 - HIGH DENSITY MAPPING FOR
CATHETER ABLATION OF PREMATURE
VENTRICULAR COMPLEXES
ORIGINATING FROM THE PAPILLARY
MUSCLES IN THE LEFT VENTRICLE
L. Koutbi, B. Maille, M. Peyrol, J. Hourdain,
E. Salaun, J.C. Deharo, F. Franceschi
POSTER SESSION
University Hospital Timone, Marseille, FRANCE
Background: Ablation of premature
ventricular complexes (PVC) originating
from left sided papillary muscles can be
particularly complicated, probably due to
anatomical reasons. The authors wished
to test a new approach by performing
high-density mapping of PVC during 3D
procedures.
Methods and results: The authors used
a 20-pole deflectable spiral catheter
during ablation procedures for PVC
originating from the papillary muscles in
4 consecutive patients. In 3 cases, this
involved the posteromedial papillary
muscle. Three patients presented with
mitral valve prolapse, and the last with
dilated cardiomyopathy implanted with a
cardiac resynchronisation therapy device.
PVC burden was 24±13%. The procedures
lasted 182±55.4 minutes (25±8.3
minutes of fluoroscopy), including 10±3.2
minutes of radiofrequency (40-45W, 45°).
In all patients, mapping evidenced internal
primary activation relative to the left
ventricle shell (mean distance 21.3±5.1
mm). Endocavitary prematurity was 38.3±4.8ms. Primary ablation success
was achieved for all patients. One case of
early recurrence was observed, 10 hours
154
after the procedure. Initial success was
maintained for the other 3 patients at
8.3±1.7 months.
Conclusions: High-density mapping of the
papillary muscles in the left ventricle using
a spiral catheter is feasible. In 4
consecutive patients, this made it possible
to identify the PVC foci away from the left
ventricular shell. This consolidates the
assumption for the origin of these ectopic
beats at the junction between the chordae
tendineae and the papillary muscles.
24 - LONG-TERM RESULTS OF
INTERVENTIONAL TREATMENT OF
ARRHYTHMIAS FOLLOWING SURGICAL
CORRECTION OF THE CONGENITAL
HEART DISEASE
E. Artyukhina, A. Revishvili
Institute of Surgery named after A.V. Vishnevskiy,
Moscow, RUSSIA
Purpose: to realize retrospective analysis
the long-term results of the interventional
treatment of arrhythmias following
correction of the congenital heart disease.
Material and Methods: 265 patients
underwent electrophysiological evaluation
and catheter ablation of different types of
arrhythmias occurring in patients operated
with congenital heart disease (tetralogy of
Fallot - 68, atrial septal defect - 81,
ventricular septal defect - 27,
transposition of the great arteries – 21,
common AV canal defect- 14, Fontan
operation – 16, aortic stenosis - 8,
Ebstein’s anomaly - 30). The mean age
26.16 ± 18. 5 years (167 men and 98
women).
Various atrial arrhythmias were observed
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
in 200 patients - typical or atypical atrial
flutter, re-entry tachycardia and atypical
AV nodal tachycardia. 15.5% two types
and 11.8% - more than three types of
tachyarrhythmias were observed.
Overall efficacy of the radiofrequency
ablation of atrial arrhythmias, including
repeated procedures was 81% after a
follow-up of 9.0 ± 3. 8 years.
In 65 patients with ventricular arrhythmias
were observed. 73.1 % had PVCs, 80.5%
- ventricular tachycardia. In 87.8% of
patients with sustained ventricular
tachycardia ICDs were implanted and
14.6% underwent radiofrequency ablation.
The overall effectiveness of ablation was
65.8% in a period of 8.0 ± 2.5 years.
Conclusion: This study suggests that
various types of arrhythmia may coexist in
patients following repair of the congenital
heart disease. Effectiveness of RFA of
atrial arrhythmias over a long-term followup is high by effective and 80% of pts with
sustained ventricular arrhythmias still
required an ICD implantation.
25 - NON-FLUOROSCOPIC NAVIGATION
SYSTEM OPPORTUNITIES IN POSTINFARCTION VENTRICULAR
TACHYCARDIA MANAGEMENT
I. Skigin, K. Shorokhov, E. Voitkovskaya, N.
Lepakhina, I. Pyaterichenko, I. Valeev
Municipal Cardiac Surgery Center, Hospital 2,
Saint-Petersburg, RUSSIA
Ventricular tachycardia (VT) is one of the
most actual problems in modern
electrophysiology. The effective way of its
treatment is radiofrequency ablation (RFA).
Non-fluoroscopic mapping greatly
facilitates RFA, minimizing radiation
exposure during fluoroscopy.
Patient S., 75 years old sought medical
attention in our center in 2015. He
complained of shortness of breath,
weakness, sudden dizziness and rapid
pulse lasting about an hour. In spite of
previous myocardial infarction, he had
never suffered from such symptoms
before. Surface ECG showed a wide
complex tachycardia with a heart rate of
200 beats per minute and conduction
disorder in apical lateral area. The disorder
location corresponded to left ventricular
segments with hypokinesia. We failed to
induce VT during electrophysiological
study (EPS). There was no ventricular
ectopic activity.
The conduction disorder area was then
located during electroanatomical and
activation mapping using Carto®3 System
(Biosense Webster, USA). Ventricular
complexes morphology seen during
mapping was similar to VT morphology.
RFA of this region was performed by
irrigated-type catheter ThermoCool SF Nav
D-F (Biosense Webster, USA) at maximum
temperature 48°C and maximum power
50 W lasting up to 90 seconds. VT was not
inducted during repeated EPS. ECG after
procedure shows no late ventricular
activation, VT never recurred.
Conclusion: Non-fluoroscopic mapping
system Carto®3 (Biosense Webster, USA)
significantly improves post-infarction VT
diagnostics and treatment results. If there
is no ectopic activity, it allows to localize
arrhythmogenic substrate and to perform
successful RFA with minimal X-ray
155
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
effective dose.
26 - HYBRID APPROACH FOR
ELECTRICAL STORM IN A PATIENT
WITH LEFT VENTRICULAR
THROMBOSIS
Y. Sato 1, K. Satomi 2, A. Miyabe 1, K. Oasada 1,
R. Ishihara 1, H. Kobayashi 2, J. Kanayama 2,
A. Tosaka 1, Y. Yazaki 2, T. Mizumura 1, A.
Yamashina 2, Y. Sugimura 1
1
POSTER SESSION
Kawakita General Hospital Heart Disease
Center, Tokyo, JAPAN, 2 Tokyo Medical
University Hospital Department of Cardiology,
Tokyo, JAPAN
A 57-years-old male admitted for
congestive heart failure and chronic renal
failure. ECG during sinus rhythm (SR)
showed CRBBB and abnormal Q wave in
V1, V2, V3 and V4. Echocardiography
showed reduced LVEF with 20% and
thrombosis with 20 mm of thickness at
the left ventricular (LV) apex. Seven days
after admission, pulseless ventricle
tachycardia (VT) suddenly developed with
CRBBB and inferior axis and 300ms of VT
cycle length. Emergency coronary
angiography showed total occlusion of
proximal LAD, subsequently PCI
successfully performed. Even after PCI,
sustained VT and ventricular fibrillation
followed by frequent ventricular
extrasystoles with R on T form. VTs were
refractory to deep sedation, amiodarone,
landiolol and over drive pacing, and
required frequent cardioversion.
Even after optimal dose of anticoagulation,
the patient still had thrombus. LV
aneurysmectomy and cryo ablation
around incision of LV apex were
156
undergone. Subsequently, catheter
ablation (CA) was performed for 2 forms
of monomorphic VT originated from LV
basal septum. The voltage map by
electroanatomical mapping system
showed markedly low voltage area and
late potentials during SR in LV apical to
basal septum. The mid diastric potentials
were recored during both VT in this area.
After the several RF applications VTs
became no-inducible.
Endocardial CA is contraindicatied in
patients with LV thrombus. Solo surgical
aneurysmectomy or epicadial CA might be
not effective in this patient with VT
originated from basal septum. The hybrid
approach with surgical removal of
thrombosis and CA was effective in
patients with drug-refractory electrical
storm and LV apex thrombosis.
27 - LATE GADOLINIUM
ENHANCEMENT AND VENTRICULAR
ARRHYTHMIAS IN PATIENTS WITH
NON-ISCHEMIC DILATED
CARDIOMYOPATHY: A METANALYSIS
I. Anguera, A. Di Marco, P. Dallaglio,
A. Cequier
Bellvitge University Hospital, Barcelona, SPAIN
Background: Risk stratification for
sudden death (SD) in patients with non
ischemic dilated cardiomyopathy (DCM) is
not optimal. Recently, several reports have
suggested a potential role for cardiac
magnetic resonance (cMR).
Purpose: To perform a systematic review
and metanalysis of studies that evaluated
the association between the presence of
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
28 - UTILITY OF SIGNAL-AVERAGED
AND HOLTER ELECTROCARDIOGRAM
AFTER PILSICAINIDE PROVOCATION
FOR RISK STRATIFICATION IN
BRUGADA SYMDROME
J. Kakihara, M Takagi, Y. Hayashi, H. Tatsumi,
A. Doi, M. Yoshiyama
Osaka City University Graduate School of
Medicine, Osaka, JAPAN
Backgrounds:
Non-invasive
risk
stratification for ventricular fibrillation (VF)
in Brugada syndrome (BrS) is not fully
evaluated.
Objects: To assess the utility of signalaveraged Holter ECG (S-Holter) and
12-lead Holter ECG (12-Holter) after
pilsicainide provocation (P-test) for the
non-invasive risk stratification in BrS.
Methods: We enrolled a total of 35
patients with BrS (divided into 2 groups;
VF group: [n=10], and non-VF group:
[n=20]) and 5 controls, whom S-Holter
with and without P-test were performed.
We evaluated late potential (LP; filtered
QRS, RMS40, and LAS40) for 4 hours after
P-test and without P-test recorded on
another day in the same patients.
Furthermore, we measured QRS duration,
QTc interval in leads V2 and V5, and Jamplitude in lead V2 at 12-Holter for 4
hours after P-test. We compared these
data between the 2 groups, and evaluated
the utility of the S-Holter and 12-Holter for
risk stratification of VF.
Results: The filtered QRS at 1 hour and
LAS40 at 3 hours after P-test were
significantly larger in VF group than nonVF group (filtered QRS at 1hour;
113.9±8.9 vs 104.9±8 ms, LAS40 at 3
157
POSTER SESSION
late gadolinium enhancement (LGE) at
cMR and sudden death or ventricular
arrhythmias in patients with DCM.
Methods: A systematic search was
performed in PubMed and Ovid using the
following keywords: late gadolinium
enhancement OR delayed gadolinium
enhancement OR magnetic resonance
AND cardiomyopathy OR arrhythmias OR
ventricular tachycardia OR ventricular
fibrillation OR sudden death OR sudden
cardiac death.
Results: 2660 citations were evaluated,
and 28 studies, involving 2787 patients,
were finally included in the analysis. LGE
was present in a variable proportion of
patients with DCM (21%-70%). The
presence of LGE was associated with an
important and statistically significant
increase in the occurrence of arrhythmic
events (pooled OR 3.9, 95%;CI 2.95.2,p<0.001). Heterogeneity was not
relevant (p=0.40). Egger and Peters tests
excluded the presence of publication bias.
Meta-regression analysis showed that
differences in LVEF across studies did not
significantly influence the association
between LGE and ventricular arrhythmias
or SD (p=0.2). The association between
LGE and arrhythmic events was present in
all the sub-groups analyzed.
Conclusions: In patients with DCM, the
presence of LGE is associated with a
significant increase in the occurrence of
ventricular arrhythmias or SD. LGE could
therefore be a useful tool to improve risk
stratification for sudden death in DCM
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
hours; 45.4±5.9 vs 35.5±7.4 ms,
respectively; p=0.01). Receiver operating
charactaristic (ROC) analysis for single
parameter of VF occurrence were
determined (filtered QRS at 1 hour; area
under curve (AUC) 0.8 with sensitivity
80%, specificity 80%, and LAS40 at 3
hours; AUC 0.87 with sensitivity 90%,
specificity 75%, respectively).
Conclusion: The LP after P-test using SHolter may be useful for risk stratification
of VF episodes in BrS.
29 - IMPACT OF MEDICATIONS ON QT
PROLONGATION AND POSSIBLE
SUBSEQUENT PATIENT MORTALITY IN
OUR CENTER
M. Lovric Bencic, L. Bradic, T. Simoncek,
G. Eder, K. Krzelj
University Clinic of Cardiovascular Diseases,
Clinical Hospital Centre Rebro, Zagreb,
CROATIA
Introduction: there are a lot of
medications
that
can
prolong
repolarization period in everyday practice.
Very often the awareness of this sideeffect is lacking, but can have deleterious
effect on patients, especially when two
such medications are administered
together. The aim of our study was to
analyze the exposure to QT prolonging
medications, the type of medications used
and the mortality in pts. with QT interval
greater than 500ms
Methods: During 22 months we
performed and analyzed 28320 ECG
recordings. The ECG with atrial fibrillation
ans bundle blocks were excluded. 680
158
(2.4%) of ECG showed QT interval greater
than 500ms, and they were analyzed
manually. The data about patients and
their medications were collected in central
hospital electronic data registry and
submitted to statistical analysis.
Results: All cause mortality in this group
of 680 pts was 21% (143/680) during the
period of 301±163 days. The medications
prolonging QT intervals were grouped:
antiarrhythmics 31%, antidepressants
27%, antibiotics 21%, and other.
Amiodarone and sotalol were the most
common among antiarrhythmics, among
antidepressants
escitalopram
and
chlorpromazine, and among antibiotics
azithromycine and erithromycine. Number
of QT prolonging medications was an age
and gender independent predictor of
mortality (HR 1.23, 95%, CI 1.04, p<0.01).
In pts who received 2 or more QT
prolonging medications mortality was stat.
significantly increased (36% vs.16%).
Conclusion: there should be higher
awareness among physicians about QT
prolonging medications and their possible
impact on higher mortality among
patients, especially when more than two
QT prolonging drugs are administered
concomitantly.
30 - PROARRHYTHMIA INDUCED BY
CONCOMITANT USE OF FLECAINIDE
AND PROPAFENONE
S. Paraskevaidis, M. Didagelos, D. Konstantinou,
I. Tziatzios, P. Rouskas, T. Koutsokostas, G.
Efthimiadis, S. Hadjimiltiades, H. Karvounis
1
st Cardiology Department, AHEPA University
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Aim: To present a case of ventricular
tachycardia induced by concomitant use
of flecainide and propafenone.
Case presentation: A 70-year-old male
with history of paroxysmal atrial fibrillation
since 4 years, treated with flecainide, was
admitted to the cardiology department
because of chest discomfort accompanied
by a presyncopal episode. The
electrocardiogram revealed a ventricular
tachycardia that was electrically converted
to sinus rhythm. The coronary angiogram
did not reveal any critical coronary artery
stenoses. The echocardiographic findings
were within normal limits. After a detailed
medical history in the coronary care unit
it was revealed that he had received on his
own 1,200 mg of propafenone during the
last 12 hours because of palpitations.
Flecainide and propafenone were
discontinued and atenolol with verapamil
were initiated. The patient was discharged
hemodynamically stable with no
recurrence of the episode.
Conclusions: Flecainide and propafenone
are effective and safe treatment strategies
for cardioversion and rhythm control in
patients with atrial fibrillation and no
structural heart disease. Rare cases of
proarrhythmia have been described, even
in patients with no structural heart
disease, especially in case of overdose.
Co-administration of these two class Ic
antiarrhythmic drugs is contraindicated
because of enhanced proarrhythmic
effects.
31 - MALIGNANT EARLY
REPOLARIZATION ASSESSMENT BY 2D
SPECKLE-TRACKING
ECHOCARDIOGRAPHY
B. Nguyen, I. Maraschi, A. Persi, R. Quaglione,
E Rauseo, E. Indolfi, G. Giunta, A.
Ciccaglioni, G. Piccirillo, N. Alessandri, C.
Gaudio
Sapienza University of Rome, Rome, ITALY
Introduction: Because sudden cardiac
death (SCD) prevalently occurs in the
general population, additional predictors
are needed. Malignant early repolarization
(ER) can lead to SCD. Several markers to
identify malignant ER patients have been
proposed, but an effective SCD prevention
is still lacking. Speckle-tracking
echocardiography (STE) showed to be a
promising tool to help assess SCD. The
role of STE in SCD risk assessment in ER
patients has never been investigated. We
aimed to compare STE indices in ER
patients with and without Ventricular
arrhythmias (VAs).
Methods: We enrolled 30 ER patients (26
without VAs, 4 with VAs and ICD). STE was
performed in all patients using QLAB
software 10.5 version by Philips Medical
System (Eindhoven, the Netherlands).
Segmental 2D speckle-tracking analysis
was performed by manually tracing the
endocardial border at an end-systolic
frame.
Results: Mean age was greater in the VAs
group compared to the non-VAs group
(54.7±16.7 vs. 35.0±9.7, respectively,
p=0.006). LVEF and QTc did not differ
between groups. Several systolic and
diastolic radial and longitudinal segmental
159
POSTER SESSION
Hospital, Thessaloniki, GREECE
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
and global STE variables were statistically
significant between groups. ROC curves
identified cutoff values with 100%
sensitivity and 80% specificity in
predicting VAs.
Conclusions: Radial and longitudinal STE
are markers of VAs in ER patients. STE
analysis could be helpful in stratifying SCD
risk. These novel parameters may add
important information about the
susceptibility for VAs and SCD in this
otherwise undertreated population.
Further prospective larger studies are
needed to impact clinical practice.
32 - UTILITY OF EXTERNAL LOOP
RECORDER SYSTEMS IN THE
DIAGNOSIS OF PAROXYSMAL
PALPITATION DURING EXERCISE
S. Bencivenga 1, L. Sciarra 2, A. Acitelli 1,
S. Siciliani 2 , A. Sette 2 , E. De Ruvo 2 ,
A. Fagagnini 2, M. Rebecchi 2, S. Romano 1,
M. Penco 1, L. Calo’ 2
1
Università dell’Aquila, Department of
Cardiology, L’Aquila, ITALY, 2 Policlinico Casilino,
Department of Cardiology, Rome, ITALY
Exercise promotes arrhythmias due to
adrenergic activity. The most common
diagnostic tools, such as ECG and Holter
ECG, are not always sensitive enough to
detect sporadic arrhythmias. This problem
is more prominent in sports. In clinical
practice, external loop recorder systems
are available, such as Spider Flash (Ela
Medical), able to monitor the ECG up to
one month. The purpose of our study was
to evaluate the utility of SpiderFlash in the
diagnosis of paroxysmal palpitation during
exercise. Methods: From January 2010 to
160
May 2016 150 athletes were enrolled
(mean age 18 years old; 47% male; 17%
at competitive level) monitored by
SpiderFlash ECG Holter. They were
symptomatic for paroxysmal palpitations
during exercise. Results: We recorded: no
arrhythmia (5%), sinus tachycardia (56%),
ventricular ectopic beats (15%),
paroxysmal supraventricular tachycardia
(12%), supraventricular ectopic beats
(10%), paroxysmal atrial fibrillation (2%).
35% of athletes complained about the
symptoms during the training session. The
average time between the beginning of
registration and the diagnosis of
arrhythmic events was 16.7 ± 8 days.
Athletes with reentrant tachycardia were
treated with radiofrequency ablation
Conclusion: SpiderFlash is an useful tool
in the diagnosis of arrhythmias during
exercise, thanks to the loop memory and
to the most ECG recording time rather than
traditional systems. It allows to record the
onset of arrhythmia and often leads to the
correct diagnosis.
33 - SHORT AND LONG-TERM
PREDICTORS OF SINUS RHYTHM
MAINTENANCE AFTER ELECTIVE
ELECTRICAL CARDIOVERSION FOR
PERSISTENT ATRIAL FIBRILLATION:
A SINGLE-CENTER RETROSPECTIVE
STUDY
S. Cattarin 2, E. Causin 2, L. De Mattia 1, V.
Calzolari 1, M. Crosato 1, P.A.M. Squasi 1,
R. Razzolini 2, Z. Olivari 1
1
Ospedale Civile Ca’ Foncello, UOC Cardiologia, Treviso, ITALY, 2 Azienda Ospedaliera Universitaria
di
Padova,
Divisone
Cardio-toraco-vascolare, Padua, ITALY
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
was an independent predictor of AF
recurrence after one month (OR = 3.22, CI
= 1.63 - 5.59) and one year (OR = 3.25,
CI = 1.53 - 6.89). Multiple recent ECVs
also predicted AF relapse after one month
(OR = 4.58, CI = 1.97 - 10.63) and one
year (OR = 4.21, CI = 1.57 - 9.93).
Amiodarone use predicted SR in the mid
(OR = 0.47; CI = 0.22 - 0.99) and long
term (OR = 0.43, CI = 0.26 - 0.93).
Conclusions: Acute success rate of ECV
is high, but AF relapse is common.
Amiodarone use was the only predictor of
SR maintenance, while older age and
multiple ECV predicted AF recurrence.
POSTER SESSION
Background:
Elective
electrical
cardioversion (ECV) is commonly
performed in patients with persistent atrial
fibrillation (AF). Strong predictors of sinus
rhythm (SR) maintenance are scarce.
To investigate the acute, mid and long
term success of ECV and possible
predictors of SR maintenance.
Methods: Data from 402 consecutive
patients referred to the Cardiology unit at
the “Santa Maria dei Battuti” Hospital in
Treviso between January 2011 and
December 2012 for ECV of persistent AF
were collected. The acute, one-month and
one-year success rate was registered.
92
clinical,
electrocardiographic,
echocardiographic and pharmacological
variables were submitted to univariate and
multivariate analysis (see Table).
Results: The acute success rate was
93,3%. 63,7% of the patients maintained
SR after one month and 38,6% after one
year.
After multivariate analysis age >80 years
161
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International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
34 - PRE-EXISTING ISCHEMIC HEART
DISEASE IS A RISK FACTOR FOR
CARDIAC MORTALITY IN ATRIAL
FIBRILLATION WITH CONTINUOUS
DIGOXIN USE FOR 10-YEAR FOLLOWUP
K. Kang, W. Kim, J. Chin
POSTER SESSION
Eulji University Hospital, Deajeon, SOUTH
KOREA
Purpose: Digoxin-associated mortality
was recently reported in atrial fibrillation
(AF). Our objective was to investigate a
clinical risk factor for digoxin-associated
mortality during 10 years follow-up.
Methods: We reviewed retrospective
cohort of AF patient in Eulji University
Hospital, Deajeon, South Korea from May
2004 to July 2015. The continuous digoxin
uses in consecutive 402 AF patients that
undertaken ECG, echocardiogram,
medication and laboratory data were
analyzed. The cardiac including cerebral
events were collected and analyzed from
index prescription for digoxin during
follow-up 10 years
Results: The duration of
QRS, QTc interval and
ejection fraction were
similar between two
groups. The mean age was
68±11 and proportion of
male was 40% at index
period. Total
cardiac
mortality including sudden
cardiac death (n=15),
recurrent ischemic heart
disease (IHD) (n=19) and
heart failure aggravation
(n=17) was found during
162
the 10 years. Cox Regression Univariate
analysis showed that diabetes mellitus
was hazard ratio (HR) =2.0, confidence
interval (CI) =1.08-3.72, p=0.027, serum
digoxin concentration (SDC) was HR=1.35,
CI=1.02-1.80, p=0.034, CHA2DS2VASc
score was HR=1.30, CI=1.00-1.70,
p=0.049, previous ischemic heart disease
(IHD) was HR=4.45, CI=1.62-12.20,
p=0.002. Multivariate analysis showed
that previous IHD was HR=4.27, CI=1.5411.82, p=0.005. In addition, Age (78±11
vs. 77±14, p=0.769), Ejection fraction
(51±15% vs. 50±17%, p=0.759) and SDC
(0.9±0.8 ng/ml vs. 1.2±1.0 ng/ml,
p=0.201) were similar between previous
IHD and non-IHD.
Conclusions: Our retrospective analysis
found that continuous digoxin use in AF
with previous IHD was associated with
greater risk for cardiac mortality.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
35 - ICTAL ASYSTOLE IN TEMPORAL
LOBE EPILEPSY: A CASE REPORT
L. Rivetti 1, G. Allocca 1, N. Sitta 1, L. Coro’ 1,
G. Turiano 1, P. Delise 2
1
Division of Cardiology, Hospital of Conegliano,
Conegliano, ITALY, 2 Division of Cardiology,
Pederzoli Hospital, Peschiera del Garda, ITALY
A 46-year-old man, with history of one
episode of transient loss of consciousness
(T-LOC) per year since 41 years of age,
underwent a global assessment in our
department. These events were all
overnight, characterized by lockjaw and
followed sometimes by vomit; the last
episode resulted in traumatic injury. He
promptly regained consciousness after 12 minute. The general physical and
neurologic examinations, including
computed tomography of the head and
brain MRI, were all normal. In the
electroencephalogram
(EEG)
no
epileptiform activity was registered. Also
ecocardiogram,
ECG
monitoring,
Flecainide test and Electrophysiological
Study did not show any abnormalities. The
cardiologic investigations was remarkable
only for the cardiac MRI that showed a
small area of intramural late enhancement
in the left ventricular lateral wall.
Consequently, he underwent Internal Loop
Recorder (ILR) implantation.
After few months, ILR recordings showed
an asystolic pause lasting up to 35
seconds during T-LOC and symptoms of
vomit and loss of sphincter control so a
dual chamber was implanted. The device
was programmed to DDDR mode with the
function of Closed Loop Stimulation (CLS)
“active”. After three months the patient
had an episode of generalised seizures.
EEG findings were consistent with
temporal lobe epilepsy. He was treated
with levetiracetam and had no recurrence
of loss of consciousness for 2 years of
follow-up. Pacemaker has shown
negligible atrial or ventricular pacing
(respectively 4%and 0%).
Conclusion: We have presented a case of
misdiagnosis of ictal asystole. According
to literature, the anti-epileptic drugs
(AeDs) therapy was effective to prevent TLOC that characterizes this disease.
Pacemaker implantation should be
reserved in documented failure of AeD
therapy. The distinction between syncope
and epileptic seizures can be challenging,
so a general assessment has to have done
in every patient whit this intriguing clinical
presentation.
163
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
36 - EXERCISE-TRAINING AND
CARDIAC REHABILITATION IN
PATIENTS WITH IMPLANTABLE
CARDIAC DEVICES
M.R. Squeo 1, B. Di Giacinto 1, A. Vaquer 1,
M. Santini 2 , M.L. Sette 1 , E. Fabrizi 1 ,
A. Parisi 3, F. Barchiesi 1, A. Spataro 1, A. Biffi 1
1
POSTER SESSION
Istituto di Medicina e Scienza dello Sport CONI, Rome, ITALY, 2 World Society of
Arrhythmias, 3 Istituto Universitario Scienze
Motorie, Rome, ITALY
Purpose: The “FIDE Project” (Fitness
Implantable Device), organized by the
Institute of Sport Medicine and Science
and World Society of Arrhythmias, has the
aim to demonstrate the usefulness of
exercise training to improve the quality of
life in patients with electronic devices.
Materials and Methods: Thirty sedentary
patients were selected for the project, 25
were male (83%), with mean age 73±5
years (range 44-94 years); all with PM and
four with PM and ICD. Patients had atrial
fibrillation/atrial flutter in 34% (n.11), post
ischaemic dilated cardiomyopathy in
17.2% (n. 5), sick sinus syndrome in
20,7% (n. 6), complete atrium-ventricular
block in 20,7% (n. 6), hypertrophic
cardiomyopathy in 3,4% (n. 1) and
recurrent syncope in 3,4% (n. 1).
The FIDE project provided three phases.
Phase 1 including anthropometric
measurements, cardiologic examination,
resting ECG, cardiopulmonary exercise
test (VO2 max), tests of strength in
different muscle groups with maximum
repetition (1-RM) according to the
Brizcky’s formula, flexibility test. Phase 2
includes 15-20 consecutive training
164
sessions, for 2 months. Finally, phase 3
which consists in the repetition of the tests
carried out in the phase 1.The exercise
prescription was set to 50-60% of VO2
max and to 50-65% of 1RM (muscular
force). Every week, patients were training
at least three times for 90 minutes (warmup, aerobic phase, strength phase and
stretching) twice in our Institute and once
or more times at home autonomously.
Results: The cardiopulmonary test
documented a significant improvement in
work load after the exercise program (87
± 30 watts vs.108± 37; p = 0.044); and a
positive trend in peak VO2 (15.2 ± 1
ml/kg/min vs. 17 ± 4; p = 0.13). Also tests
of strength capacity significant increase
after the cardiac rehabilitation program,
(quadriceps: 36 ± 20 kg vs 48 ± 21 kg, p
= 0.03). Flexibility tests (sit and reach test:
-19 ± 11 cm vs -14.5 ± 11 cm, back
scratch test: -18 ± 11 cm vs -15 ± 10 cm,
lateral flexibility right -43 ± 6 cm vs -43
± 9 cm, left -43 ± 5 vs. -44 ± 9 cm) and
anthropometric measurements (weight:
81 ± 14 vs 81 ± 16 Kg, BMI: 27.3 ± 4 vs.
27.6 ± 4; abdomen circumference: 105
cm ± 3 vs 105 ± 11 cm, body fat mass
percentage: 33.34 ± 9 vs 27.64 ± 4)
showed a positive trend, but without
achieving statistical significance.
Conclusion: A brief period of cardiac
rehabilitation improves aerobic fitness and
strength capacity in patients with
pacemakers and ICD.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
37 - PREDICTION OF HEMORRHAGIC
COMPLICATIONS AFTER PACEMAKER
IMPLANTATION IN PATIENTS TREATED
WITH DABIGATRAN USING ARTIFICIAL
NEURAL NETWORK
D. Terekhov, V. Samitin, V. Agapov,
V. Maslyakov, S. Zadorozhnaya, K. Kulikov,
I. Kildeev
Saratov Regional Cardiac Centre, Saratov,
RUSSIA
Objective: To appraise the effectiveness
of artificial neural network (ANN) based on
routine coagulation parameters to predict
occurrence of complications after
pacemaker implantation in patients
receiving dabigatran etexilate.
Methods: Retrospective study included
data of 60 patients with atrial fibrillation
receiving dabigatran, who underwent
pacemaker implantation. The first 35
patients were used to create and train
ANN and data of the following 25 patients
were used to validate the ANN.
Information about hemorrhagic events
was collected during the hospitalization.
The outcome variable was defined as “1”
when some hemorrhagic complication
present, or as “0” when patient was free
of such complications. The set of input
parameters (covariates) included 6 routine
coagulation tests: protrombin time,
prothrombin
index, INR, partial
thromboplastin time (PTT), fibrinogen,
thrombin time (TT). Establishment of ANN
models was performed by using the
Multilayer Perceptron procedure of IBM
SPSS Statistics 23.
Results: The cases of active dataset were
randomly assigned into training (43%),
testing (15%), and holdout samples (42%).
We used hyperbolic tangent activation
functions for the hidden layer, softmax
function for output layers, and standard
training settings (Figure 1). Classification
results showed 88,5% of correctly
classified cases in training sample, 77,8%
in testing and 88% in holdout samples.
Following predictors have the highest
normalized importance: PTT (100%), TT
(78,4%), fibrinogen (67,6%).
Area under the receiver operating curve
for ANN was 0.873, which means a good
accuracy of diagnostic test.
Conclusions: The use of ANN can improve
prediction of post-operative hemorrhagic
complications
after
pacemaker
implantation in patients receiving
dabigatran.
165
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
38 - VERY LONG TERM PERFORMANCE
OF A MRI CONDITIONAL VENTRICULAR
LEAD: BEFLEX MRI RF46D
(VENTRICULAR) AND RF45D (ATRIAL).
THE ASTUR-GALAICO BEFLEX STUDY
J. Lapuerta 1, R. Bangueses 2, E. Garcia 3,
E. Fernandez-Obanza 4 , I. Valverde 5 ,
J. Casares 6, M. Gonzalez 7
1
POSTER SESSION
Hospital Universitario De Cabuenes, Gijon,
SPAIN, 2 Hospital Universitario San Agustin,
Aviles, SPAIN, 3 Hospital Alvaro Cunqueiro, Vigo,
SPAIN, 4 Hospital Arquitecto Marcide, Ferrol,
SPAIN, 5 Hospital Universitario De Cabuenes,
Gijon, SPAIN, 6 Hospital Universitario San
Agustin, Aviles, SPAIN, 7 Hospital Universitario
De Cabuenes, Gijon, SPAIN
Introduction: The aim of this study was to
assess the long-term electrophysiological
properties and complication rate in a
recently approved (CEE) MRI-conditional
leads: Beflex MRI RF45D and RF46D
(Sorin-LivaNova PLC).
Methods: We conducted an observational,
retrospective, case-control, 4-center
cohort study of 294 patients underwent
implant of Sorin generator models. At all
follow-up controls (at implant, 3 months,
1 year, and yearly), pacing threshold at
0,35ms, P/R-wave amplitudes and pacing
impedance were measured in bipolar lead
configuration.
Results: The atrial lead (RF45D) was
implanted in 147 patients and the
ventricular lead (RF46D) in 227 patients
(56 % men; mean age of 77 ± 8 years,
and followed for up to 6 years: RF45D:
Median 1400 days. RF46D: Median 1103
days). At 6 years, the measured values
were 0, 61 ± 0, 17 V (threshold); 3, 1 ± 2,
166
1 mV (P-wave), and 485 ± 98 Ohm for
RF45D leads, and were 0, 78 ± 0, 2 V; 11,
7 ± 4, 2 mV, and 594 ± 156 Ohm for
RF46D leads. During the entire follow-up
period only five out 227 ventricular leads
(2, 2 %) required invasive intervention,
which was necessitated by dislocation and
four leads developed an high ventricular
pacing threshold (>4V at 0,35ms). One
insulation defects was observed in atrial
leads. Sixteen patients developed new AF
(RF45D group). Forty nine patients died
during the observation period.
Conclusions: The studied Beflex MRI
RF45D and RF46D leads offer stable and
reliable clinical performance in the very
long-term and excellent electrophysiological
values.
39 - EXTRACTION OF INDWELLING
CARDIAC RHYTHM MANAGEMENT
DEVICE LEADS. WHAT’S THE RISK?
I. Harding, J. Lalor, G. Domenichini,
H. Gonna, G. Nero, M. Gallagher
St George’s Hospital, London, UNITED
KINGDOM
Background: Historical data suggest that
percutaneous extraction of leads over 1yr
old fails frequently and carries a 2-7% risk
of major complications. However,
techniques evolve and operator
experience increases continually.
Aim: To compare contemporary
complication rates in extraction vs nonextraction device revision procedures.
Methods: All cardiac device procedures
performed between 01/05/2012 and
01/05/2016 were screened. Data on
procedural outcome were collected
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
40 - TRANSVENOUS CATHETER
EXTRACTION. THE NEW JOB FOR
DOCTORS PERFORMING
TRANSVENOUS LEAD EXTRACTION
A. Kutarski 1, L. Tulecki 2, K. Tomkow 2, J.
Malyszko 3, A. Bednarek-Skublewska 4, A.
Swatowski 4, R. Pietura 5
1
Department of Cardiology Medical University
of Lublin, Lublin, POLAND, 2 Department of
Cardiac Surgery The Pope John Paul II Province Hospital, Zamosc, POLAND, 3 Second Department of Nephrology and Hypertension with
Dialysis Unit, Bialystok, POLAND, 4 Department
of Nephrology Medical University of Lublin, Lublin, POLAND, 5 Department of Radiography
Medical University of Lublin, Lublin, POLAND
Introduction: Nowadays more and more
permanent catheters (PC) are implanted
by vascular surgeons for haemodialysis
and vascular ports for chemotherapy or for
parenteral nutrition as well. Due to
different reasons such catheters often
should be removed. Sometimes however,
in rare situations catheter cannot be
removed by simple traction due to strong
connection of its distal part with vascular
wall. Surgical liberation of such catheters
with opening superior cava vein or
brachio-cephalic trunks remain difficult.
Less invasive methods of catheter removal
are demandable. Objective: Analysis of our
experience with permanent catheter
removal using TLE designed tools.
Methods: We have extracted strongly
ingrown 3 vascular ports and 4
haemodialysis designed catheters in 6
patients using simple angiographic
guidewire and polypropylene sheaths
(Cook®) designed for lead extraction.
167
POSTER SESSION
prospectively. All radiological data were
reviewed. Procedural details and
complications within 30 days were
identified.
Results: 193 extraction and 270 nonextraction procedures were performed.
Patients undergoing lead extraction were
younger and more likely to have infected
or malfunctioning systems (P<0.0001). No
death occurred during a procedure or as
an identifiable consequence of the
procedure. Neither intra-procedural nor
post-procedural complications were more
common in extractions compared to nonextraction revisions (1.0% vs 1.5% (ns)
and 5.7% vs 4.8% (ns) respectively). See
Figure 1.
Conclusion: Contemporary lead extraction
techniques at St George’s Hospital are not
associated with excess complications
compared with non-extraction revisions.
Complication rates remain comparable to
other published series.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Results: All 7 catheters were strongly
imbedded to vascular wall (one of them
with coronary sinus ostium, in one patient
vascular port was strongly connected with
haemodialysis catheter). Dwell time of
extracted PC was 2,4 years only. During
the procedure proximal PC ending was
liberated, guide wire was introduced
inside. The next step consisted PC
liberation with polypropylene sheaths. All
procedures were simple and successful.
Tips of all extracted PCs were in close
contact with vascular wall and that
probably
induced
accelerated
development of connective tissue. We
have strong impression that permanent
catheter implantation using X-ray control
could probably prevent future problems.
Conclusions: Lead extraction tools and
technique could be useful in permanent
cathether removal preventing the patient
from difficult open chest surgery
41 - THE EFFECTS OF DIFFERENT
IMPLANTATION POSITION OF
SUBCUTANEOUS INSERTABLE
MONITOR ON ELECTRICAL OUTCOMES
S. Budassi 1, G. Massaro 1, C. Galante 1,
G. Panattoni 1, S. Rizzo 1, D.G. Della Rocca 1,
V. Ribatti 1, G. Magliano 1, V. Schirripa 2,
D. Sergi 1, F. Ammirati 2, L. Santini 2, G.B.
Forleo 1, F. Romeo 1
168
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 Ospedale G. B.
Grassi - Department of Cardiology, Ostia-RM,
ITALY
Introduction: BioMonitor 2 is a
programmable, subcutaneous insertable
monitor designed to automatically record
the occurrence of arrhythmias or to be
activated by the patient during
symptomatic episodes. The aim of our
study was to evaluate the effects of the
different implantation position on electrical
outcomes.
Methods: We evaluated 25 patients
implanted with subcutaneous insertable
devices Biomonitor 2 (48% male; age: 63
± 16 years). Patients were divided into two
groups according to the different
implantation position: in 17 patients (68%)
devices were placed in left parasternal
region (parasternal BIOMONITOR Group)
and in 8 patients (32%) devices were
located at a 45° angle from the plane of
the sternum (45° BIOMONITOR Group). We
collected electrical data at baseline and 3months follow-up visit.
Results: The implantation success rate
was 100%. At implant we found
acceptable electrical values into the two
group and at 3-months follow-up visits,
parameters remained stable. However,
ventricular sensing values of parasternal
BIOMONITOR Group were significantly
lower than 45° BIMONITOR Group at
implant and at 3-months follow-up visits
(0,6±0,3 mV vs 1±0,5 mV, p=0,02;
0,6±0,3 mV vs 1,2±0,6 mV, p=0,02).
Conclusion: This study provides evidence
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
42 - CLINICAL USEFULNESS OF A NEW
GENERATION OF IMPLANTABLE LOOP
RECORDERS IN THE MANAGEMENT OF
PATIENTS WITH HEART RHYTHM
DISORDER
S. Budassi 1, C. Galante 1, G. Panattoni 1, S.
Rizzo 1, D.G. Della Rocca 1, V. Ribatti 1, G.
Magliano 1, V. Schirripa 2, D. Sergi 1, F. Ammirati 2, L. Santini 2, G.B. Forleo 1, F. Romeo 1
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 Ospedale G. B.
Grassi - Department of Cardiology, Ostia-RM,
ITALY
Introduction: Insertable cardiac monitors
(ICMs) are subcutaneous implantable
devices that continuously record an ECG
signal, used for the management of patient
with unexplained syncope or heart rhythm
disorder.
Recently, a new generation of implantable
loop recorders, Biomonitor 2, has been
designed in order to improve detection of
occurrence of arrhythmias. The aim of our
study was to evaluate the clinical
usefulness of this new technology.
Methods: We evaluated 25 patients
implanted with Biomonitor 2 (48% male;
age: 63 ± 16 years ). During follow-up we
assessed all cardiac arrhythmia alerts
detected by devices: based on analysis of
IEGMs, occurrence of an episode was
classified as true positive alerts by three
independent experienced cardiologists.
Results: During follow-up, 727
asystole/bradycardia alerts occurred in 8
patients (32%) and 622 atrial fibrillation
events in 13 patients. Based on analysis of
IEGMs 653 events of asystole/bradycardia
and 413 episodes of AF were classified as
true positive alerts. The positive predictive
value (PPV) for the detection of
asystole/bradycardia
and for atrial
fibrillation was 90% and 66 %,
respectively.
Conclusion: Our experience confirms the
feasibility and clinical usefulness of this
new generation loop recorder devices in
the management of patients with heart
rhythm disorder.
43 - THE PERFORMANCE OF NEW
GENERATION OF IMPLANTABLE LOOP
RECORDERS FOR THE DETECTION OF
ATRIAL FIBRILLATION
G. Massaro 1, C. Galante 1, V. Ribatti 1, G.
Panattoni 1, S. Rizzo 1, D. G. Della Rocca 1,
R. Morgagni 1, D. Sergi 1, V. Schirripa 2, F.
Ammirati 2, L. Santini 2, G.B. Forleo 1, F.
Romeo 1
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 Ospedale G. B.
Grassi - Department of Cardiology, Ostia-RM,
ITALY
Introduction: Insertable cardiac monitors
(ICMs) are subcutaneous implantable
devices that continuously record an ECG
signal, used for long-term heart rhythm
monitoring. The usefulness of ICMs for the
detection of AF in patients with
cryptogenic stroke and with recurrent AF
169
POSTER SESSION
that feasibility and safety of this novel
technology. Follow-up results suggest
patients with the location at a 45° angle
from the plane of the sternum have better
electrical values. However, confirmation of
these results by long-term observational
studies is needed.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
diagnosis was clear. We investigated the
performance of new generation of
implantable loop recorders for the
detection of atrial fibrillation.
Methods: We enrolled 50 patients who
underwent new generation of loop
recorders insertion between November
2014 and May 2016, 25 patients (19 male,
age: 66 ± 13 years) were implanted with
Reveal LINQ (LINQ Group) and 25 patients
(14 male; age 63 ± 16 years) were
implanted with Biomonitor 2 (Biomonitor
Group). Atrial fibrillation events were
assessed during follow up: based on
analysis of IEGMs, occurrence of an AF
episode was classified as true positive
alerts by three independent experienced
cardiologists.
Results: During follow-up, 5045 events of
AF were identified in 11 patients in LINQ
Group. Based on analysis of IEGMs 1033
alerts were classified as false positive
alerts. In Biomonitor 2 Group, 622 alerts of
AF occurred in 13 patients: 209 events
were evaluated as false positive alerts.
The positive predictive value (PPV) for the
detection of atrial fibrillation was 80 % in
LINQ Group and 66% in BIOMONITOR 2
Group.
Conclusion: The present study confirms
the feasibility and clinical usefulness of
new generation of implantable loop
recorders for the detection of atrial
fibrillation. Additional studies are needed
to evaluate the performance of this
algorithms in a larger population.
170
44 - REMOTE MONITORING REDUCES
TIME FOR FIRST ATRIAL FIBRILLATION
DETECTION AND RISK FOR ISCHEMIC
EVENTS
F. Mercanti 1, V. Doldo 1, L. Santini 2, V.
Minni 1, M. Gugliotta 1, A. Sanniti 1, P. La
Prova 1, R. Morgagni 1, G. Magliano 1, G.B.
Forleo 1, D. Sergi 1, F. Romeo 1
1
Department of Internal Medicine, Division of
Cardiology, University of Rome Tor Vergata,
Rome, ITALY, 2 Department of Internal Medicine, Division of Cardiology, G.B. Grassi Hospital, Rome, ITALY
Introduction: Remote monitoring (RM) is
an established technology integrated into
clinical practice. Potential benefits of RM
are early atrial fibrillation (AF) detection
and
patient’s
continuous
monitoring.Several studies of device RM
consistently demonstrated that AF
represents the most common clinical alert
and that detailed information on
arrhythmia onset, duration, and burden as
well as on the ventricular rate may be
early obtained for clinical evaluation
Methods: 74patients (aged 69.2 ± 6.94)
with pacemaker and loop recorder were
included in this study and analyzed by RM.
In this group, 18 patients (24%) had AF
history and were already treated with oral
anticoagulant therapy. RM was performed
on each patient once a month to detect
possible arrhythmic events and in
particular AF new onset.
Results: During our monitoring 11
patients (14%) had one or more episodes
of asymptomatic AF longer than 6 hours.
They were called back and admitted to our
outpatient clinic to start oral
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
anticoagulation therapy. At two years
follow up none of them had major bleeding
and just one had a transient ischemic
attack. All patients had a good compliance
with oral anticoagulant therapy and INR
was in range during our evaluation.
Conclusions: Clinically relevant atrial
tachyarrhythmia may be identified by RM
in asymptomatic patient allowing
reduction of access in emergency room,
earlier hospitalization and an optimized
pharmacological treatment. Based on our
preliminary analysis, daily monitoring may
reduce the ischemic cerebral injuries.
45 - MANAGEMENT OF NEW
GENERATION INJECTABLE LOOP
RECORDER COULD BE PERFORMED
SAFETLY BY TRAINIED NURSE STAFF.
R. Cervellione, M. Moltrasio, A. Somenzi, G.
Bucca, M. Moro, C. Tondo
Cardiac Arrhythmia Research Center, Centro
Cardiologico Monzino, IRCCS, Milan, ITALY
Purpose: Traditionally, implantable loop
recorder(ILR) have been implanted by
medical staff in cath-lab. Recently,
injectable ILR become available; this
device is significantly smaller than
traditional ones and, thus,reduces
implantation trauma and scarring. Few are
the experiences that bring the fully
management of this technology to nurse
staff.
Methods: Very recently in our facility, in
complete alignment with nurse staff,
electrophysiology physicians(EPp) and
hospital directors, we decided to move
injectable ILR management(implant and
remote follow-up) to our nurse staff, under
EPp responsibility(please see matrix for
shared responsibilities).
All the nurses that are allowed to manage
injectable ILR pathway were appropriately
trained by our EPp before. ILR device
programming have been done by trained
nurse staff, based on EPp’s indication.
After implant, all patients were enrolled by
nurse staff in remote monitoring service
(MedtronicCareLink) and were daily
follow-up remotely by nurses that
managed triaging information and alert
EPp only when medical judgment or
action needed to be implemented.
Results: From May2016, 37patients(70%
male;mean age 55yrs) underwent to
injectable ILR(Medtronic Reveal LINQTM)
implantation performed by trained nurses.
Reasons for ILR implant were: 8(22%)
ventricular tachycardia,12 (33%) atrial
fibrillation,13(35%) syncope, 2 stroke(5%)
and 2(5%) Brugada. All these implants
were performed by previously trained
nurse staff inside or outside cath-lab.
Success implant rate was 100%, no major
or minor adverse event occurred.
Conclusions: In our experience, nonmedical, non-cath-lab injectable ILR
implantation is feasible and safe. Based on
our data, we encourage the adoption of
this strategy it could be done safely out of
cath-lab in a less resource intensive
environment.
171
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
46 - HEART FAILURE-INDUCING
MECHANISMS IN PACEMAKER
CARRIERS WITH OBSTRUCTIVE SLEEP
APNEA: PACING BURDEN
T. Guimarães 1, P. Marques 1, G. Lima Da
Silva 1, M Nobre Menezes 1, J. Agostinho
1
, I. Gonçalves 1, A. Bernardes 1, M. Dias 2,
N. Cortez Dias 1, P. Pinto 2, J. De Sousa 1,
F.J. Pinto 1
1
POSTER SESSION
Santa Maria University Hospital- Department
of Cardiology, Lisbon, PORTUGAL, 2 Santa
Maria University Hospital- Department of
Pneumology, Lisbon, PORTUGAL
Obstructive sleep apnea (OSA) is common
in patients with sinus node disease or
atrioventricular node disease with
indication for pacemaker implantation
(PM) and is associated with heart failure
(HF). New generation PM have respiratory
monitoring algorithms that monitor the
respiratory distress index (RDI), identifying
patients with possible OSA.
Purpose: To compare ventricular pacing
(Vp) % in patients with diagnosis of OSA
by polysomnography (PSG) criteria or
pacemaker monitoring algorithms (RDIPM) criteria.
Methods: Single center prospective study
of patients submitted to double-chamber
pacemaker implantation or generator
replacement. Patients underwent clinical
interview to access OSA symptoms and
PSG overnight study with RDI
determination. RDI-PM during PSG study
was registered.
Results: 24 patients (63% male, aged
75±11 years) were studied. Diagnosis of
OSA was established based on the AASM
criteria, RDI-PM greater than 20 and RDI-
172
PM greater than 17,5 in 50%, 54% and
58%, respectively. The % Vp was
statistically similar in patients with OSA
diagnosis based on AASM criteria versus
non-OSA patients (19 [0-99) vs 23 [0-39]
p = NS). However, using the RDI-PM
greater than 20 and RDI-PM greater than
17,5 criteria, patients with OSA have a
higher Vp % burden versus non-OSA
patients (61 [11-97] vs 0 [0-34] p =
0.013; (42[3-96] vs 0[0-34] p = 0,041,
respectively).
Conclusion: Pacemaker monitoring
algorithms criteria are more sensitive in
detection OSA and show that in
pacemaker carriers, the diagnosis of OSA
is associated with higher Vp %. This may
be a contributing factor to the higher
incidence of LV dysfunction and HF.
47 - KEY ROLE OF PACING SITE AS
DETERMINANT FACTOR OF EXERCISE
TESTING PERFORMANCE IN PEDIATRIC
PATIENTS WITH CHRONIC
VENTRICULAR PACING
M. Cabrera Ortega 1, D.B. Benítez Ramos 1,
F. Di Gregorio 2, A. Barbetta 2
1
Department of Arrhythmia and Cardiac Pacing. Cardiocentro Pediatrico William Soler, La
Havana, CUBA, 2 Unitá di Ricerca Clinica, Medico Spa, Padua, ITALY
Background: Chronic right ventricular
(RV) apical pacing has been associated
with deterioration of functional capacity
and chronotropic incompetence during
exercise testing in children. The effects of
alternative pacing site on exercise
performance in pediatric population
remains unknown.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
48 - LONG ATRIOVENTRICULAR DELAY
IN PACING ALGORITHMS MAY INDUCE
HEMODYNAMIC HARMFUL EFFECTS
M. Lovric Bencic, I. Ivanac Vranesic,
L. Bradic, T. Simoncek, M. Pavlovic
University Clinic of Cardiovascular Diseases,
Clinical Hospital Centre Rebro, Zagreb,
CROATIA
Introduction: Longterm right ventricle (RV)
pacing can have negative effects on
cardiac remodeling, transmitral flow and
occurrence of atrial fibrillation (AF).There
are algorithms to prevent unnecessary RV
pacing by prolonging AV delay and
promoting intrinsic ventricular activation.
This AV delay prolongation may result in
left atrial (LA) contraction against closed
mitral valve and may cause cardiac
dysfunction, especially at higher heart
rates(HR).
Methods: 42 pts (32 M, mean age
64±6.2y,10 F mean age 56 ± 5.7y) with
complaints of exertional dyspnea and with
implanted DDDR pacemakers with above
mentioned algorithms were tested.
Cardiac function was assessed by
echocardiograpy (EF,transmitral and
transaortic Doppler flow measurements).
All recordings were made during fixed AV pacing with increasing AV intervals from
160 to 320ms in 20 ms steps, at two
paced heart rates 70/min and 100/min.
Results: In 16 pts (38%, p <0,001) we
noticed altered cardiac function at HR
lower than 100/min, with a mean AV delay
of 260ms. At HR above 100/min additional
group of 22 pts showed cardiac
dysfunction (total 90%pts) with
significantly altered ECHO parameters
173
POSTER SESSION
Aims: To evaluate the influence of
ventricular pacing site on exercise
capacity in pediatric patients with
complete congenital atrioventricular block
requiring permanent pacemaker therapy.
Methods and Results: Sixty-four children
paced from RV apex (n=26), RV
midseptum (n=15) and left ventricular (LV)
apex (n=23) were prospectively evaluated.
Treadmill exercise stress testing was
performed according to modified Bruce
protocol. LV apical pacing was associated
with greater exercise capacity. In
comparison with the other study groups,
children with RV apical pacing showed
significantly lower VO2 speak (37±4.11;
p=0.003), O2 pulse (8.78±1.15; p=0.006),
metabolic equivalents (7±0.15; p=0.001)
and exercise time (6±3.28; p=0.03).
Worse values in terms of maximum heart
rate (139±8.83 bpm; p=0.008) and
chronotropic index (0.6±0.08; p=0.002)
were detected in the RV apical pacing
group despite maximal effort (respiratory
exchange ratio) did not differ among
groups (p=0.216). Pacing from RV apex
predicted significantly decrease of
exercise capacity and chronotropic
incompetence (odds ratio, 9.4; confidence
interval, 2.5-18.32; wald, 4.91;
p=0.0036). Duration of pacing, gender,
VVIR mode, and QRS duration had not
significant impact on exercise capacity.
Conclusion: The site of ventricular pacing
has the major impact on exercise capacity
in children requiring permanent pacing.
Among the sites assessed, LV apex is
related with the better exercise
performance.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
suggesting «pacemaker syndrome» as AV
delay prolonged and HR went faster.
Conclusion: In some pts long AV delay at
lower HR has no consequences on cardiac
function, but in majority of our group of pts
(90%) prolongation of AV delay above
260ms and at faster HR caused significant
changes in cardiac function altering
transmitral and transaortic blood flow and
LV filling pattern, with clinical presentation
of «pacemaker syndrome».
49 - THE ROLE OF DYNAMIC
ECHOCARDIOGRAPHIC SCREENING IN
ASSESSMENT THE EFFECTIVENESS
ANTITACHYCARDIA PACING
I. Skigin, K. Shorokhov, E. Voitkovskaya, N.
Lepakhina, A. Abramov, I. Pyaterichenko,
A. Danilova
Municipal Cardiac Surgery Center, Hospital,
Saint-Petersburg, RUSSIA
Objective: To demonstrate the capabilities
of the dynamic echocardiographic
screening in the follow-up of patients after
implantation DDDR/DDDRP pacemaker
(PM).
The study included 65 patients with an
sick sinus syndrome or syndrome binodal
weakness (59-82 years of ages), who
have had implanted PM with algorithms to
prevent paroxysmal atrial fibrillation (PAF),
and find their own AV delay (AVD): 36
patients (Group I)-ReplyDR, 29 (II Group)EspritDR (Sorin). In the I-st group,
activated PAF prevention algorithms
search their intrinsic AVD and in the II-nd
group of the default settings are not
changed.
Results: Comparing volume and ejection
174
fraction (EF) of left atrium (LA) in dynamics
by the Wilcoxon signed-rank test in both
cases is p<0,05. That shows that
decrease of volume and increase in
ejection fraction LA after 3 months of
initial PM programming is significant.
There were differences in the dynamics of
each parameter-the volume of LA and EF
of LA. There was determined differences
of related parameters of each patient, and
there was also a comparison of changes
in the two groups using the Mann-Whitney
test held: by the volume and ejection
fraction of LA p<0,05, which means
significantly higher dynamics of reducing
the volume and increasing the ejection
fraction LA in the I-st group of patients are
against the background of the activated
PAF prevention algorithms, than that of the
patients in II-nd group.
Thus, the use of the dynamic
echocardiographic monitoring allows
timely adjustment medical tactics of
patients
with
implanted
PM
antitachycardia settings that significantly
prove long-term results.
50 - THE PREVALENCE OF STRICT
CRITERIA FOR DEFINING LBBB IN
PATIENTS IMPLANTED WITH CARDIAC
RESYNCHRONIZATION THERAPY
S. Ventresca 1, G. Panattoni 1, D.G. Della
Rocca 1, V. Ribatti 1, P. Paolisso 1, F. Condemi 1,
G. Magliano 1 , A. Capria 2 , D. Sergi 1 ,
M. Borzi 1, L. Santini 3, G.B. Forleo 1, F.
Romeo 1
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 University of
Rome Tor Vergata - Department of Internal Medicine, Rome, ITALY, 3 Ospedale G.B. Grassi -
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Background: Cardiac resynchronization
therapy (CRT) is a well-established therapy
for the treatment of patients with heart
failure and evidence of left bundle branch
block (LBBB). However, definition of LBBB
is not universally shared. Recently, Strauss
et al. proposed new strict criteria in order
to define LBBB. The aim of the study was
to evaluate the prevalence of true LBBB
according to Strauss Criteria in a population
of patients implanted with CRT-D.
Methods: We enrolled 155 patients
implanted with CRT-D; they were classified
into two groups: patients with LBBB
according to Strauss Criteria (Strauss
LBBB Group) and patients without LBBB
according to Strauss Criteria (Control
Group).
Proposed criteria for LBBB were:
- QRS duration: 140 ms (men) or 130 ms
(women);
- QS or rS in V1 and V2;
- mid-QRS notching or slurring in 2 of
leads V1, V2, V5, V6, I and aVL.
Results: Complete LBBB according to
Strauss was recorded in 90 patients
(58,1%). In our group 64% of patients had
a QRS duration > 130 ms (women) and >
140 ms (men), 93% a QS or rS aspect in
V1 and V2, 70% had a mid-QRS notching
or slurring in 2 of the leads I, aVL, V1, V2,
V5 or V6.
Conclusion: This study allowed us to
observe that only 58,1% of patients
implanted with CRT-D according to current
guidelines showed strict criteria for
defining LBBB according to Strauss.
Further studies are needed to evaluate the
implications of these criteria in the
selection of patients for CRT-D.
51 - RATE AND INCIDENCE OF
PACEMAKER DEPENDENTSY AFTER
IMPLANTATION IN THE MACEDONIAN
POPULATION
J. Taleski, L. Poposka, F. Janusevski,
V. Boskov
University clinic of Cardiology, Department of
Electrostimulation and Electrophysiology,
Skopje, REPUBLIC OF MACEDONIA – FYROM
Background: Pacemaker-dependent (PD)
patients have inadequate or even absent
intrinsic rhythm and therefore can suffer
significant symptoms or cardiac arrest
after
termination
of
pacing.
Aim of this study is to show the PD
incidence in a long follow up period, in
relation to various indications for
pacemaker implantation (PM) in only high
volume referral center in our Country.
Methods: The study included 1140
patients from January 2011 until May
2014,(age range 30-90 years). Indications
for pacing were sick sinus syndrome
(SSSy) in 88 patients, second degree AV
block (AVB gr. II ) in 271, third degree AV
block ( AVB gr. III ) in 554 and atrial
fibrillation (AF) with bradycardia in 227
patients. The mean follow-up was 3.2 +/1.5 years. Pacemaker dependency was
defined as the absence of an intrinsic
rhythm of 30 beats/min during back-up
pacing and after switching off the
pacemaker. If any significant symptoms of
bradycardia developed or if the underlying
rhythm did not appear (asystole > 3 s) the
175
POSTER SESSION
Department of Cardiology, Ostia (RM), ITALY
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
pacing was restarted.
Results: Pacemaker dependency was
observed in 247 (21 %) of the 1140
patients. In this subgroup pacing
indications were SSSy in 3 (3%) of 88
patients, AVB gr. II in 19 (7%) of 271, AVB
gr. III in 206 (37%) of 554 and AF with
bradycardia in 19 (8%) of 227.
Conclusions: In our study PD occurred in
21% of all patients. Our results show that
patients with AVB have a significantly
higher incidence of PD than patients with
SSSy or AF.
52 - ZERO FLUOROSCOPY DURING
DEVICE IMPLANTATION. WHAT DOES IT
GIVE US?
E. Kropotkin, E. Ivanitskiy, V. Sakovitch, D.
Shlyakov
Federal Centre for Cardiovascular Surgery Department of Cardiac Surgery Unit 2,
Krasnoyarsk, RUSSIA
Aim of the study: to assess safety and
effectiveness of anti arrhythmic device
implantation under the intracardiac echo
guidance.
Patients and methods: 255 consecutive
patients (mean age 58 + 36 years) with
indications for pacemaker or implantable
cardioverter-defibrillator implantation
were enrolled in the study. All patients
were randomized into two groups. In the
first group (130 patients) device
implantation was performed in a routine
way by using fluoroscopy. In the second
group (125 patients) device implantation
was performed under the intracardiac
echo guidance (Acu Nav, Sound Star) from
right femoral approach. Mean follow up
176
time was 12,2 + 8,4 month’s. Outpatient
visits were performed at 6 and 12
month’s.
Results: no major complications were
seen in both groups. No groin
complications were seen in zero
fluoroscopy groups. Pacing parameters
were similar in both groups and did not
differ significantly at 6 and 12 month’s.
Procedure time in the first group was 52
+ 12 minutes, in the second group - 57 +
18 minutes. Lead dislodgment was
revealed in early postoperative period in 6
patients in the first group and in 5 patients
in the second. One exit block was seen in
non fluoroscopic group. All leads were
replaced successfully the next day. One
pneumothorax was seen in the first group
and treated by draining.
Conclusion: device implantation under
the intracardiac guidance is safe and
effective method. It helps to exclude
negative effects of fluoroscopy on patient
and physician. Intracardiac echo
visualization can be used to prevent
tricuspid valve damage.
53 - DOES INDEPENDENT CONDUCT OF
LIFE CHANGE AFTER OHCA: A LONG
TERM FOLLOW-UP INVESTIGATION
S. Amirie, M. Christ, M. Grett, H.-J. Trappe
Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University of Bochum,
Herne, GERMANY
Introduction: The survival rate of patients
after an out of hospital cardiac arrest
(OHCA) is low. The majority of the survivors
is reportedly discharged in a good
neurological condition. Nevertheless, data
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
54 - CARDIAC MAGNETIC RESONANCE
IMAGING IN A PATIENT IMPLANTED
WITH A MAGNETIC RESONANCECONDITIONAL IMPLANTABLE
CARDIOVERTER DEFIBRILLATOR WITH
CARDIAC RESYNCHRONIZATION
THERAPY
P. Gallo 1, S. Dellegrottaglie 1, A. Fiorentino
2
, N. Rovai 2, S. Pezzullo 1, A. Scatteia 1, C.E.
Pascale 1, P. Guarini 1
1
Divisione di Cardiologia, Clinica Villa dei Fiori,
Acerra (NA), ITALY, 2 Biotronik Italia Spa, Vimodrone (MI), ITALY
Background: Magnetic resonance (MR)conditional implantable cardioverter
defibrillators (ICDs) have been designed to
minimize the risk from MR imaging, but
there is still a lack of data on feasibility in
patients undergoing cardiac MR imaging.
Furthermore in patients receiving an ICD
with cardiac resynchronization therapy
(CRT-D) some concerns were raised about
potential artifacts generated by the left
ventricular lead.
Aims: Verify the diagnostic quality of
cardiac MR imaging performed in a patient
implanted with an MRI-conditional CRT-D
system.
Methods: A 64-year-old male with left
ventricular (LV) dysfunction (EF=32% by
cardiac MR imaging), normal coronary
artery, NYHA class II-III and LBBB (QRS =
140 ms) received an MR-conditional CRTD system (Biotronik Iforia 5 HF-T). After 3
months, the patient was re-admitted
suffering from a worsening clinical status
(III-IV NYHA). The patient was referred for
a new cardiac MR imaging.
Results: Cardiac MR study was performed
177
POSTER SESSION
of objective long-term follow-up
treatments are rare. We investigated how
many patients with OHCA require
assistance in everyday life in the longterm.
Methods: Every patient, who had been
hospitalized because of OHCA between
01/01/2008 and 30/06/2015 and was
discharged alive, was contacted between
01/11/2015 and 30/04/2016. They were
asked via a telephone interview about a
possible change of need for help in their
daily routine (e.g. nursing care 24h a day,
nursing service).
Results: From 280 affected patients 93
survived (33,2%) and were released out of
hospital. We contacted 51 patients
(average follow up time 38 months).
Meanwhile, 18 of them (35%) have died.
16 from the living 33 patients (31%) need
help in their daily routine. 11 patients
(21,6%) from those 16 need a 24h care.
Three patients (5%) need nursing services,
two (4%) are independent of nursing care,
but require constant help in their daily lives
due to i.e. lack of orientation. 11 from the
18 dead patients had also required special
care after OHCA.
Conclusions: The long-term survival rate
of OHCA is low. The numbers of a new
need for help after an OHCA are high. In
further research it should be looked at
whether the numbers could be reduced
through better rehabilitation and intense
ambulant medical treatment to help
minimize the need for nursing.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
POSTER SESSION
using a 1.5T whole body scanner. No
adverse effects were noticed during the
study and no malfunctions of the CRT-D
were detected at a post-study evaluation.
Image quality was adequate to allow
accurate functional assessment of the left
ventricle (EF=61%). Neither the right
ventricular lead (Biotronik Linox SmartPromri-S) nor the LV one (Biotronik
Sentus-ProMR-BP-L) did not generate
significant artifacts (Figure). A severe right
pleural effusion was considered to be
responsible of the current clinical status.
Conclusions: This is the first experience
of a cardiac MR scan performed in a
patient implanted with an MR-conditional
CRT-D, showing the preserved diagnostic
value of the acquired images.
55 - REQUIREMENT OF
CARDIOVERTER-DEFIBRILLATOR
FUNCTION IN ELDERLY PATIENTS FOR
CARDIAC RESYNCHRONIZATION
THERAPY IN JAPAN
K. Nakajima, T. Noda, T. Kamakura, M.
Wada, K. Ishibashi, Y. Inoue, K. Miyamoto,
H. Okamura, S. Nagase, T. Aiba, K. Kusano
National Cardiovascular Center, Osaka, JAPAN
Background: Requirement of cardioverter
defibrillator function in elderly patients for
cardiac resynchronization therapy (CRT) is
178
controversial in Japan.
Methods: Among our cohort of 260
patients with CRT capable of defibrillator
function (CRT-D) for primary prevention,
we selected 156 patients (age 61±14,
LVEF=28±9%) taking into consideration of
the contemporary device settings. We
divided the study subjects into two groups;
patients 75 years of age and more (Egroup: n=20) and patients less than 75
years old (Y-group: n=136) to investigate
subsequent arrhythmic events and devicerelated complications.
Results: During a median follow-up of
1045 days, Kaplan-Meier analysis
revealed that there were no significant
differences in both appropriate and
inappropriate device therapy between the
two groups (6/20 vs 47/136; log-rank
p=0.66 and 2/20 vs 6/136; log-rank
p=0.23, respectively). There were no
device-related infection but one
perioperative hematoma, and one
exacerbation of heart failure in E-group.
Conclusion: Cardioverter defibrillator
function can be required for some elderly
patients with CRT.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
Oita University - Department of Cardiology and
Clinical Examination, Yufu, JAPAN
Background: Spleen reserves monocytes,
which deploys to inflammatory site.
Recently, it has been reported that blocker prevents monocytosis observed in
the patients with myocardial infarction.
Monocytosis is also known to be observed
in chronic low-grade inflammatory state,
including chronic heart failure (CHF). CHF
also induces splenomegaly.
Objective: We tested the hypotheses that
the number of peripheral blood monocytes
and size of spleen at baseline could
predict the response to cardiac
resynchronization therapy (CRT).
Methods: From 2010, a total of 49
consecutive patients implanted with CRT
device were evaluated at baseline and 68 months later. The size of spleen was
evaluated at baseline by computed
tomography. Blood monocyte counts
(BMCs) were examined by blood test
apparatus.
Results: Patients were categorized as
responders (11 female, mean age
69.7±7.6 years, n=29) and nonresponders
(8 female, mean age 68.1±9.7 years,
n=20) according to echocardiographic
findings. In non-responders, spleen index
was also greater in non-responder than in
responder (4030±305 mm2 v.s.
3290±304 mm2; mean±S.E, P<0.05).
Median baseline BMC were significantly
smaller in responders than nonresponders (340 ± 122/µl vs. 539 ±
197/µl, p<0.01). In addition, Blood
monocyte count is positively correlated
with the spleen index (R2=0.132,
P=0.0060). Based on the receiveroperating characteristic curve, normal
BMC was set at <400/µl. Kaplan-Meier
survival analysis demonstrated that the
normal BMC patients had lower
prevalence of new hospitalization due to
HF progression (log rank 5.62, P=0.0178).
Conclusions: Our results demonstrated
that BMC and the size of spleen could be
the important determinant factors for
response to CRT.
57 - SHORT-TERM AVAILABILITY OF
VIABLE LEFT VENTRICULAR PACING
SITES WITH QUARTET QUADRIPOLAR
LEADS
H. Jin, W. Hua, M. Gu, H. Niu, C. Xue, S.
Zhang
The Cardiac Arrhythmia Center, Fuwai Hospital,
Beijing, CHINA
Background: Whether the quadripolar
leads can provide sufficient viable left
ventricular pacing sites (LVPSs) for device
optimization and multipoint pacing
remains unclear. This study aimed to
evaluate the acute and 3-month
availability of viable LVPSs provided by a
quadripolar LV pacing lead.
Methods and Results: A single-center
cohort study evaluated consecutive
patients who underwent a CRT implant
with the Quartet LV lead under local
179
POSTER SESSION
56 - BASELINE PERIPHERAL BLOOD
MONOCYTE COUNTS AND THE SIZE OF
SPLEEN PREDICT RESPONSE TO
CARDIAC RESYNCHRONIZATION
THERAPY IN PATIENTS WITH
ADVANCED HEART FAILURE
H. Kondo, K. Yufu, N. Takahashi
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
guidelines. The availability of viable LVPSs
was assessed at the pre-discharge and 3month follow-up visit. Bipolar lead
configurations, served as the control
group, were modeled by eliminating the
two proximal electrodes on the Quartet LV
lead. A total of 24 patients were enrolled
and finished 3-month follow-up. The mean
follow-up period was 93±3 days. At predischarge, the Quartet LV lead provided
more viable LVPSs compared with the
bipolar equivalents (median 3 [IQR 2–4] VS
median 2 [IQR 1–2], P<0.001). The
percentage of patients with at least 1, 2,
3, and 4 viable LVPSs were 100% (24/24),
91.7% (22/24), 58.3% (14/24) and 33.3%
(8/24) for Quartet leads and 91.7%
(22/24), 70.8% (17/24), 0% (0/24) and 0%
(0/24) for bipolar lead configurations,
respectively. The median and IQR values
of viable LVPSs provided by the Quartet LV
lead remained the same (3 [IQR 2–4])
between pre-discharge and 3-month
follow-up (P=0.45).
Conclusions: Compared with the bipolar
equivalent, Quartet LV lead provides more
viable LVPSs and opportunities for CRT
optimization and multipoint LV pacing. The
number of LVPSs provided by Quartet
leads remained unchanged between predischarge and 3-month follow-up.
180
58 - HIGH CAPTURE THRESHOLDS AND
PHRENIC NERVE STIMULATION
MANAGED NONINVASIVELY WITH
ELECTRICAL REPOSITIONING OF A
QUADRIPOLAR LEFT VENTRICULAR
LEAD
F. Notaristefano 1, G. Zingarini 2, A. Tordini 1,
F. Pagnotta 1, G. Ambrosio 1, C. Cavallini 2
1
University Hospital - Department of Cardiovascular Physiology and Pathophysiology, Perugia, ITALY, 2 Hospital of Perugia - Department
of Cardiology, Perugia, ITALY
High pacing thresholds of the left
ventricular lead and PNS are among the
commonest causes of non response. They
are usually managed with physically
reposition of the lead usually in a vein
other than the target affecting the results
of CRT. A patient with non ischaemic
cardiomyopathy underwent CRT-D. The EF
was 28%. EKG showed LBBB with a QRS
width of 200 ms (Figure 1) and first degree
AVB. A quadripolar left ventricular lead
(QuartetTM 1458Q-86 St. Jude Medical,
Sylmar, CA, US) was placed in a posterolateral vein. He was a responder with a EF
of 40% after 1 year. Then he had an acute
decompensated heart failure and the EKG
revealed a loss of biv pacing. For the
evidence of macrodislocation of the LV
lead it was physically repositioned. A
configuration unique to the LV quadripolar
lead (Mid 3 – Prox 4) was choosen
because of a low capture threshold (0,5 V
with 0,5 ms) and no PNS. After three
months we found again a loss of
biventricular pacing (Figure 2) and the
capture threshold for the Mid 3 – Prox 4
configuration raised four times. A macro
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
dislodgment was excluded. Because of
PNS some vectors were useless (Table 1).
Anyway thank to the quadripolar lead we
could pace from the Mid 3 – RV coil with
an acceptable capture threshold and
without PNS obtaining a good EKG result
with a QRS width of 160 ms (Figure 3) and
we avoided a second surgical reposition
procedure.
59 - DYNAMIC OPTIMIZING LEFT
VENTRICULAR PACING
CONFIGURATIONS WITH QUADRIPOLAR
LEADS IMPROVES RESPONSE TO
CARDIAC RESYNCHRONIZATION
THERAPY
M. Gu, W. Hua, X. Fan, L. Ding, C. Xue, H.
Jin, S. Zhang
quadripolar LV leads (QUAD) group or the
conventional bipolar leads (CONV) group.
In the QUAD group, optimization of LVPC
was performed for all patients before
discharge and for nonresponders at 3month follow-up. Clinical evaluations and
transthoracic echocardiograms were
performed before, 3- and 6 months after
CRT implantation.
Results: At 3-month follow-up, 16 of 25
(64%) patients in the CONV group (one
patient was lost to follow-up) and 18 of 26
(69%) patients in the QUAD group were
classified as responders (P = 0.69). After
optimizing the LVPCs in 3-month
nonresponders in QUAD group, 21 of 26
(80.8%) patients in the QUAD group were
classified as responders at 6 months as
compared with 17 of 25 (68%) patients in
the CONV group (P = 0.30). ESV reduction,
LVEF increase and NYHA functional class
reduction at 6 months were significantly
greater in the QUAD group than in the
CONV group (ESV: -26.9 ± 13.8 vs. -17.2
± 13.3%, P = 0.013; LVEF: +12.7 ± 8.0
vs. +7.8 ± 6.3 percentage points, P
=0.017; NYHA: -1.27 ± 0.67 vs. -0.72 ±
0.54 functional classes, P = 0.002).
Conclusion: Compared with conventional
The Cardiac Arrhythmia Center, Fuwai Hospital,
Beijing, CHINA
Aims: To investigate whether dynamic
optimizing left ventricular pacing
configurations (LVPC) with quadripolar
leads can improve response to cardiac
resynchronization therapy (CRT).
Methods: Fifty-two eligible patients were
enrolled and 1:1 randomized to either the
181
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
bipolar leads, CRT using quadripolar leads
with dynamic optimized LVPCs resulted in
an additional increase in LVEF and
reduction in ESV and NYHA functional
class at 6-month follow-up.
60 - BETA BLOCKERS IN HEART
FAILURE PATIENTS: DUAL CHAMBER
VS SINGLE CHAMBER ICD
M. Pinto, C. Mandurino, A. Gualano, A.
Guido, L. Sgarra, M. Anaclerio, G. Luzzi,
F. Nacci, R. Memeo, V. E. Santobuono,
P. Palmisano, S. Favale
POSTER SESSION
AOU Policlinico di Bari D.E.T.O. UO Cardiologia
Universitaria, Bari, ITALY
Background: The choice of a single
chamber (S) or a dual chamber (D) ICD in
heart failure (HF) patients in sinus rhythm
(SR) is often controversial. Beta-blockers
(BB) dosage-regimen optimization may be
limited by poor tolerated sinus
bradycardia. In these cases, atrial pacing
may be useful; on the contrary, S devices
may allow either a frequent right
ventricular pacing (RVP) or non optimal BB
dosages.
Objectives: Aim of the study was to
evaluate if, in HF patients, there is a
difference in BB dosages between S-ICD
and D-ICD recipients.
Materials and methods: 97 HF patients
in SR were enrolled. ICD were
programmed as follows: D-ICD – AAI/DDD
mode, lower rate 60/m’; S-ICD – VVI
mode, lower rate: 60/m’: 6%, 50/m’: 39%,
40/m’: 54%.
Results: 33 patients had S-ICD and 64
had D-ICD. No clinical differences between
the two groups were found. Mean
182
carvedilol dosage was 27±18 mg (D) and
20±19 mg (S) (p=0,05); mean bisoprolol
dosage was 5,3±3,5 mg (D) and 4,5±2,8
mg (S) (p=NS); mean metoprolol dosage
was 164±67 mg (D) and 125±69 mg (S)
(p=NS). BB up-titration was completed in
39% of D group and in 21% of S group
(p=0.05). RVP percentage was 2.7±9% in
D group and 5.7±12.5% in S group.
Conclusions: In one center evaluation, SICD patients assumed lower doses of BB
than D-ICD patients, without significant
difference in clinical characteristics.
Further studies on larger groups of
patients are needed to achieve a better
choice of the type of device and an optimal
BB up-titration.
61 - ADDITIONAL CLINICAL BENEFIT
OF MULTIPOINT LEFT-VENTRICULAR
PACING IN PATIENTS NOT MEETING
STRICT CRITERIA FOR LEFT BUNDLE
BRANCH BLOCK
S. Ventresca 1, G. Panattoni 1, F. Condemi 1,
D.G. Della Rocca 1, V. Ribatti 1, G. D’Ascoli 1,
G. Magliano 1, A. Capria 2, D. Sergi 1, M.
Borzi 1, L. Santini 3, G.B. Forleo 1, F. Romeo 1
1
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 University of
Rome Tor Vergata - Department of Internal Medicine, Rome, ITALY, 3 Ospedale G.B. Grassi Department of Cardiology, Ostia-RM, ITALY
Background: Cardiac resynchronization
therapy (CRT) has shown to be an effective
additional therapy in patients with heart
failure associated with severely impaired
left ventricular (LV) systolic function and
left bundle branch block (LBBB). However,
after application of the current selection
criteria, a substantial percentage of
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
62 - REDUCTION OF SUSTAINED
VENTRICULAR TACHYARRHYTHMIAS
AMONG CRT RECIPIENTS: DOES IT
DEPEND ON TRUE LEFT BUNDLE
BRANCH BLOCK?
M. Grett, H.J. Trappe
Marien Hospital Herne - Cardiology - Ruhr
University Bochum, Herne, GERMANY
Background: A retrospective analysis of
the MADIT-CRT trial demonstrated the best
reduction of sustained ventricular
tachyarrhythmias (SVTA) among CRT
recipients with good echocardiographic
response. There is ongoing discussion,
whether the definition of left bundle
branch block (LBBB) should be more
strictly in the era of CRT as patients (pts)
with LBBB have the highest chance of
benefit from CRT. We tried to figure out if
pts with “true” LBBB as defined by the
methods of the modified Selvester ECGscore (MSES) have lower rates of SVTA.
Methods: We performed a retrospective
analysis of 146 pts with primary
prophylactic CRT-D and complete follow
up over a 2 years period. MSES applied to
all pre-implant ECG. The endpoint was a
first ICD-therapy for SVTA.
Results: 104 pts fulfilled the criteria of
true LBBB, 42 had other reasons for QRS
prolongation. 14/104 (13,5%) pts with and
9/42 (21,4%) without true LBBB suffered
an ICD-therapy within the 2 years. This
correlates with a relative risk of 2.17 (95%
CI 1.01 to 4.66, p=0.046) for a first ICDtherapy in pts without true LBBB. The rates
of ICD-therapy are comparable to those
found in MADIT-CRT: ICD-only patients
21%, good responders to CRT-D 12%
Conclusion: The causal chain for a benefit
183
POSTER SESSION
patients do not benefit from CRT. Recent
studies suggest that multipoint LV pacing
(MPP) via a LV quadripolar lead, could
provide an alternative approach to improve
CRT response.
The aim of the study was to evaluate the
additional clinical benefit conferred by
MPP in CRT patients not meeting strict
criteria for LBBB.
Methods: We enrolled 12 CRT patients
implanted with a quadripolar LV lead: the
cohort was 80% male, ages ranged from
43 to 85 years. All these patients did not
meet strict criteria for LBBB.
Patients were randomized to receive either
standard biventricular pacing (MPP-OFF)
or MPP (MPP-ON) within 4-6 months
following the implantation procedure. After
3 months each subject was crossed over
to the other study group. We examined NTproBNP at baseline evaluation, before
randomization, and repeated at the end of
each three month crossover period.
Results: After MPP-ON period, levels of
NT-proBNP were reduced, compared to
data acquired at baseline (Delta NTproBNPMPP ON: -741,8±1992,7); on the
contrary, we observed an increase of NTproBNP value compared to baseline after
the MPP-OFF period (Delta NT-proBNP
MPP OFF: 1087,9±3862,8) (p = 0,2).
Conclusion: Regarding our experience, in
patients not meeting strict criteria for left
bundle branch block, multipoint leftventricular pacing seems to improve
hemodynamic response.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
from
CRT
(improvement
of
echocardiographic measurements and
reduction of SVTA) might start with a true
LBBB pattern.
63 - DOES ELECTRICAL REMODELING
OCCUR IN LONG-TERM CARDIAC
RESYNCHRONIZATION THERAPY
PATIENTS?
M. Arafat, J. Antonio, L. Di Biase, E. Palma
POSTER SESSION
Albert Einstein College of Medicine, Department of Medicine (Cardiology), New York, USA
Introduction: Although mechanical
remodeling has been well documented in
Cardiac Resynchronization Therapy (CRT)
patients, data on electrical remodeling,
defined as a change in the intrinsic QRS
width, is controversial. Studies with a
maximum follow-up of 1 year have shown
opposing results.
The aim of this study was to determine if
electrical remodeling occurs in CRT
patients implanted for more than 1 year,
and if this corresponds to mechanical
remodeling.
Methods: Consecutive CRT patients were
enrolled into the study during routine
follow-up. An ECG was performed with
CRT pacing inhibited to measure native
electrical conduction. Baseline patient
characteristics were obtained including
pre-implantation QRS width and
morphology, and left ventricular ejection
fraction (LVEF).
Patients were stratified into two groups,
CRT responders and CRT non-responders.
Responders were defined as patients with
an LVEF increase of at least 10%. In each
group, intrinsic QRS width of pre-CRT and
184
post-CRT was compared using a paired
Student’s t-test.
Result: 49 patients were enrolled with a
mean follow-up of 5.4±3.2 years, of which
24 were CRT responders and 25 were
non-responders. There were 28 males and
21 females. Baseline and follow-up
intrinsic QRS durations for responders
were, respectively, 158.1±20.4ms and
149.4±18.8ms (p<0.01), with a change in
LVEF of 22.5±9.3%. While, baseline and
follow-up intrinsic QRS width for nonresponders
were,
respectively,
153.8±23.6ms and 155.6±22.0ms
(p=0.73) with a change in LVEF of 1.4±7.2%.
Conclusion: Even up to 5 years, electrical
remodeling occurred only minimally in
patients who were responders. Electrical
remodeling did not occur in patients who
were non-responders.
64 - HOME MONITORING
IMPLANTABLE DEVICES IN HEART
FAILURE PATIENTS: SINGLE CENTRE
EXPERIENCE AND ECONOMIC
ANALYSIS
L. Striuli, B. Breggion, C. Martina, C. Talini,
L. Puricelli, M. D’Urbano, D. Spaziani
Ospedale Fornaroli, Magenta, ITALY
We analyzed 161 heart failure patients
implanted with wireless transmissionenabled ICD/CRT-D and we followed them
with remote monitoring for a mean time of
26 months.
We had 1017 scheduled transmissions
(ST). In 33 cases we performed an inoffice visit after the transmission with a
cost of 783.75 € for the health care
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
65 - ULTRASOUND-GUIDED VENOUS
ACCESS FOR PACEMAKERS AND
DEFIBRILLATORS. RANDOMIZED TRIAL
M. Liccardo 1, P. Nocerino 1, A. Borrino 1, C.
Carbone 1, G. Salzano 2
1
Ospedale Santa Maria delle Grazie, Naples,
ITALY, 2 Boston Scientific, Milan, ITALY
With the increase in the number of
installations of systems used for cardiac
resynchronization and then with the
increasingly growing need to insert three
leads, one of which often defibrillation, is
becoming more urgent the need for an
approach to a large vein such as the
subclavian vein.
In recent years interesting and proves to
be studied is the approach to the axillary
vein (extrathoracic subclavian vein)
presenting the advantage of less risk of
pneumothorax, not to present a risk of
breakage of leads, it can be used for the
implantation of more leads, but it has the
disadvantage of a low success rate when
using the traditional approach.
In the light of increasingly stringent
recommendations of companies of
anesthesiology and intensive care units to
use approaches vascular eco-guided we
wanted to evaluate the safety and efficacy
approach to the axillary vein. After a
learning period of the echo-guided
technique were enrolled 90 patients in
which consecutive, randomly 1:1, was
chosen the initial approach (echo or
subclavian).
If in a maximum time of 5 minutes the first
approach failed in the cannulation is
passed to the second approach. The
proposed technique appears to be
185
POSTER SESSION
system (23.75 €/visit). In 58 cases only a
phone call was performed by nurse. No
action was required in 976 cases.
We observed 908 unscheduledtransmissions (UST) related to atrial
fibrillation
(16%),
ventricular
tachycardia/fibrillation (15%), heart failure
alarms (9%), device problems (16%), low
biventricular pacing (9%). They required
86 in-office visits for checking patient’s
status or reprogramming device, with a
cost of 2042 €.
We think that standard FU would bring to
emergency department about 10% of
patients after UST with hypothetical cost
for health care system 21791 €. In case of
standard follow up (2 in-office visits/year)
we would have been only 688 scheduled
follow up in our population with a cost of
16349 €. This should be added to the cost
of hypothesized ED visits for a total of
38.141 €.
It took 201 hours to screen all
transmissions by a trained nurse (5
minutes/transmission). Physician attended
in-office visits requiring 39 hours of work
(20 minutes/visit). In standard follow up
nurse and physician are both employed for
229 hours.
Remote monitoring in heart failure patients
is cost-effective, time saving and improves
the patient’s quality of life compared to
standard follow up. We think its use will
grow.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
effective and safe as the classical
technique for subclavian, also presents the
advantage of being free from risk of
pneumothorax and breaking of leads.
Ratings on a follow-up in the medium and
long term are in place to assess their
reliability.
Studies with an adequate number of
patients would be desirable to confirm our
preliminary results.
POSTER SESSION
66 - EXCLUSIVELY CEPHALIC VENOUS
ACCESS FOR CARDIAC
RESYNCHRONISATION DEVICE
IMPLANTATION; A MULTI-CENTRE
EXPERIENCE
I. Harding 1, J. Lalor 1, I. Beeton 2, Z. Zuberi 3,
A. Bajpai 1, A. Li 1, B. Ussen 2, M. Sohal 1,
Z. Chen 1, P. Dhillon 1, M. Gallagher 1
1
St. Georges Hospital, London, UNITED KINGDOM, 2 St. Peters Hospital, Chertsey, UNITED
KINGDOM, 3 Royal Surrey Hospital, Guildford,
UNITED KINGDOM
Aims: We have previously shown in a
single operator series that cardiac
resynchronization therapy can be
achieved in a majority of patients using
exclusively cephalic venous access. We
sought to determine whether this method
is suitable for widespread use.
Methods: A group of 17 operators
including 9 trainees in 3 neighbouring
pacing centres attempted to use cephalic
access alone for all CRT device implants
over a period of 7 years.
Results: We analysed the results of
procedures involving a new implantation
of a CRT device performed by the
participating cardiologists in 714 patients
(72% male) aged 68±17 years.
186
Implantation was achieved using cephalic
venous access alone in 561/714 cases
(79%) and by a combination of cephalic
and other access in a further 59 cases
(8.2%). In each of 5 of the operators
responsible for a total of 436 cases, the
rate of success using cephalic access
alone exceeded 90%. Of the 2079 pacing
leads implanted in the patient group, 1726
(83%) were implanted via the cephalic
vein. No pneumothorax or haemothorax
occurred. Pericardial tamponade occurred
in 2 cases (0.3%).
Conclusion: CRT devices can be
implanted using cephalic access alone in
a substantial majority of cases by
operators possessing a range of
experience. This approach is safe and
efficient.
67- SUPERIOR VENA CAVA SYNDROME
AS RARE COMPLICATIONS IN YOUNG
PATIENT WITH DUAL CHAMBER
PACEMAKER IMPLANTED FOR
COMPLETE ATRIOVENTRICULAR BLOCK
F. Melandri, G. Lolli, M. Scapinelli, E. Leci
U.O. Cardiologia, Sassuolo, ITALY
Thrombosis in the area of the leads is a
known complication in patients with
device.
We report the case of a 25 years old
patient with a dual chamber pacemaker
implanted in 2010 due to complete,
congenital and symptomatic atrioventricular block, with insertion of
intravenous leads with axillary approach
and with a sub-axillary pocket. Since
December 2015 the patient has
experienced the onset of abdominal
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
portal hypertension by catheterization of
the hepatic veins. Which therapeutic
strategy we can offer the patient?
• Long time anticoagulation therapy?
• Cardiac intervention recanalization of
the superior vena cava?
• Attempted venoplastica percutaneous?
68 - IMPLANTATION OF PERMANENT
PACEMAKER IN A PATIENT WITH LSVC
J. Sanyal
Neotia Getwel Healthcare Centre, Siliguri, INDIA
65 year old male patient with a habit of
smoking having congestive obstructive
pulmonary
disorder,
hypertension
presented with syncope. ECG showed
complete AV block. The echo report was
normal. The patient was referred for a
single chamber pacemaker implant.
To select the implant pathway the left
subclavian dye shoot was taken. The
fluoroscopic image showed LSVC to CS.
To explore an alternate path, an angio
shoot was taken from the right side as
well. Incidentally it also showed RSVC to
LSVC to CS. Based on the anatomy, the left
side was chosen for the implant.
Medtronic 5076 active fixation lead was
selected to ensure chronic stability. The
lead was navigated through LSVC to CS to
RA to RV via tricuspid valve. The lead was
manipulated by stylets of various shapes
and curves. The final pathway also
ensured higher stability for the lead.
The thresholds and sensing parameters for
the chosen implant site were tested and
found to be satisfactory.
187
POSTER SESSION
swelling, peripheral edema, weight gain
and right subcostal pain.
it was found clinical signs compatible with
congestive heart failure; echocardiogram
confirmed the absence of significant
changes .The total body CT scan showed
an important pleural and abdominal
effusion, the recanalization of the azygos
veins and hepatic congestion, but with
portal system within the limits.
The clinical situation has clearly improved
after diuretic therapy and the beginning of
anticoagulation dose of heparin but after
one week the patient was readmitted due
to the reappearance of signs of peripheral
congestion.
To deepen the diagnostic test, a
venography was performed in the superior
and inferior vena cava, observing the
complete occlusion of the superior vena
cava and the left anonymous trunk, with
severe dilation of the azygos system with
drains partially the superior caval circle in
the inferior vena cava. It was also
observed normal venography of the
hepatic veins and the absence of signs of
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
69 - CHRONIC TOTAL OCCLUSION IN
AN INFARCT RELATED ARTERY: A NEW
PREDICTOR OF VENTRICULAR
ARRHYTHMIAS IN PATIENTS WITH
IMPLANTABLE CARDIOVERTER
DEFIBRILLATORS.
I. Anguera, A. Di Marco, L. Teruel, P. Dallaglio,
J. Gomez-Hospital, A. Cequier
Bellvitge University Hospital, Barcelona, SPAIN
Background: Recent evidences suggest a
pro-arrhythmic effect of a coronary
chronic total occlusion (CTO), especially
when associated with a myocardial
infarction in its territory (IRA-CTO, i.e.
Infarct Related Artery-CTO).
Purpose: To evaluate the impact of an
IRA-CTO on the occurrence of ventricular
arrhythmias (VA) in a broad population of
ICD patients.
Methods: Observational study of all
consecutive ICD patients with ischemic
cardiomyopathy and a coronary
angiography before ICD implantation. Fast
ventricular tachycardia (VT) was defined
as a VT with a CL <300ms.
188
Results: 243 patients were included, 110
(45%) had a primary prevention ICD. 116
(48%) had an IRA-CTO. Patients with a
secondary prevention ICD had higher
prevalence of IRA-CTO (69% vs 31%,
p<0.001). During a median follow up of 39
months (IQR 17-68), 119 patients (49%)
had at least one episode of VA correctly
treated by the ICD. IRA-CTO was
associated with higher rates of any VA
(67% vs 32%, p<0.001), fast VT/VF (41%
vs 16%, p<0.001) and appropriate ICD
discharges (49% vs 20%, p<0.001). At
multivariate Cox regression, IRA-CTO was
the strongest independent predictor of VA
(HR 2.62;95%CI 1.73-3.96, p<0.001) and
fast VT/VF (HR 2.82;95%CI 1.59-5,
p<0.001). IRA-CTO was not a predictor of
total mortality (HR 1.5;95%CI 0.91-2.7,
p=0.11).
Conclusions: In ischemic patients
implanted with an ICD, a coronary chronic
total occlusion associated with a previous
infarction in its territory (IRA-CTO) is an
independent predictor of any VA (both fast
VT/VF) and identifies a subgroup of
patients with a very high incidence of
arrhythmic events at follow up.
70 - EFFICACY OF ANTITACHYCARDIA
PACING FOR VENTRICULAR
TACHYCARDIA IN PATIENTS WITH
HYPERTROPHIC CARDIOMYOPATHY
I. Anguera, P. Dallaglio, A. Di Marco, L. Perez,
J. Alzueta, A. Garcia-Alberola, I. FernandezLozano, E. Diaz-Infante, A. Rodriguez, N.
Basterra, D. Calvo, J. Martinez-Ferrer
Bellvitge University Hospital, Barcelona, SPAIN
Background: Antitachycardia pacing (ATP)
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
71 - CLINICAL IMPACT OF
CONCOMITANT IMPLANTABLE SHOCK
DEVICE IN PATIENTS WITH LEFT
VENTRICULAR ASSIST DEVICE
M. Maruyama 1, T. Noda 2, T. Kamakura 2,
M. Wada 2, K. Ishibashi 2, Y. Inoue 2, K.
Miyamoto 2, H. Okamura 2, S. Nagase 2, T.
Aiba 2, S. Kamakura 2, S. Yasuda 2, H
Ogawa 2, T Kurita 1, K Kusano 2
1
Kindai University, Osaka, JAPAN, 2 National
Cerebral and Cardiovascular Center, Osaka,
JAPAN
Background: The role of implantable
shock devices (ICD/CRT-D) in patients with
left ventricular assist device (LVAD)
remains unclear.
Methods: 143 consecutive patients (111
males, 37±13 years) undergoing
implantation of LVAD between January
2002 and December 2014 were
retrospectively investigated. We divided
the study subjects into two groups;
patients with shock device (D-group:
n=54) and patients without shock device
(ND-group: n=89) to clarify the incidence
of subsequent ventricular arrhythmias
(VTAs) and those effects on prognosis.
Results: The clinical background of two
groups are shown in Table. During a
median follow-up period of 846 days,
Kaplan-Meier analysis revealed that the
incidence of VTAs events was significantly
higher in D-group than in ND-group (18/54
vs 11/89; log-rank p=0.003, Figure 1).
However, there was no significant
difference in the cumulative probability of
death between the two groups (10/54 vs
21/89; log-rank p=0.38, Figure 2)
Conclusion: Concomitant ICD/CRT-D in
LAVD patients may not reduce mortality.
189
POSTER SESSION
is highly effective in terminating
ventricular tachycardia (VT) in patients
with ICDs. In patients with hypertrophic
cardiomyopathy (HCM), ATP therapy is
seldom used because the role of ATP in
terminating monomorphic VT (MVT) in
these patients is unknown.
Purpose: The aim of our study was to
analyze ATP effectiveness in a nonselected population of high-risk HCM
patients treated with ICD.
Methods: We analyzed data from the
UMBRELLA trial, a multicenter prospective
observational study including ICD patients
followed by remote monitoring.
Results: A total of 187 patients with HCM
treated with ICD were identified, 139
primary prevention patients (74.3%). Mean
age was 55 ± 18 and 34 patients were
male (87%). Over a mean follow-up of
37±22 months, 163 episodes of MVT were
recorded. Median CL of MVT was 320 ms
(IQR 280-350) and 101 episodes (62%) CL
was <320 ms. The 1st burst of ATP was
effective in 99 of 112 episodes (88.4%), a
2nd burst of ATP was effective in 13 of 24
(54.2%) episodes and 3 or more bursts
were effective in 9 of 24 (37,5%) episodes,
resulting in an overall effectiveness of ATP
for MVT of 74.2% (121 out of 163
episodes). ATP was effective in 46 of 63
(73%) episodes with CL>320 ms and in 75
of 100 (75%) with CL< 320 ms. Shocks
were required in 27 (16.6%) episodes.
Conclusion: In patients with HCM treated
with ICD, ATP therapy is highly effective in
terminating the majority of MVT episodes.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
72 - COMPETITIVE PACING IN DUAL
CHAMBER ICD DURING VENTRICULAR
EXTRASYSTOLES: MALFUNCTION OR
NOT?
A. Coppolino, L. Valeri, G. Amoroso, G. Bricco,
E. Cavallero, C. Iacovino, D. Pancaldo,
L. Correndo, A. Battisti, A. Magliarditi, M. De
Benedictis, S. Dogliani, A. Bassignana, B.
Doronzo
ASL CN1 SC Cardiologia Ospedale Ss.
Annunziata, Savigliano, ITALY
The ecg interpretation in patients with
pacemaker and icd requires specific
knowledge about the functional
mechanism of these devices. In fact a
suspected malfunction can be excluded by
correct valuation of the intervals
programmed. Moreover an “ ad hoc”
programmation, based on patient
peculiarities, allows to avoid the
competitive pacing that can be potentially
dangerous.
A young patient affected by dilated
cardiomyopathy was referred to the
hospital because of appropriated icd
shocks and syncope. Device was a dual
chamber (DDD) icd. During initial ecg
monitoring it was noted a variable
190
response of the pacing system to
ventricular extrasystoles, dependent on
the coupling interval of premature beats.
For relatively short coupling interval the
premature spontaneous event was
detected by icd with inhibition of the atrial
and ventricular pacing.
In contrast, for relatively long coupling, the
pacing system delivered the atrial spike
following by the ventricular spike at the
end of the programmed atrioventricular
interval. The ventricular spike occurred on
extra systolic T wave with consequent
competitive pacing and potential
proarrhitmic effect.
This behavior, suspected to be a sensing
malfunction, disappeared after shortening
of the post atrial ventricular blanking
(PAVB) that is a brief period during which
the ventricle sensing is disabled to protect
it by crosstalk.
This case shows that the presence of non
sensed ventricular extrasystole doesn’t
mean the presence of sensing
malfunction. A specific knowledge of
pacing mechanism and a correct device
programmation can help to escape the
proarrhytmic effect of the competitive
pacing.
73 - PACING-QRS DURATION
REGARDLESS OF PACING-SITE IS A
MAJOR DETERMINANT FOR
OCCURRENCE OF PACING-INDUCED
CARDIOMYOPATHY IN THE COMPLETE
AV BLOCK FOR 15 YEARS FOLLOW-UP
K. Kang 1, J. Kim 2, J. Chin 1, J. Park 2
1
Eulji University Hospital, Deajeon, SOUTH
KOREA, 2 Chungnam National University, Deqjeon, SOUTH KOREA
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
of 52%. Cox analysis showed that p-QRS
duration was hazard ratio (HR) =1.04,
confidence interval (CI) =1.02-1.06,
p<0.001.
Conclusions: Our long-term retrospective
analysis found that post-implant p-QRS
duration regardless of pacing-site was
associated with greater risk for PICMP.
74 - OUR EXPERIENCE WITH LEADLESS
PACING
J. Simon
Na Homolce Hospital, Prague, CZECH REPUBLIC
Objectives: To develop a leadless
pacemaker (LPP) based on induction
technology..
Background: Standard cardiac pacing
(CP) is still associated with a high
complication rate,primarily attributed to
the leads.
Methods: The LPP is a single VVIR
pacemaker.It is introduced into the right
ventricle via the femoral vein using a
controllable catheter. The Nanostim (N)
LPP system has a fixing srew. The Micra
(M) system uses atraumatic flexfix nitinol
191
POSTER SESSION
Purpose: The risk factor of pacinginduced cardiomyopathy (PICMP) was still
controversial in the complete AV block
(CAVB) who undertaken with permanent
pacemaker (PPM). Our objective was to
investigate clinical risk factor for PICMP in
the PPM with CAVB during 15 years
follow-up.
Methods: We reviewed retrospective
cohort of consecutive patients with PPM
who had CAVB in Chung-Nam National and
Eulji University Hospital, DeajeonChungcheong Province, South Korea from
Dec 2001 to Aug 2015. Total 130 CAVB
with PPM (>90% chronic pacing) that also
undertaken ECG, echocardiogram,
medication and laboratory data in the
before and after PPM implant were
analyzed. The data including cardiac
events were collected and compared
between non-PICMP and PICMP group
from index pacemaker implant during
follow-up 15 years.
Results: Total 15.3% (n=20) PICMP
among all patients was found. The average
age (74±11 vs. 76±11), the proportion of
sex (35.5% vs. 30.0%), ischemic heart
disease (10.9% vs. 15.0%), pre-implant
ejection fraction (66±9% vs. 66±8%),
septal pacing (38.8% vs. 40.7) and postimplant p-QRS axis (2±78° vs. -3±90°)
were similar between two groups. Preimplant QRS duration (123±34ms vs.
147±32ms) and post-implant p-QRS
duration (138±29ms vs. 164±27ms) were
significantly different between two groups.
ROC curve showed that above p-QRS
duration 146ms is cut-off value for PICMP
with the sensitivity of 85% and specificity
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
tines. After introducing the device into the
apex of the right ventricle, the parameters
are tested, the device is fixed in place and
then released from the catheter.
Results: Since 2012, we have implanted
a total of 146 leadless pacemakers. LPP
(N) was used in 101 patients (F 41,M 60)
and LPP (M) in 45 patients (F 25,M 20). 2
women died at the ages of 87 and 90. 1
man died of sepsis and second of cancer.
In addition to the normal indications for
permanent pacing, 5 patients were
indicated for LPP due to infection
complications with standard cardiac
pacing. One case was the patient´s´
request and in one case there was no
possibility of entry into the right ventrckle
using a conventional lead. There was a
surgical complication in one patient. The
fixation system had already been released
and the device then dislocated into the left
ventricle through the foramen ovale. One
patient recorded high pacing thresholds.
Pacing thresholds in this group were from
0.4-0.8V/040ms,R wave 8-10 mV. The
battery capacity is estimated 10 years.
Conclusions: The LPP is a good
alternative to (CP).
75 - IMPLANTATION OF THE WICS
LEADLESS CRT SYSTEM USING PREPROCEDURAL STRAIN
ECHOCARDIOGRAPHY TO DETERMINE
OPTIMAL ENDOCARDIAL LV
ELECTRODE POSITION
D. Twomey, D. Thomas, E. Beaney, J.
Ainsworth, A. Owens, A. Turley, S. James
Division of Cardiothoracic Services, James
Cook University Hospital, Middleborough,
UNITED KINGDOM
192
Introduction: Endocardial LV pacing is a
viable option for CRT where CS pacing is
not possible. The WiCS LV system (EBR
systems) is a leadless ultrasound-based
electrode that can be implanted in any LV
region. We report outcomes following the
use of strain echocardiography to
determine optimal implantation site.
Methods:
Seven
patients
with
symptomatic heart failure, prolonged QRS
duration and failed CS lead placement
(n=5), post-CS lead extraction (n=1) or CS
atresia (n=1) were studied. Pre-procedural
speckle-tracking strain echocardiography
performed during RV pacing was used to
measure latest mechanical activation and
determine optimal LV electrode placement.
QRS duration, NYHA grade, QoL, 6MWT
and strain echocardiography were
assessed at baseline and one month postprocedure.
Results: Electrodes were positioned at the
site of latest mechanical activation in 5/7
(71%) patients and in an adjacent
segment in 2/7. QRS duration was
reduced in all patients (164±14 vs
118±24ms, p=0.0005) and dP/dT
increased
significantly
following
implantation (1009±168 vs 1226±202,
p=0.047). At one month, NYHA grade
improved in 5/7 (71%) patients,
associated with significant improvements
in 6MWT (279±76 vs 296±87m, p=0.049)
and QoL (50±21 vs 37±25, p=0.03).
Echocardiographic
assessment
demonstrated significant improvement in
EF (38±4 vs 47±8%, p=0.01) and strain
dyssynchrony (92±53 vs 40±60ms,
p=0.006) along with reduced LVESV
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
(73±12 vs 55±7ml, p=0.001).
Conclusion: Endocardial leadless LV
pacing is feasible and effective in patients
with no option for CS pacing.
Echocardiographic strain may have a
potential role in determining optimal LV
electrode placement; we demonstrated
significant improvements in symptoms
and dyssynchrony after only 1 month.
76 - PROCEDURE TIME, FLUOROSCOPY
TIME AND DEPLOYMENT RATE IN
LEADLESS CARDIAC PACEMAKER
IMPLANTATION: A TWO-YEAR SINGLECENTER EXPERIENCE
S. Schwarz, C. Steinwender, K. Saleh, J.
Kammler, H. Blessberger, T. Lambert, S.
Hönig, D. Kiblböck, A. Nahler, J. Kellermair,
C. Reiter, A. Kypta
Kepler University Hospital - Department of
Cardiology, Linz, AUSTRIA
Introduction:
Leadless
cardiac
pacemaker (LCP) implantation represents
a novel technique when it comes to
vascular access via large-caliber venous
introducer sheaths, handling with the
delivery system and deployment of the
pacemaker itself. Procedure and
fluoroscopy time as well as the
deployment rate were evaluated to specify
the expected learning curve.
Methods: Between December 2013 and
February 2016, a Micra™ Transcatheter
Pacing System (Medtronic Inc.,
Minneapolis, MN, USA) was implanted in
eighty-four patients. The two operators
were selected via assessment center and
trained on animal models. Our cohort was
divided chronologically into four equal
groups to compare differences between
groups over time.
Results: Mean procedure time was 43.4
± 16.1 (group 1), 35.2 ± 12.1 (group 2),
41.8 ± 22.9 (group 3) and 36.6 ± 14.8
(group 4) minutes with a mean fluoroscopy
time of 8.2 ± 6.4, 6.0 ± 4.4, 7.5 ± 6.0 and
7.2 ± 4.4 minutes, respectively. KruskalWallis test showed no statistical
significance between groups, neither for
procedure time (p = 0.170) nor for
fluoroscopy time (p = 0.243). This finding
also applied to the deployment rate (p =
0.756), though interprocedural fluctuation
range was high, ranging from one to
twenty attempts. Mean deployment rate in
the four groups was 1.9 ± 1.9, 2.0 ± 1.7,
2.8 ± 4.1 and 1.9 ± 1.8.
Discussion: The absence of the expected
learning curve seems to have
multifactorial causes. In our interpretation,
a high-level operator experience plus the
technical concept and practicability of the
Micra™ TPS are the main contributing
factors.
193
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
77 - SUBCUTANEOUS ABSORBABLE
DOUBLE PURSE-STRING SUTURE FOR
FEMORAL VEIN ACCESS SITE CLOSURE
IN LEADLESS CARDIAC PACEMAKER
IMPLANTATION
S. Schwarz, A. Kypta, K. Saleh, H. Blessberger,
J. Kammler, S. Hönig, T. Lambert, J.
Kellermair, D. Kiblböck, C. Reiter, A. Nahler, C.
Steinwender
Kepler University Hospital - Department of
Cardiology, Linz, AUSTRIA
Background:
Leadless
cardiac
pacemakers (LCP) require large-caliber
venous introducer sheaths for device
placement. The sheath size of the Micra™
Transcatheter Pacing System (Medtronic
Inc., Minneapolis, MN, USA) is 23 French
(F) inner diameter and 27 F outer diameter.
Common access site complications are
hematomas, pseudoaneurysms and
arterio-venous fistulas. Complete and
secure closure of the venous access site
is an important step at the end of the
procedure.
Methods: After venous puncture and skin
incision, two subcutaneous purse-string
sutures were prepared for groin closure,
using Novosyn® 3.0 (B. Braun Melsungen
194
AG, Melsungen, Germany), a mediumterm absorbable suture consisting of
Polyglactin 910. Groin complications were
evaluated during hospital stay, after four
weeks and three months.
Results: Between December 2013 and
February 2016, eighty-three patients
received a LCP. In 29 (34.9%) patients an
unfractionated heparin bolus (UFH 4362 ±
1109 units) was given at the beginning of
the procedure. 23 (27.7%) patients were
on phenprocoumon in therapeutic range
(INR 2.14 ± 0.41) and 10 (12%) patients
on phenprocoumon not in therapeutic
range (INR 1.84 ± 0.32). Access site
complications occurred in three (3.6%)
patients, two (2.4%) groin hematomas and
one (1.2%) arterio-venous fistula. After
four weeks, both hematomas resolved
spontaneously and the fistula was not
detectable by ultrasound anymore.
Conclusion: Subcutaneous absorbable
double purse-string suture closure is a
simple, safe and cost-effective method to
achieve appropriate hemostasis after
removal of large-caliber venous sheaths
as used in LCP implantation.
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
1
Department of Internal Medicine, Division of
Cardiology, University of Rome Tor Vergata,
Rome, ITALY, 2 Department of Internal Medicine,
Division of Cardiology, G.B. Grassi Hospital,
Rome, ITALY
Introduction: Implantable cardioverter
defibrillators (ICDs), introduced in clinical
practice in 1980,proved to reduce
arrhythmic mortality in patient at risk of
sudden cardiac death. However, ICDs are
also associated with acute procedurerelated complications and longer term
complications. Recently, an entirely
subcutaneous ICD (s-ICD) system has
entered in clinical practice. This system
detects and treats ventricular tachycardia
(VT) and ventricular fibrillation (VF) without
the use of transvenous lead.
Methods: In these case series, we report
on feasibility and safety of s-ICD in young
patients. The first case was a patient with
a history of alcoholic dilated
cardiomyopathy already submitted to ICD
implantation and with subsequent ICD
pocket infection and related right side
endocarditis. We perform a complete
device removal and the implantation of sICD to avoid reinfection and endocarditis
recurrence. The same strategy was used
in a patient affected by ischemic dilated
cardiomyopathy with ICD pocket infection
and history of deep venous thrombosis.
The device was also implanted in other
two young patients: one affected by dilated
cardiomyopathy caused by H1N1 related
myocarditis,the other by idiopathic dilated
cardiomyopathy (in the list at the
transplant center). Consecutive follow-up
have been performed.
Results and conclusions: Absence of
arrhythmic events or delivered shocks and
good acceptance of the s-ICD have been
assessed. The s-ICD could constitute the
gold standard for young patients with
pocket infection history and with no
venous access. Young patient with severe
cardiomyopathy could benefit from such
device when bridged to heart
transplantation to preserve venous capital.
79 - SUBCUTANEOUS IMPANTABLE
CARDIOVERTER DEFIBRILLATOR:
BEST SOLUTION IN GREY ZONE
R. Di Rosa, M. Petrassi, P.F. Savocchi, D.
Coletta
S.M. Goretti Hospital, Latina, ITALY
A wide variety of structural abnormalities
are associated with the vast majority of
cardiac arrests. However, there is no
evidence of structural heart disease in 5%
of victims of sudden death, indicating that
cardiac arrest in the absence of organic
heart disease may be frequent In this case
report we describe the use of
subcutaneous implantable defibrillator (SICD) as a therapeutic option in case of
uncertain indications.
A 42-years patient came in our hospital
after a syncopal episode during the night
preceded by gasping. After investigations,
195
POSTER SESSION
78 - BENEFITS OF SUBCUTANEOUS
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR IN YOUNG PATIENT
V. Doldo 1, L. Santini 2, F. Mercanti 1, M.
Gugliotta 1, V. Minni 1, A. Sanniti 1, P. La
Prova 1, G.A. Volpe 1, S. Scaldarella 1, R.
Morgagni 1, G. Magliano 1, G.B. Forleo 1, D.
Sergi 1, F. Romeo 1
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
fouz 1, G. Magliano 1, A. Capria 2, D. Sergi 1,
L. Santini 3, G.B. Forleo 1 , F. Romeo 1
he resulted negative at all exams.
1
POSTER SESSION
University of Rome Tor Vergata - Department
of Cardiology, Rome, ITALY, 2 University of
Rome Tor Vergata - Department of Internal Medicine, Rome, ITALY, 3 Ospedale G.B. Grassi Department of Cardiology, Ostia (Rome), ITALY
In this case, despite the lack of structural
heart disease and other clear clinical
evidence, an indication to a defibrillator
implantation was done. The implantation
of a subcutaneous ICD, a less invasive
alternative, was proposed to the patient
for prevention of sudden death.
Three months after the implant, the
patient received an appropriate ICD
therapy for a ventricular arrhythmia
episode ( heart rate 270 bpm). A second
episode occurred 3 months later. Both
episodes occurred during sport activity,
not reproducible with stress test.
We suggest that a subcutaneous ICD may
be the first choice in case of uncertain
indications
80 - IMPACT OF STRICT LEFT BUNDLE
BRANCH BLOCK CRITERIA ON CLINICAL
OUTCOMES OF CRT PATIENTS
S. Ventresca 1, G. Panattoni 1, D.G. Della
Rocca 1, V. Ribatti 1, F. Condemi 1, K. Mah196
Background: Cardiac resynchronization
therapy (CRT) is an established treatment
in patients with Heart Failure (HF) and
ventricular conduction delay. Strauss et al.
have recently introduced new strict criteria
in order to define left bundle branch block
(LBBB). The aim of the study was to
evaluate whether patients with LBBB
according to Strauss have better response
to CRT compared to patients without
Strauss LBBB.
Methods: A total of 155 patients
implanted with CRT-D were enrolled.
Patients were classified into two groups,
analyzing ECG: patients with LBBB
according to Strauss Criteria (Strauss
LBBB Group) and patients without LBBB
according to Strauss Criteria (Control
Group). We examined mortality, number of
hospitalizations for heart failure and
Packer HF Clinical Composite Score (CCS).
Results: At twelve-month follow-up,
primary
endpoint
(mortality
or
hospitalization for HF) occurred in 32
patients (20,6%): 15 in Strauss LBBB
Group (16,7%) and 17 in Control Group
(26,2%) (p=ns). In CCS, 44 patients were
classified as improved (28,4%): 31
patients in Strauss LBBB Group (34,4%)
and 13 in Control Group (20%) (p=0,025).
Fourtynine patients were classified as
worsened (31,6%): 23 patients in Strauss
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
LBBB group (25,6%), 26 patients in
Control Group (40%) (p=ns). In both
groups 40% of patients were classified as
unchanged (p=ns).
Conclusion: Follow-up results suggest
that patients with LBBB according to
Strauss have better clinical response to
CRT. Although the results should be
confirmed by larger studies, the use of
stricter criteria for the definition of LBBB
could provide an additional benefit in
selection of patients candidates for CRT-D.
81 - USE OF DIRECT ORAL
ANTICOAGULANTS AFTER LEFT
VENTRICULAR ENDOCARDIAL LEAD
PLACEMENT
J. Diaz 1, A. Molina 2, J. Marin 1, J. Aristizabal 1,
J. Velasquez 1, W. Uribe 1, M. Duque 1
1
CES Cardiologia, Medellin, COLOMBIA, 2 Clinica
Las Americas, Medellin, COLOMBIA
Background: Left ventricular endocardial
pacing has been used as an alternative to
coronary sinus and epicardial lead
placement in patients who need cardiac
resynchronization. To avoid embolism
associated with thrombus formation in the
leads, patients receive anticoagulation
with warfarin which in turn is associated
with problems maintaining a therapeutic
INR. Initial experience with the use of
direct oral anticoagulants (DOAC) in
patients receiving left ventricular
endocardial is described.
Methods: 7 patients (4 females, 57%; age
66.9 ± 5.6 years) with left ventricular
endocardial pacing treated with aspirin
100mg daily and DOAC were followed for
a mean 6.8 ±3.5 months. All patients
were previously on DOAC for the treatment
of atrial fibrillation (apixaban 5 patients,
rivaroxaban 2 patients) and refused to
receive warfarin. Mean LVEF was 26.3 ±
10%, with a CHADS2VA2SC score of 2 in
2 patients, 3 in 4 patients and 4 in 1
patient; ischemic cardiomyopathy was
present in 3 patients (42.9%). During
follow up, there were no embolic
complications; 1 patient died of worsening
heart failure 7 months after lead implant
and 1 patient required lead repositioning
due to dislodgement. 2 patients had
postoperative hematoma which required
no intervention. There were no bleeding
events during follow up.
Conclusion: Use of DOACs and aspirin
was associated with a favorable risk
profile in this series, with no embolic
events or bleeding during follow up.
Further studies are needed to better
establish the safety and effectiveness of
this strategy compared to traditional
anticoagulation with warfarin.
82 - LEFT VENTRICULAR
ENDOCARDIAL PACING IN A PATIENT
WITH AV BLOCK AND A MECHANICAL
TRICUSPID VALVE
J. Diaz 1, J Velasquez 1, J. Romero 2, J.
Marin 1, J Aristizabal 1, W. Uribe 1, M. Duque
1
1
CES Cardiologia, Medellin, COLOMBIA, 2 Montefiore
Medical Center/Albert Einstein College of
Medicine, New York, USA
Background: Atrioventricular block after
mechanical tricuspid valve replacement is
common; in most cases an epicardial lead
is the treatment of choice, with coronary
sinus lead placement described as an
197
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
alternative. A different approach is
described, using left ventricular
endocardial pacing.
Methods: A 26-year-old female patient
developed complete heart block after
tricuspid valve replacement with a
mechanical valve. Epicardial pacemaker
lead placement was discarded because of
a high risk of myocardial damage (due to
pericardial adhesions) and right ventricular
dysfunction, and attempts to place a lead
in the coronary sinus failed. Using an atrial
transeptal puncture through a right
femoral approach a sheath (SL-1, St Jude
Medical, St Paul, Minnesota) was
advanced into the left ventricle using a
standard ablation catheter as a steering
mechanism. Once in place, an active
fixation lead was advanced (5086-83cm,
Medtronic, Minneapolis, Minnessota).
Pacing parameters were checked (pacing
threshold: 0.5 volts, impedance 564 ohm,
no R wave detected) and an active fixation
right atrial lead was placed through a left
cephalic vein cutdown technique (figure 1.
A: RAO view; B: LAO view). The patient was
discharged after appropriate INR levels
were maintained (target INR: 3.5-4.5).
After 6 months follow up, appropriate
pacemaker function has been confirmed
and the patient has had no embolic
events.
Conclusion: LV endocardial pacing
through an atrial transeptal puncture is an
alternative for ventricular pacing in
patients with a mechanical tricuspid valve
and postoperative AV block when pacing
through an epicardial lead or coronary
sinus lead is not feasible or desired.
198
83 - FEASIBILITY OF DDD PACING BY A
VDD SINGLE-PASS LEAD IN MUSTARD
SURGERY
M. Cabrera Ortega 1, D.B. Benítez Ramos 1,
F. Di Gregorio 2, A. Barbetta 2
1
Department of Arrhythmia and Cardiac
Pacing. Cardiocentro Pediatrico William Soler,
La Havana, CUBA, 2 Unità Di Ricerca Clinica,
Medico Spa, Padua, ITALY
Background: Sinus node disease (SND) is
a frequent complication of Mustard
surgery,
requiring
pacemaker
implantation. Positioning the leads for
optimal sensing and pacing in atrium and
ventricle might be difficult due to an
extensive baffling and distorted anatomy.
Aims: We studied the feasibility as well as
the short- and long-term stability of
atrioventricular pacing, performed by a
VDD single-pass lead in patients treated
with Mustard surgery.
Methods and Results: We recruited 16
patients (age 18.9±3.5 years) with SND
from a single pediatric cardiology center,
between January 2011 and December
2015. The Phymos 4 VDD lead (MEDICO
Spa, Italy), with floating atrial rings, was
implanted in all cases and connected to a
DDD stimulator to achieve atrial pacing.
The position of the atrial dipole considered
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
as optimal was the superior part of the
systemic venous baffle. Parameters of
sensing and pacing were assessed at
implantation and at 1, 3, 6 and 12 months
of follow-up. The mean atrial threshold
was 0.9±0.2 V/0.5 ms at implant, and
1.2±0.7 V/0.5 ms at 12 months (not
significant change). Similarly, a nonsignificant difference was detected in
atrial sensing (4.7±1.5 mV vs 3.9±1.4 mV
at implant and 1-year follow-up,
respectively). Three patients (18.75 %)
required antiarrhythmic drugs due to atrial
arrhythmias. Effective atrial capture and
reliable atrial sensing were obtained in all
patients over 12-months follow-up period.
Phrenic nerve stimulation was present in
one case only.
Conclusion: The study suggests the
possibility of using a VDD single-pass lead
to provide DDD pacing in young patients
receiving Mustard surgery.
84 - INTRACARDIAC PACEMAKER:
ANALYSIS OF MID TERM EFFICACY
AND PERFORMANCES
C. Mandurino, M. Pinto, R. Trotta, A. Guido,
L. Sgarra, M. Anaclerio, G. Luzzi, F. Nacci,
R. Memeo, V.E. Santobuono, S. Favale
A.O.U. Policlinico di Bari D.E.T.O. U.O.
Cardiologia Universitaria, Bari, ITALY
Background: Conventional Pacemaker
(PM) implantation is related to mechanical
and infective complications. Total
intracardiac devices are proposed as
valuable and effective alternative.
Aim of the study: To describe our Centre
experience with intracardiac leadless
pacing technology.
Materials and Methods: 8 consecutive
patients submitted to implant of
intracardiac pacemaker with Flexfix ™
fixation
(Medtronic
Micra™
Transcathether Pacing System-TPS)
evaluated at implantation time and then at
1,3,6 months for: 1) adverse events; 2)
pacing/sensing parameters.
Results: 6 men and 2 women, average
age 82,3 ±7,2 yo. Implant indications:
slow ventricular response AF (6); AF with
A-V block of 3rd degree (1); sincope
related to episodes of 2nd degree A-V
block (1). Mean EF: 56%±4%. TPS
implantation was successful in all cases
at first fixation site, without any
complications or adverse events related to
device in 6 months follow-up. Pacing
percentage ranged from 1,1% to 100%;
estimated mean battery duration 10,7
years.Pacing threshold mean value
(standard duration of 0.24 msec) was
1.23V at implantation time and at 6
months. Mean R-wave was 9.7 mV at
implant and 12.7 mV at 6 months. Mean
pacing impedence value was 631 ohms at
implant and 550 ohms at 6 months.
Conclusions: Although in a small cohort
of patients the first experience with
Micra™ Transcathether Pacing System
showed: 1-simple and safe implantation
procedure; 2-effective pacing and sensing
in acute and at mid-term; 3-steady electric
performance without complications in 6
months follow-up.
199
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
POSTER SESSION
Chairman: Massimo SANTINI Co-Chairman: Luca SANTINI
200
XVII
International Symposium
on Progress
in Clinical Pacing
2016
Rome, Italy - NOV 29 - DEC 2, 2016
Scientific Secretariat
Via Giambattista Vico 1 – 00196 Roma (Italia)
Tel: +39 06 3218343 – Fax:+39 06 3218343
E-mail: [email protected]
Organizing Secretariat
AIM Group International
Via Flaminia, 1068 – 00189 Rome, Italy
Ph. +39 06 330531 – Fax +39 06 33053229
E-mail: [email protected]