Detection of atrial fibrillation in persons aged 65 years and above using a mobile electrocardiogram device.

BACKGROUND: Untreated atrial fibrillation (AF) often results in increased morbidity and mortality. Opportunistic AF screening in persons aged ≥ 65 years is recommended to identify patients with AF in order to prevent AF-related complications. OBJECTIVE: The aim of this study was to assess the feasibility of screening persons for AF with the Kardia mobile electrocardiogram device (MED) and to determine the percentage of newly detected AF cases by selective population screening in the Netherlands. METHODS: Persons aged ≥ 65 years, without a medical history of AF, in nursing homes, at public events or visiting the general practitioner (GP) were approached to participate. A Kardia MED smartphone ECG (sECG) was recorded and the CHA2DS2-VASc score was calculated. An automated AF algorithm classified the sECGs as 'sinus rhythm', 'AF' or 'unclassified'. In the case of AF, participants were referred to their GP. All sECGs were assessed by blinded experts. RESULTS: A total of 2168 participants were screened for AF. According to the expert's interpretation, 2.5% had newly detected AF, of whom 76.4% never experienced palpitations and 89.1% had a CHA2DS2-VASc score ≥ 2. The algorithm result was unclassified in 12.2% of cases, of which 95.5% were interpretable by experts. With expert opinion as the gold standard and excluding unclassified sECGs, the Kardia MED's negative and positive predictive value for detecting AF was 99.8% and 60.0%, respectively. CONCLUSION: Screening for AF using the Kardia MED is feasible and results in 2.5% newly detected AF cases. Expert interpretation of algorithm outcomes AF and unclassified is recommended.

Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy.

AIMS: Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS: In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 µVs and T-wave area ≥ 66 µVs compared with QRS area ≥ 109 µVs and T-wave area < 66 µVs (P = 0.004), QRS area < 109 µVs and T-wave area ≥ 66 µVs (P < 0.001) and QRS area < 109 µVs and T-wave area < 66 µVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 µVs and T-wave area ≥ 66 µVs (n = 616, P < 0.001) and QRS area ≥ 109 µVs and T-wave area < 66 µVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION: Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.

When and how to perform venoplasty for lead placement.

Because of the increasing use of cardiac implantable electronic devices (CIEDs) with one or more intracardiac electrodes, the rate of lead failure is increasing. Moreover, upgrade of the CIED frequently is indicated for cardiac resynchronization therapy or other reasons. Both these situations require a new intervention, preferably using ipsilateral venous access. However, venous obstruction after CIED insertion occurs in 10%-20% of patients and poses a major obstacle for implantation of additional leads. Possible solutions include lead extraction, contralateral lead insertion, and venoplasty. Preprocedural venoplasty is associated with the lowest short- and long-term risks. Here we describe a step-by-step approach to this technique, which can be introduced and safely performed in most interventional catheterization laboratories.

Special Issue: Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing.

Cardiac Resynchronization Therapy (CRT) is an established technique to improve morbidity and mortality in selected heart failure patients [...].

Cardiac Resynchronization Therapy beyond Nominal Settings: An IEGM-Based Approach for Paced and Sensed Atrioventricular Delay Offset Optimization in Daily Clinical Practice.

Optimization of the atrioventricular (AV) delay has been performed in several landmark trials in cardiac resynchronization therapy (CRT), although it is often not performed in daily practice. Our aim was to study optimal AV delays and investigate a simple intracardiac electrogram (IEGM)-based optimization approach. 328 CRT patients with paired IEGM and echocardiography optimization data were included in our single-center observational study. Sensed (sAV) and paced (pAV) AV delays were optimized using an iterative echocardiography method. The offset between sAV and pAV delays was calculated using the IEGM method. The mean age of the patients was 69 ± 12 years; 64% were men, 48% had ischemic etiology of heart failure. During echocardiographic optimization, an offset of 73 ± 18 ms was found, differing from nominal AV settings (p < 0.001). Based on the IEGM method, the optimal offset was 75 ± 25 ms. The echocardiographic and IEGM-generated AV offset delays showed good correlation (R2 = 0.62, p < 0.001) and good agreement according to Bland-Altman plot analysis. CRT responders had a near zero offset difference between IEGM and echo optimization (-0.2 ± 17 ms), while non-responders had an offset difference of 6 ± 17 ms, p = 0.006. In conclusion, optimal AV delays are patient-specific and differ from nominal settings. pAV delay can easily be calculated from IEGM after sAV delay optimization.