ABSTRACT
BACKGROUND: To investigate the real-world clinical experience of persistent atrial fibrillation (persAF) ablation using the THERMOCOOL SMARTTOUCH® catheter with contact force (CF)-sensing ability in a prospective, multicenter registry. METHODS: Patients with persAF (excluding long-standing persAF) undergoing ablation were enrolled. Primary adverse events (AEs), 12-month success, quality of life (QoL), and correlation of success with CF were assessed. RESULTS: Overall, 150 patients with persAF (age 61.6 ± 9.4 years; 76.0% male; 90.7% Caucasian; left ventricular ejection fraction 56.9% ± 10.3%; left atrial diameter 41.5 ± 7.9 mm) underwent catheter insertion (safety cohort); 142 met eligibility criteria and were ablated (evaluable cohort). Confirmation of entrance block for all targeted pulmonary veins was achieved in 99.3% of patients. The primary AE rate was 4.0% (6/150), and 12-month success was 63.1% (95% confidence interval: 54.2%-71.4%). A non-significant trend towards higher success was observed in patients with isoproterenol/adenosine challenge vs. those without (73.1% vs. 60.2%, respectively; P=0.065). Investigators stayed within their pre-selected CF working range (catheter-tissue contact stability) 79.7% ± 12.7% of the time. When investigators stayed within the CF range ≥80% vs. <80% of the time, ablation success was 69.2% vs. 58.5%, respectively (P=0.285). QoL improved significantly at 6 months and was sustained through the 12-month follow-up (P<0.0001). CONCLUSIONS: Symptom control in a real-world setting of persAF ablation using the THERMOCOOL SMARTTOUCH® catheter was 63.1%, with significant improvements in QoL, and trended non-significantly towards increased success in patients receiving isoproterenol/adenosine challenge and when investigators stayed within their pre-selected CF range ≥80% of the time.
ABSTRACT
OBJECTIVE: To determine the incremental value of implantable cardioverter defibrillators (ICD) in contemporary optimally treated patients with heart failure (HF) undergoing cardiac resynchronisation therapy (CRT). METHODS: Consecutive patients with HF undergoing CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) implantation in a single tertiary care centre between October 2008 and August 2015 were retrospectively evaluated. For patients with a primary prevention indication of the CRT-D, no benefit of the ICD was defined as absence of appropriate therapy (device analysis) or lethal ventricular tachyarrhythmias (mode of death analysis) during follow-up. RESULTS: 687 patients (CRT-P/CRT-D; n=361/326) were followed for 38±22 months. CRT-P recipients were older (75.7±9.1 vs 71.8±9.3 years; p<0.001) and had a higher comorbidity burden. Five patients with CRT-P (1%) experienced episodes of sustained ventricular-tachycardia vs 64 (20%) patients with CRT-D (p<0.001). Remote tele-monitoring detected the episodes of sustained ventricular tachycardia in four patients with CRT-P, allowing for elective upgrade to CRT-D. All-cause mortality was higher in patients with CRT-P versus CRT-D (21% vs 12%, p=0.003), even after adjusting for baseline characteristics (HR 2.5; 95% CI 1.36 to 4.60; p=0.003). However, mode of death analysis revealed a predominant non-cardiac mode of death in CRT-P recipients (n=47 (71%) vs n=13 (38%) in CRT-D, p=0.002). Multivariate analysis revealed that age >80 years, New York Heart Association class IV, intolerance to beta-blockers and underlying non-ischaemic cardiomyopathy were independently associated with little incremental value of a primary prevention ICD on top of CRT. CONCLUSIONS: The majority of patients with contemporary HF as currently selected for CRT-P exhibit mainly non-cardiac-driven mortality. Weighing risk of ventricular-tachyarrhythmic death versus risk of all-cause mortality helps to address the incremental value of an ICD to CRT-P.
