Real-world validation of smartphone-based photoplethysmography for rate and rhythm monitoring in atrial fibrillation.

AIMS: Photoplethysmography- (PPG) based smartphone applications facilitate heart rate and rhythm monitoring in patients with paroxysmal and persistent atrial fibrillation (AF). Despite an endorsement from the European Heart Rhythm Association, validation studies in this setting are lacking. Therefore, we evaluated the accuracy of PPG-derived heart rate and rhythm classification in subjects with an established diagnosis of AF in unsupervised real-world conditions. METHODS AND RESULTS: Fifty consecutive patients were enrolled, 4 weeks before undergoing AF ablation. Patients used a handheld single-lead electrocardiography (ECG) device and a fingertip PPG smartphone application to record 3907 heart rhythm measurements twice daily during 8 weeks. The ECG was performed immediately before and after each PPG recording and was given a diagnosis by the majority of three blinded cardiologists. A consistent ECG diagnosis was exhibited along with PPG data of sufficient quality in 3407 measurements. A single measurement exhibited good quality more often with ECG (93.2%) compared to PPG (89.5%; P < 0.001). However, PPG signal quality improved to 96.6% with repeated measurements. Photoplethysmography-based detection of AF demonstrated excellent sensitivity [98.3%; confidence interval (CI): 96.7-99.9%], specificity (99.9%; CI: 99.8-100.0%), positive predictive value (99.6%; CI: 99.1-100.0%), and negative predictive value (99.6%; CI: 99.0-100.0%). Photoplethysmography underestimated the heart rate in AF with 6.6 b.p.m. (95% CI: 5.8 b.p.m. to 7.4 b.p.m.). Bland-Altman analysis revealed increased underestimation in high heart rates. The root mean square error was 11.8 b.p.m. CONCLUSION: Smartphone applications using PPG can be used to monitor patients with AF in unsupervised real-world conditions. The accuracy of AF detection algorithms in this setting is excellent, but PPG-derived heart rate may tend to underestimate higher heart rates.

The MADIT-ICD benefit score helps to select implantable cardioverter-defibrillator candidates in cardiac resynchronization therapy.

AIMS: The aim of this study is to evaluate whether the MADIT-ICD benefit score can predict who benefits most from the addition of implantable cardioverter-defibrillator (ICD) to cardiac resynchronization therapy (CRT) in real-world patients with heart failure with reduced ejection fraction (HFrEF) and to compare this with selection according to a multidisciplinary expert centre approach. METHODS AND RESULTS: Consecutive HFrEF patients who received a CRT for a guideline indication at a tertiary care hospital (Ziekenhuis Oost-Limburg, Genk, Belgium) between October 2008 and September 2016, were retrospectively evaluated. The MADIT-ICD benefit groups (low, intermediate, and high) were compared with the current multidisciplinary expert centre approach. Endpoints were (i) sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) and (ii) non-arrhythmic mortality. Of the 475 included patients, 165 (34.7%) were in the lowest, 220 (46.3%) in the intermediate, and 90 (19.0%) in the highest benefit group. After a median follow-up of 34 months, VT/VF occurred in 3 (1.8%) patients in the lowest, 9 (4.1%) in the intermediate, and 13 (14.4%) in the highest benefit group (P < 0.001). Vice versa, non-arrhythmic death occurred in 32 (19.4%) in the lowest, 32 (14.6%) in the intermediate, and 3 (3.3%) in the highest benefit group (P = 0.002). The predictive power for ICD benefit was comparable between expert multidisciplinary judgement and the MADIT-ICD benefit score: Uno's C-statistic 0.69 vs. 0.69 (P = 0.936) for VT/VF and 0.62 vs. 0.60 (P = 0.790) for non-arrhythmic mortality. CONCLUSION: The MADIT-ICD benefit score can identify who benefits most from CRT-D and is comparable with multidisciplinary judgement in a CRT expert centre.

Predicting Early Mortality Among Implantable Defibrillator Patients Treated With Cardiac Resynchronization Therapy.

BACKGROUND: The beneficial effects of a cardiac resynchronization defibrillator (CRT-D) in patients with heart failure, low left ventricular ejection fraction (LVEF), and wide QRS have clearly been established. Nevertheless, mortality remains high in some patients. The aim of this study was to develop and validate a risk score to identify patients at high risk for early mortality who are implanted with a CRT-D. METHODS AND RESULTS: For predictive modelling, 1282 consecutive patients from 5 centers (74% male; median age 66 years; median LVEF 25%; New York Heart Association class III-IV 60%; median QRS-width 160 ms) were randomly divided into a derivation and validation cohort. The primary endpoint is mortality at 3 years. Model development was performed using multivariate logistic regression by checking log likelihood, Akaike information criterion, and Bayesian information criterion. Model performance was validated using C statistics and calibration plots. The risk score included 7 independent mortality predictors, including myocardial infarction, LVEF, QRS duration, chronic obstructive pulmonary disease, chronic kidney disease, hyponatremia, and anemia. Calibration-in-the-large was suboptimal, reflected by a lower observed mortality (44%) than predicted (50%). The validated C statistic was 0.71 indicating modest performance. CONCLUSION: A risk score based on routine, readily available clinical variables can assist in identifying patients at high risk for early mortality within 3 years after CRT-D implantation.

Atrial fibrillation screening with photo-plethysmography through a smartphone camera.

AIMS: This cross-sectional study was set up to assess the feasibility of mass screening for atrial fibrillation (AF) with only the use of a smartphone. METHODS AND RESULTS: A local newspaper published an article, allowing to subscribe for a 7-day screening period to detect AF. Screening was performed through an application that uses photo-plethysmography (PPG) technology by exploiting a smartphone camera. Participants received instructions on how to perform correct measurements twice daily, with notifications pushed through the application's software. In case of heart rhythm irregularities, raw PPG signals underwent secondary offline analysis to confirm a final diagnosis. From 12 328 readers who voluntarily signed up for screening (49 ± 14 years; 58% men), 120 446 unique PPG traces were obtained. Photo-plethysmography signal quality was adequate for analysis in 92% of cases. Possible AF was detected in 136 individuals (1.1%). They were older (P < 0.001), more frequently men (P < 0.001), and had higher body mass index (P = 0.004). In addition, participants who strictly adhered to the recommended screening frequency (i.e. twice daily) were more often diagnosed with possible AF (1.9% vs. 1.0% in individuals who did not adhere; P = 0.008). Symptoms of palpitations, confusion, and shortness of breath were more frequent in case of AF (P < 0.001). The cumulative diagnostic yield for possible AF increased from 0.4% with a single heart rhythm assessment to 1.4% with screening during the entire 7-day screening period. CONCLUSION: Mass screening for AF using only a smartphone with dedicated application based on PPG technology is feasible and attractive because of its low cost and logistic requirements.

Cardiac sarcoidosis: a diagnostic and therapeutic challenge.

OBJECTIVE: Cardiac involvement in sarcoidosis can present in various ways, with atrioventricular (AV) block and ventricular arrhythmias being the most common signs. Because of initial non-specific findings, diagnosis can be a challenge. Very few data can support treatment decisions as cardiac manifestations of this systemic disorder are rare. METHODS AND RESULTS: We reviewed current guidelines, cohort studies, and expert opinions concerning diagnosis and treatment of cardiac sarcoidosis. CONCLUSIONS: Longitudinal follow-up studies are necessary to improve the diagnostic process and risk stratification of cardiac sarcoidosis. The optimal dose of steroids, indications for internal cardioverter-defibrillator (ICD), and technique and optimal timing of ablation are still under debate.

EuroEco (European Health Economic Trial on Home Monitoring in ICD Patients): a provider perspective in five European countries on costs and net financial impact of follow-up with or without remote monitoring.

AIM: Remote follow-up (FU) of implantable cardiac defibrillators (ICDs) allows for fewer in-office visits in combination with earlier detection of relevant findings. Its implementation requires investment and reorganization of care. Providers (physicians or hospitals) are unsure about the financial impact. The primary end-point of this randomized prospective multicentre health economic trial was the total FU-related cost for providers, comparing Home Monitoring facilitated FU (HM ON) to regular in-office FU (HM OFF) during the first 2 years after ICD implantation. Also the net financial impact on providers (taking national reimbursement into account) and costs from a healthcare payer perspective were evaluated. METHODS AND RESULTS: A total of 312 patients with VVI- or DDD-ICD implants from 17 centres in six EU countries were randomised to HM ON or OFF, of which 303 were eligible for data analysis. For all contacts (in-office, calendar- or alert-triggered web-based review, discussions, calls) time-expenditure was tracked. Country-specific cost parameters were used to convert resource use into monetary values. Remote FU equipment itself was not included in the cost calculations. Given only two patients from Finland (one in each group) a monetary valuation analysis was not performed for Finland. Average age was 62.4 ± 13.1 years, 81% were male, 39% received a DDD system, and 51% had a prophylactic ICD. Resource use with HM ON was clearly different: less FU visits (3.79 ± 1.67 vs. 5.53 ± 2.32; P < 0.001) despite a small increase of unscheduled visits (0.95 ± 1.50 vs. 0.62 ± 1.25; P < 0.005), more non-office-based contacts (1.95 ± 3.29 vs. 1.01 ± 2.64; P < 0.001), more Internet sessions (11.02 ± 15.28 vs. 0.06 ± 0.31; P < 0.001) and more in-clinic discussions (1.84 ± 4.20 vs. 1.28 ± 2.92; P < 0.03), but with numerically fewer hospitalizations (0.67 ± 1.18 vs. 0.85 ± 1.43, P = 0.23) and shorter length-of-stay (6.31 ± 15.5 vs. 8.26 ± 18.6; P = 0.27), although not significant. For the whole study population, the total FU cost for providers was not different for HM ON vs. OFF [mean (95% CI): €204 (169-238) vs. €213 (182-243); range for difference (€-36 to 54), NS]. From a payer perspective, FU-related costs were similar while the total cost per patient (including other physician visits, examinations, and hospitalizations) was numerically (but not significantly) lower. There was no difference in the net financial impact on providers [profit of €408 (327-489) vs. €400 (345-455); range for difference (€-104 to 88), NS], but there was heterogeneity among countries, with less profit for providers in the absence of specific remote FU reimbursement (Belgium, Spain, and the Netherlands) and maintained or increased profit in cases where such reimbursement exists (Germany and UK). Quality of life (SF-36) was not different. CONCLUSION: For all the patients as a whole, FU-related costs for providers are not different for remote FU vs. purely in-office FU, despite reorganized care. However, disparity in the impact on provider budget among different countries illustrates the need for proper reimbursement to ensure effective remote FU implementation.

The figure-of-eight artifact in the echocardiographic assessment of percutaneous disc occluders: impact of imaging depth and device type.

PURPOSE: Echocardiography is increasingly important in the guidance and follow-up of percutaneous transcatheter device closures. It was recently shown that the Amplatzer left atrial appendage occluder frequently presents as a figure-of-eight artifact due to interaction of device mesh and ultrasound waves. It remains unknown whether this can be translated to other types of disc occluders. Furthermore, the morphology of this figure-of-eight artifact appears to be different in the transesophageal and transthoracic image of the same device. The aim of this study was to evaluate the echocardiographic appearance of different types of disc occluders, and to clarify differences in morphology of the figure-of-eight artifact. METHODS: A mathematical model of an epitrochoid curve was used for numerical simulation of disc occluder appearance at various imaging depths. In addition, an in vitro setup was used for echocardiographic analysis of different types of disc occluders at adjustable imaging depth and position. RESULTS: Mathematically, decreasing the imaging depth resulted in a more asymmetric figure-of-eight, i.e. with small upper part and wide lower part. In vitro results were in close agreement with the mathematical results. In addition, in vitro a figure-of-eight artifact was obtained in all different types of disc occluder devices. CONCLUSIONS: Different types of percutaneous disc occluders all present as a figure-of-eight artifact on echocardiography when imaged from a coronal imaging position. The morphology of the artifact depends on the imaging depth, with a more asymmetric figure-of-eight morphology at smaller probe-to-device distance. This clarifies the differences observed between transesophageal and transthoracic imaging.

Asymptomatic episodes of device-registered atrial tachyarrhythmia are not associated with worse cardiac resynchronization therapy response.

AIMS: To assess the influence of device-registered episodes of atrial tachyarrhythmia (AT) on the response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Consecutive CRT patients without history of atrial fibrillation (AF; n = 118) were followed prospectively. AT was defined as a device-registered episode of atrial rate >190 b.p.m. for ≥30 s. Episodes of electrocardiographically documented AF, accompanied by symptoms, or need for cardioversion, were classified as clinical AF. During mean follow-up of 26 ± 9 months, 39 patients (33%) had ≥1 episode of asymptomatic device-registered AT. Twenty-one patients (18%) developed clinical AF of whom seven had previously experienced episodes of asymptomatic device-registered AT. Patients with asymptomatic AT or AF had a higher body mass index, but otherwise similar baseline characteristics, compared with the subjects without AT. Reverse remodelling after CRT was similar among the groups. While clinical AF was significantly associated with the composite endpoint of all-cause mortality or unplanned hospital admission (hazard ratio = 2.43, 95% confidence interval: 1.40-4.24), this correlation was not observed in patients with asymptomatic device-registered AT (P value = 0.540). CONCLUSION: Episodes of asymptomatic device-registered AT are frequent in CRT patients, but are not associated with impaired reverse remodelling. In contrast to clinical AF, such episodes are not associated with worse clinical outcome.

Revisiting diastolic filling time as mechanistic insight for response to cardiac resynchronization therapy.

AIMS: Intraventricular dyssynchrony and commonly associated prolonged atrioventricular conduction both reduce diastolic filling time (DFT), which can be improved by cardiac resynchronization therapy (CRT). Our aim was to investigate whether change in DFT corrected for RR interval (DFTC) after CRT might serve to assess the mechanistic response to CRT. METHODS AND RESULTS: Echocardiography data of consecutive patients in sinus rhythm (n = 91) were studied before and 6 months after implantation. Mortality and heart failure hospitalization data were collected. Patients with vs. without DFTC increase after 6 months were compared. The programmed atrioventricular delay, percentage of biventricular pacing, and change in PR interval were similar in both groups. DFTC increase after 6 months reflected favourable reverse left ventricular remodelling and was significantly associated with freedom from death or heart failure admission (P = 0.008). In multivariate analysis including guideline criteria for CRT (i.e. QRS width, presence of left bundle branch block, and ejection fraction), interventricular mechanical delay, and Tei index, baseline DFTC was the strongest predictor of adverse outcome. Notably, while patients with impaired relaxation had a large and highly significant reduction in all-cause mortality and heart failure admissions when DFTC increased [hazard ratio (HR), 95% confidence interval (CI) = 0.24, 0.08-0.73; P = 0.012], this benefit was less pronounced and did not reach statistical significance in patients with pseudonormal or restrictive filling (HR, 95% CI = 0.64, 0.23-1.77; P = 0.388). CONCLUSION: DFTC increase after CRT reflects favourable reverse remodelling and is associated with better clinical outcome.

Cardiac resynchronization therapy with or without defibrillator: experience from a high-volume Belgian implantation centre.

OBJECTIVE: Cardiac resynchronization therapy (CRT) is an important treatment modality for heart failure with reduced ejection fraction and ventricular conduction delay. Considering limited health care budgets in an aging population, adding a defibrillator function to CRT remains a matter of debate. Our aim was to describe the experience of a high-volume Belgian implantation centre with CRT with/without defibrillator (CRT-D/P). METHODS AND RESULTS: Consecutive CRT patients (n = 221), implanted between October 2008 and April 2011 in Ziekenhuis Oost-Limburg (Genk), were reviewed. From 209 primo-implantations, 74 CRT-D and 98 CRT-P patients with complete follow-up inside the centre, were analysed. Despite differences in baseline characteristics, both groups demonstrated similar reverse left ventricular remodelling, improvement in New York Heart Association functional class and maximal aerobic capacity. During mean follow-up of 18 +/- 9 months, 21 patients died and 83 spent a total of 1200 days in hospital. Annual mortality was 8% and equal among the groups. The mode of death differed between CRT-D (predominantly pump failure) and CRT-P patients (pump failure, comorbidity and sudden death). The yearly population attributable risk of malignant ventricular arrhythmia was 8.16% in CRT-D and 1.38% in CRT-P patients. CONCLUSIONS: With current guidelines applied to the Belgian reimbursement criteria and at physicians'discretion, patient selection for CRT-D/ CRT-P was appropriate, with similar reverse remodelling, functional capacity improvement and good clinical outcome in both groups. High-risk patients for malignant ventricular arrhythmia were more likely to receive CRT-D, although the yearly attributable risk remained 1.38% in CRT-P patients.

No Effect of Continued Antiarrhythmic Drug Treatment on Top of Optimized Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation: Results From the POWDER-AF2 Trial.

BACKGROUND: In patients with persistent atrial fibrillation (PersAF), catheter ablation aiming for pulmonary vein isolation (PVI) is associated with moderate clinical effectiveness. We investigated the benefit of continuing previously ineffective class 1C or 3 antiarrhythmic drug therapy (ADT) in the setting of a standardized PVI-only ablation strategy. METHODS: In this multicenter, randomized controlled study, patients with PersAF (≥7 days and <12 months) despite ADT were prospectively randomized 1:1 to PVI with ADT continued versus discontinued beyond the blanking period (ADT ON versus ADT OFF). Standardized catheter ablation was performed aiming for durable isolation with stable, contiguous, and optimized radio frequency applications encircling the pulmonary veins (CLOSE protocol). Clinical visits and 1-to-7-day Holter were performed at 3, 6, and 12 months. The primary end point was any documented atrial tachyarrhythmia lasting >30 seconds beyond 3 months. Prospectively defined secondary end points included repeat ablations, unscheduled arrhythmia-related visits, and quality of life among groups. RESULTS: Of 200 PersAF patients, 98 were assigned to ADT OFF and 102 to ADT ON. The longest atrial fibrillation episode qualifying for PersAF was 28 (10-90) versus 30 (11-90) days. Clinical characteristics and procedural characteristics were similar. Recurrence of atrial tachyarrhythmia was comparable in both groups (20% OFF versus 21.2% ON). No differences were observed in repeat ablations and unscheduled arrhythmia-related visits. Marked improvement in quality of life was observed in both groups. CONCLUSIONS: In patients with PersAF, there is no benefit in continuing previously ineffective ADT beyond the blanking period after catheter ablation. The high success rate of PVI-only might be explained by the high rate of durable isolation after optimized PVI and the early stage of PersAF (POWDER-AF2). REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03437356.

Comorbidity significantly affects clinical outcome after cardiac resynchronization therapy regardless of ventricular remodeling.

BACKGROUND: The influence of comorbid conditions on ventricular remodeling, functional status, and clinical outcome after cardiac resynchronization therapy (CRT) is insufficiently elucidated. METHODS AND RESULTS: The influence of different comorbid conditions on left ventricular remodeling, improvement in New York Heart Association (NYHA) functional class, hospitalizations for heart failure, and all-cause mortality after CRT implantation was analyzed in 172 consecutive patients (mean age 71 ± 9 y), implanted from October 2008 to April 2011 in a single tertiary care hospital. During mean follow-up of 18 ± 9 months, 21 patients died and 57 were admitted for heart failure. Left ventricular remodeling and improvement in NYHA functional class were independent from comorbidity burden. However, diabetes mellitus (hazard ratio [HR] 3.45, 95% confidence interval [CI] 1.24-9.65) and chronic kidney disease (HR 3.11, 95% CI 1.10-8.81) were predictors of all-cause mortality, and the presence of chronic obstructive pulmonary disease (HR 1.89, 95% CI 1.02-3.53) was independently associated with heart failure admissions. Importantly, those 3 comorbid conditions had an additive negative impact on survival and heart failure admissions, even in patients with reverse left ventricular remodeling. CONCLUSIONS: Reverse ventricular remodeling and improvement in functional status after CRT implantation are independent from comorbidity burden. However, comorbid conditions remain important predictors of all-cause mortality and heart failure admissions.

A randomized comparison of transseptal and transaortic approaches for magnetically guided ablation of left-sided accessory pathways.

OBJECTIVES: Radiofrequency catheter ablation of left-sided accessory pathways (APs) can be performed either by a transseptal (TS) or transaortic (TA) approach. When performed manually, these techniques are equally effective. The aim of this prospective randomized study was to compare these approaches using a magnetic navigation system (MNS) (Niobe, Stereotaxis, St. Louis, MO, USA). METHODS: Twenty-two consecutive patients were randomized to undergo ablation of a left-sided AP by either a TS or a TA approach. The MNS was used in all patients for catheter navigation and eventual ablation, after electrophysiology study (EPS) confirmed the presence of left-sided APs. Crossover was allowed after failure of the initial approach. Success rates, procedure, fluoroscopy, and ablation times were compared. RESULTS: Of 11 procedures, 10 (91%) were successful in the TS group. The patient crossed over to the TA approach remained unsuccessful. Successful elimination of the AP was obtained in nine (82%) of 11 of the TA procedures. Of the two patients who crossed over to a TS procedure in the same session, one was successful and one remained unsuccessful. Total procedure time did not differ in both groups (87.1 ± 30.8 vs 90.9 ± 26.5 minutes). When total procedure and patient fluoroscopy times were divided into EPS time, time to first application, to successful application, and time to perform TS puncture or to retrogradely cross the aortic valve, only the last measurement differed significantly for both groups (P < 0.01). Ablation times were comparable in both groups. No major complications occurred. CONCLUSIONS: Our data show that TS and TA approaches are equal in success rate and total procedure, patient fluoroscopy, and ablation time when using the MNS for left-sided AP ablation. However, crossing the aortic valve with the MNS is faster than completing a TS puncture.

Analysis of 57,148 transmissions by remote monitoring of implantable cardioverter defibrillators.

INTRODUCTION: Remote monitoring of implantable cardioverter defibrillators (ICD) is designed to decrease the number of ambulatory visits and facilitate the early detection of adverse events. We examined the impact of remote monitoring on clinical workload by a comprehensive analysis of transmitted events. METHODS: The study population consisted of 146 recipients of ICD capable of remote monitoring. Data were transmitted daily or in case of pre-specified events (e.g., arrhythmia, out-of-range lead and/or shock impedance). Transmitted events were classified as clinical (disease-related) or system-related. Event rates/patient/month were calculated and compared according to events classification and clinical groups. RESULTS: During a mean follow-up of 22 +/- 16 months, a total of 57,148 remote transmissions were recorded. Of these transmissions, 1009 (1.8%) were triggered by a pre-specified event, including induced ventricular fibrillation (VF) episodes during defibrillation threshold testing. The median number of events/patient/month was 0.14. Event rates were similar in patients with primary and secondary prevention indications for ICD (0.15 vs. 0.11). After exclusion of the induced VF episodes, 5.6% of transmitted events were classified as system-related and 94.4% as clinical. The median number of clinical events/patient/month was 0.023. The clinical event-free rates were 62% and 45%, at 1 and 4 years, respectively. CONCLUSION: Remote monitoring of ICD patients is feasible. Despite the large number of data transmissions, remote monitoring imposed a minimal additional burden on the clinical workload. The rate of triggered data transmissions by critical events was, relatively, very low.

New-onset atrial fibrillation is an independent predictor of in-hospital mortality in hospitalized heart failure patients: results of the EuroHeart Failure Survey.

AIMS: The prognostic significance of atrial fibrillation (AF) in hospitalized patients with heart failure (HF) remains poorly understood. To evaluate in what way AF and its different modes of presentation affect the in-hospital mortality in patients admitted with HF. METHODS AND RESULTS: The EuroHeart Failure Survey was conducted to ascertain how hospitalized HF patients are managed in Europe. The survey enrolled patients over a 6-week period in 115 hospitals from 24 countries. For this analysis, patients were categorized into three groups according to the type of AF, previous AF (patients known to have had AF prior to admission), new-onset AF (no previous AF with AF diagnosed during hospitalization), and no AF (no previous AF and no AF during hospitalization). Clinical variables, duration of hospitalization, and in-hospital survival status were assessed and compared among groups. Of the 10 701 patients included in the survey; 6027 (57%) had no AF, 3673 (34%) had previous AF, and 1001 (9%) had new-onset AF. Patients with new-onset AF had a longer stay in the intensive care unit (ICU) when compared with previous AF and no AF patients (mean 2.6 +/- 5.3, 1.2 +/- 3.5, and 1.5 +/- 4.1 days, respectively; P < 0.001). In-hospital mortality was higher among patients with new-onset AF when compared with previous AF or no AF patients (12, 7, and 7% respectively; P < 0.001). After adjusting for multiple clinical variables, new-onset AF (not previous AF) was an independent predictor of in-hospital mortality (odds ratio 1.53, 95% CI 1.1-2.0). CONCLUSION: In hospitalized patients with HF, new-onset AF is an independent predictor of in-hospital mortality and a longer ICU and hospital stay.

Sacubitril/valsartan reduces ventricular arrhythmias in parallel with left ventricular reverse remodeling in heart failure with reduced ejection fraction.

BACKGROUND: Sacubitril/valsartan reduced the occurrence of sudden cardiac death in the PARADIGM-HF trial. However, limited information is available about the mechanism. METHODS: Heart failure (HF)-patients receiving sacubitril/valsartan for a class-I indication equipped with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) with remote tele-monitoring were retrospectively analyzed. Device-registered arrhythmic-events were determined [ventricular tachycardia/fibrillation (VT/VF), appropriate therapy, non-sustained VT (NsVT; > 4beats and < 30 s), hourly premature ventricular contraction (PVC)-burden], following sacubitril/valsartan initiation (incident-analysis) and over an equal time period before initiation (antecedent-analysis). Reverse remodeling to sacubitril/valsartan was defined as an improvement of left ventricular ejection fraction of ≥ 5% between baseline and follow-up. RESULTS: A-total of 151 HF-patients with reduced LVEF (29 ± 9%) were included. Patients were switched from ACE-I or ARB to equal doses of sacubitril/valsartan (expressed as %-target-dose; before = 58 ± 30% vs. after = 56 ± 27%). The mean follow-up of both the incident and antecedent analysis was 364 days. Following the initiation, VT/VF-burden dropped (individual patients with VT/VF pre_n = 19 vs. post_n = 10, total-episodes of VT/VF pre_n = 51 vs. post_n = 14, both p < 0.001), resulting in reduced occurrence of appropriate therapy (pre_n = 16 vs. post_n = 6; p < 0.001). NsVT-burden per patient also dropped (mean episodes pre_n = 7.7 ± 11.8 vs. post_n = 3.7 ± 5.4; p < 0.001). There was no impact on atrial-fibrillation burden. PVC-burden dropped significantly which was associated with an improvement in BiV-pacing in patients with < 90% BiV-pacing at baseline. A higher degree of reverse remodeling was associated with a lower burden of NsVT and PVCs (both p < 0.05). CONCLUSION: Initiation of sacubitril/valsartan is associated with a lower degree of VT/VF, resulting in less ICD-interventions. This beneficial effect on ventricular arrhythmias might be related to cardiac reverse remodeling.

Magnetically guided left ventricular lead implantation based on a virtual three-dimensional reconstructed image of the coronary sinus.

AIMS: Left ventricular (LV) lead implantation is feasible using remote magnetic navigation of a guidewire (Stereotaxis, St Louis, MO, USA). A novel software that performs a three-dimensional (3D) reconstruction of vessels based on two or more angiographic views has been developed recently (CardiOp-B system, Paeion Inc., Haifa, Israel). The objective of this paper is to evaluate: (i) the performance of the 3D reconstruction software which reproduce the anatomy of the coronary sinus (CS) and (ii) the efficacy of remotely navigating a magnetic guidewire within the CS based on this reconstruction. METHODS AND RESULTS: In patients undergoing cardiac resynchronization therapy implantation, a 3D reconstruction of the CS was performed using the CardiOp-B system. Accuracy of the reconstruction was evaluated by comparing with the CS angiogram. This reconstruction was imported into the Stereotaxis system. On the basis of the reconstruction, magnetic vectors were automatically selected to navigate within the CS and manually adjusted if required. Feasibility of deploying the guidewire and LV lead into the selected side branch (SB), fluoroscopy time (FT) required for cannulation of the target SB, and total FT were also evaluated. Sixteen patients were included. In one case, the software could not reconstruct the CS. The quality of the reconstruction was graded as good in 13 and poor in 2. In 10 cases, manual adjustments to the traced edges of the CS were required to perform the 3D reconstruction, and in 5, no adjustments were required. In 13 patients, the target SB was engaged on the basis of the automatically selected vectors. In two cases, manual modification of the vector was required. Mean total FT was 23 +/- 14 min and the FT required to cannulate the target SB was 1.7 +/- 1.3 min. CONCLUSION: A 3D reconstruction of the CS can be accurately performed using two angiographic views. This reconstruction allows precise magnetic navigation of a guidewire within the CS.

Morphology discrimination in implantable cardioverter-defibrillators: consistency of template match percentage during atrial tachyarrhythmias at different heart rates.

BACKGROUND: Morphology discrimination (MD) in implantable cardioverter-defibrillators (ICDs) is based on the comparison of the ventricular electrogram during tachycardia with a stored reference template obtained during baseline rhythm. However, the effect of heart rate on the template match percentage during supraventricular tachyarrhythmias (SVT) is not known. The purpose of this study was to evaluate the performance of the template match percentage during SVT at different heart rates. METHODS AND RESULTS: Stored electrograms of 868 tachyarrhythmias from 88 patients with a dual-chamber ICD (St Jude Medical, USA) were analysed by the investigators. The effect of heart rate on template match percentage was estimated by regression analysis. For performance measures, data were corrected for multiple episodes in a patient by using the generalized estimating equation method. The mean template match percentage was 86.6 +/- 22.2% (median 100%) for SVT episodes. No significant differences in template match percentage between fast [ventricular cycle length (CL) 300-350 ms] and slow (ventricular CL >400 ms) SVTs were observed (85.4 +/- 27.0 vs. 87.1 +/- 19.7%). Using nominal settings, MD alone provided sensitivity and specificity of 70.2% and 89.4% overall, respectively. Morphology discrimination in conjunction with rate branch analysis, sudden onset, and stability yielded sensitivity and specificity of 98.5% and 91.2%, respectively. CONCLUSION: Morphology discrimination has a consistently high template match percentage during SVTs, which is independent of ventricular CL. The consistent high match percentage results in high specificity for arrhythmia discrimination.

Magnetic navigation in left-sided AV reentrant tachycardias: preliminary results of a retrograde approach.

INTRODUCTION: A novel magnetic navigation system allows remote guidance of floppy radiofrequency (RF) ablation catheters. We evaluated the feasibility of mapping and ablation of left-sided accessory pathways (APs) using the retrograde transaortic approach with this system. This might open the gate to retrograde ablation of left atrial arrhythmias. METHODS AND RESULTS: Twenty consecutive patients were included. A Helios II was used in five and in 15 a Celsius RMT RF catheter with higher magnetic mass and different flexibility was used. Mapping and ablation were attempted. The learning curve was analyzed. Ablation was acutely successful in 60% of the patients using the Helios II and in 80% using the Celsius RMT. Median procedure time was 158 minutes, with median patient and physician fluoroscopy times of 26 and 4 minutes. In the last 10 patients, procedure times became significantly shorter (median 122 minutes, only Celsius RMT catheters) and standard catheters had to be used only twice. No complications occurred. CONCLUSIONS: Remote retrograde transaortic RF ablation of left-sided APs is feasible, safe, and reduces the physician's fluoroscopy exposure. There is a very steep initial learning curve, with the success rate increasing from 50% in the first 10 cases to 80% in the last 10 cases. Different catheter configurations may influence the outcome.