Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
TB OO K AB ST RA C 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 FREE PAPERS 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 FREE PAPERS 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 FREE PAPERS 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 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 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 FREE PAPERS CATHETER ABLATION TECHNIQUES TUESDAY, NOVEMBER 29, 12.30-14.00 [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 TUESDAY, NOVEMBER 29, 12.30-14.00 [Leptis magna 1] 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 XVII 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 FREE PAPERS CATHETER ABLATION TECHNIQUES TUESDAY, NOVEMBER 29, 12.30-14.00 [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 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 on Progress 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 FREE PAPERS CATHETER ABLATION TECHNIQUES TUESDAY, NOVEMBER 29, 12.30-14.00 [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, 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 on Progress 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 FREE PAPERS ELECTRICAL AND CHEMICAL SUPPRESSION OF ATRIAL FIBRILLATION 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 on Progress in Clinical Pacing 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 FREE PAPERS ELECTRICAL AND CHEMICAL SUPPRESSION OF ATRIAL FIBRILLATION 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 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 FREE PAPERS SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR WEDNESDAY, NOVEMBER 30, 12.30-14.00 [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, 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 FREE PAPERS SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR WEDNESDAY, NOVEMBER 30, 12.30-14.00 [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, 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 FREE PAPERS SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR WEDNESDAY, NOVEMBER 30, 12.30-14.00 [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, 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 FREE PAPERS 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 FREE PAPERS 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 FREE PAPERS 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 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 International Symposium on Progress in Clinical Pacing 2016 Rome, Italy - NOV 29 - DEC 2, 2016 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 FREE PAPERS CATHETER ABLATION: IMPACT OF MODERN TECHNOLOGIES WEDNESDAY, NOVEMBER 30, 17.30-19.00 [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 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 in Clinical Pacing 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 FREE PAPERS CATHETER ABLATION: IMPACT OF MODERN TECHNOLOGIES WEDNESDAY, NOVEMBER 30, 17.30-19.00 [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 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 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 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 93 FREE PAPERS 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 97 FREE PAPERS 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, 99 FREE PAPERS 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 101 FREE PAPERS 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 FREE PAPERS 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 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 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 113 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. 117 FREE PAPERS 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, 119 FREE PAPERS 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. 121 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 123 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 145 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 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 POSTER SESSION 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 XVII International Symposium on Progress in Clinical Pacing 2016 Rome, Italy - NOV 29 - DEC 2, 2016 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. 149 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 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 XVII 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]