Effects of contemporary hard- and software mapping and ablation features on acute and long-term success in premature ventricular complex ablation.

BACKGROUND: Current standards of ablation of premature ventricular complexes (PVC) combine modern hard- and software mapping and ablation features like multielectrode mapping catheters (MEC), contact force (CF) guided ablation catheters and pattern matching filters (PMF). Benefits of these individual tools were described for selected patients with PVC, but data on combination of these features in the real world setting is sparse. METHODS: Between 2015 and 2021 we retrospectively enrolled 172 consecutive patients undergoing PVC ablation in our center. The utilization of MEC, CF guided ablation catheters and PMF software was analyzed in terms of procedural data, acute and long-term success after 12 months. RESULTS: Acute ablation success was reached in 71% of patients (n = 118) with an overall recurrence rate of 34% after 12 months. PMF software was used in 130 patients (78%), MEC in 131 patients (79%) and ablation was guided using CF in 99 patients (60%). PMF significantly reduced procedural duration and time of radiofrequency application (RF, 150 vs. 185 min, p 0.04 and 325 vs. 556 min, p 0.01). CF enabled significantly shorter radiation time (7.9 vs. 12.3 min, p 0.01), whereas MEC did not influence procedural data. Acute and long-term outcomes were not affected by these modern mapping and ablation features, yet, multivariable regression analysis revealed an underlying cardiomyopathy and the respective focus as independent predictors for recurrence. CONCLUSION: Contemporary hard- and software mapping and ablation features could reduce procedural, radiation and RF time in PVC ablation. Furthermore, patient characteristics rather than technical factors alter outcome of this all-comer collective.

Prevalence, management, and prediction of venous access site occlusion in patients undergoing lead revision surgery.

BACKGROUND: Implantable electronic cardiac devices (CIED) have emerged as an essential component in the treatment of cardiac arrhythmias and heart failure. Due to increased life expectancy, expanding indications and limited technical survival, an increasing number of revision procedures can be anticipated. Venous access site occlusion (VASO) is the main obstacle during revision surgery. In this retrospective study we evaluated the prevalence, predictive parameters and operative management of venous access site occlusion. METHODS AND RESULTS: Between 01/2016 and 12/2020 304 patients underwent lead revision surgery of transvenous CIED in our department. Prevalence of VASO was 25.7% (n = 78), one patient was symptomatic. Independent predicting clinical parameters were male sex (2.86 (1.39-5.87), p < 0.01) and lead age (1.11 (1.05-1.18), p < 0.01)). Revision surgery despite VASO was successful in 97.4% (n = 76) without prolongation of the total surgery time or higher complication rates. Yet, lead extraction was possible in 92% of patients with VASO vs. 98.2% of patients without VASO (p 0.01). CONCLUSION: VASO is a frequent condition in patients undergoing lead revision surgery, but successful revision is feasible in most cases without preceding lead extraction. However, the lower success rates of lead extractions may be prognostically relevant, especially for younger patients.

Evaluation of a Standardized Training and Adherence Surveillance Programme to Overcome Quality-of-Life Impairments and Enhance Compliance in Patients Treated with Wearable Cardioverter Defibrillator.

Background: Treatment with wearable cardioverter defibrillators (WCD) is a non-invasive, transient therapy option for prevention of sudden cardiac death (SCD) in patients with temporary contraindications for implantation of a permanent cardioverter defibrillator. Due to the constant risk of fatal arrhythmias, compliance is the fundamental requirement for effectiveness of a WCD, but this might be hindered by the poor quality-of-life (QoL) during WCD therapy. In this retrospective single-center study, we examined if a standardized WCD training and adherence surveillance programme could enhance compliance and QoL. Methods: All patients with a prescription for WCD treatment from January 2017 to August 2019 were included and received a standardized WCD training programme. QoL was validated using the modified EQ-5D-3L questionnaire. The findings were compared to a historical, previously published, retrospective cohort from our center (WCD prescription period 03/2012-02/2016), not receiving the additional training programme. Endpoints comprised therapy adherence, arrhythmic episodes, and dimensions of QoL. Results: Ninety-two patients underwent WCD treatment in the study cohort for a median of 49 days. Median daily wear time was enhanced in the study cohort (historical cohort vs study cohort 21.9 vs 23.3 hours/per day, p<0.01) and artefact alarms occurred less frequently (67.9% vs 48.9%, p 0.01). Major restrictions in QoL in the study cohort were found in mobility (48%), daily routine (44%), and sleep (49%), but the dimensions pain (36% vs 4%, p<0.01), mental health (43% vs 29%, p 0.03), and restrictions in daily routine (48% vs 30%, p 0.04) improved. Conclusion: A standardized training and adherence surveillance programme might have beneficial effects on compliance and QoL. As these findings are essential for therapy success, they might potentially lead to a reduction in arrhythmic deaths in upcoming WCD trials.

Impairment of Quality of Life in Patients with Implanted Subcutaneous Cardioverter Defibrillator (S-ICD) Compared to Implanted Transvenous Cardioverter Defibrillator Therapy.

Background: The subcutaneous cardioverter defibrillator (S-ICD) has been shown to be a viable alternative to transvenous ICDs (TV-ICD) in all patients at risk of sudden cardiac death (SCD) but without pacing indication. Aim: The aim of this study was to examine the impact of therapy with current S-ICD devices on quality of life (QoL) in comparison to patients with TV-ICD devices. Methods: In our single-centre study, 52 consecutive patients with S-ICD and 52 matched patients with TV-ICD were analysed. QoL has been assessed by a standardized questionnaire (EQ-5D-3L, modified). Additionally, clinical baseline and follow-up data were evaluated. Results: Two-thirds of the total study population reported restrictions in daily routine compared to their life before ICD implantation. A total of 27.7% of S-ICD patients stated to expect an improvement of QoL by deactivation or explantation of their defibrillator compared to only 6.4% of patients with TV-ICD (p=0.006), which was mainly caused by discomfort and pain from the S-ICD pocket (relevant discomfort and pain in 32.6% vs 11.5%; p<0.01). Limitations: Main limitation of the study is that quality of life was assessed for one single time point only and time since implantation differed significantly between S-ICD and TV-ICD. Furthermore our collective is younger, and, due to the high proportion of patients without cardiomyopathy, the mean EF is better than usual ICD collective. The absence of heart failure in about the half of our patients might have relevant impact on our QoL analysis. Conclusion: A relevant proportion of S-ICD patients expects an improvement of QoL by explantation of the device. Of note, this impression was not driven by the fear of receiving shocks but mainly by discomfort and pain caused by the pulse generator.

Targeted Temperature Management in Postresuscitation Care After Incorporating Results of the TTM2 Trial.

Cardiac arrest still accounts for a substantial proportion of cardiovascular related deaths and is associated with a tremendous risk of neurological injury and, among the few survivors, poor quality of life. Critical determinants of survival and long-term functional status after cardiac arrest are timely initiation of cardiopulmonary resuscitation and use of an external defibrillator for patients with a shockable rhythm. Outcomes are still far from satisfactory, despite ongoing efforts to improve cardiac arrest response systems, as well as elaborate postresuscitation algorithms. Targeted temperature management at the wide range between 32 °C and 36 °C has been one of the main therapeutic strategies to improve neurological outcome in postresuscitation care. This recommendation has been mainly based on 2 small randomized trials that were published 20 years ago. Most recent data derived from the TTM2 (Targeted Hypothermia Versus Targeted Normothermia After Out-of-Hospital Cardiac Arrest) trial, which included 1861 patients, challenge this strategy. It showed no benefit of targeted hypothermia at 33 °C over normothermia at 36 °C to 37.5 °C with fever prevention. Because temperature management at lower temperatures also correlated with an increased risk of side effects without any benefit in the TTM2 trial, a modification of the guidelines with harmonizing temperature management to normothermia might be necessary.

Prevalence of pathological arrhythmia in patients triaged to "cardiac arrhythmia" in the emergency department: a preliminary study.

BACKGROUND: Symptoms caused by cardiac arrhythmia are common problems that lead to presentation to the emergency department. However, the prevalence of pathological heart rhythm in patients triaged for cardiac arrhythmia in the emergency department remains up to now unknown. METHODS AND RESULTS: In this retrospective study, patients triaged for cardiac arrhythmia admitted to the interdisciplinary emergency department of the Ludwig-Maximilians University Hospital in Munich within 1 year were included. Subsequently, cardiac rhythm in the 12-lead electrocardiogram, clinical presentation, admission rate, and diagnosis at discharge was analyzed. A total of 558 out of 39,798 patients were triaged for cardiac arrhythmia. Of these 42.3% of patients showed a pathological heart rhythm on the initial electrocardiogram (66.9% atrial fibrillation, 16.5% atrial flutter, 16.5% others). About 80% presented in emergency severity index III (many resources are needed without critical vitals) conditions. Sixty-two percent of the pathological electrocardiogram group and 60% of the sinus rhythm group of patients were admitted to the hospital, and 34.7% with pathological electrocardiogram underwent invasive investigations (16.8% in the sinus rhythm group). In 43.4% of patients, the diagnosis of cardiac arrhythmia was already known from previous medical contacts. CONCLUSION: A total of 1.8% of patients who presented to our interdisciplinary emergency department were triaged for cardiac arrhythmia. With 49.5%, the hospital admission rate was quite high but the patients presented to the emergency department in our cohort were rarely in critical condition. As a high percentage of our cohort had a history of cardiac arrhythmia, better outpatient management is needed for these patients to reduce emergency department visits and save resources.

Determination of time of death by blinded post-mortem interrogation of cardiac implantable electrical devices.

Postmortal interrogation of cardiac implantable electrical devices (CIED) may contribute to the determination of time of death in forensic medicine. Recent studies aimed to improve estimation of time of death by combining findings from autopsy, CIED interrogation and patients´ medical history. CIED from deceased undergoing forensic autopsy were included, if time of death remained unclear after forensic assessment. CIED explanted from deceased with known time of death were analysed as a control cohort. CIED were sent to our device interrogation lab and underwent analysis blinded for autopsy findings, medical history and police reports. The accuracy of time of death determination and the accuracy of time of death in the control cohort served as primary outcome. A total of 87 CIED were analysed. The determination of time of death was possible in 54 CIED (62%, CI 52-72%). The accuracy of the estimated time of death was 92.3% in the control cohort. Certain CIED type and manufacturers were associated with more successful determination. Blinded postmortal analysis enables a valid determination of the time of death in the majority of CIED. Analysis of explanted CIED in a cardiological core lab is feasible and should be implemented in forensic medicine.

Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology.

The Impella device (Impella, Abiomed, Danvers, MA) is a percutaneous transvalvular microaxial flow pump that is currently used for (1) cardiogenic shock, (2) left ventricular unloading (combination of venoarterial extracorporeal membrane oxygenation and Impella concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion, and coronary blood flow in observational studies and some randomized trials. However, because of the need for large-bore femoral access (14 F for the commonly used Impella CP device) and anticoagulation, the incidences of bleeding and ischemic complications are as much as 44% and 18%, respectively. Hemolysis is reported in as many as 32% of patients and stroke in as many as 13%. Despite the rapidly growing use of the Impella device, there are still insufficient data on its effect on outcome and complications on the basis of large, adequately powered randomized controlled trials. The only 2 small and also underpowered randomized controlled trials in cardiogenic shock comparing Impella versus intra-aortic balloon pump did not show improved mortality. Several larger randomized controlled trials are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock [Danish-German Cardiogenic Shock Trial; NCT01633502]), left ventricular unloading (DTU-STEMI [Door-To-Unload in ST-Segment-Elevation Myocardial Infarction; NCT03947619], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO], and REVERSE [A Prospective Randomised Trial of Early LV Venting Using Impella CP for Recovery in Patients With Cardiogenic Shock Managed With VA ECMO; NCT03431467]) and high-risk percutaneous coronary intervention (PROTECT IV [Impella-Supported PCI in High-Risk Patients With Complex Coronary Artery Disease and Reduced Left Ventricular Function; NCT04763200]).

Single-center experience of ultra-high-density mapping guided catheter ablation of focal atrial tachycardia.

INTRODUCTION: Catheter ablation is the treatment of choice for recurrent focal atrial tachycardia (FAT) as medical therapy is limited. Routinely, a three-dimensional mapping system is used. Whether or not optimized signal detection does improve ablation success rates has not yet been investigated. This retrospective cohort study compared ablation procedures using an ultra-high-density mapping system (UHDM, Rhythmia, Boston Scientific) with improved signal detection and automatic annotation with procedures using a conventional electroanatomic mapping system (CEAM, Biosense Webster, CARTO). METHODS: All patients undergoing ablation for FAT using UHDM or CEAM from April 2015 to August 2018 were included. Endpoints comprised procedural parameters, acute success as well as freedom from arrhythmia 12 months after ablation. RESULTS: A total of 70 patients underwent ablation (48 with UHDM, 22 with CEAM). No significant differences were noted for parameters like procedural and radiation duration, area dose, and RF applications. Acute success was significantly higher in the UHDM cohort (89.6% vs. 68.2%, p = .03). Nevertheless, arrhythmia freedom 12 months after ablation was almost identical (56.8% vs. 60%, p = .87), as more patients with acute success of ablation presented with a relapse during follow-up (35.0 vs. 7.7%, p = .05). CONCLUSION: Acute success rate of FAT ablation might be improved by UHDM, without an adverse effect on procedural parameters. Nevertheless, further research is needed to understand the underlying mechanism for increased recurrence rates after acute successful ablation.

Permanent pacemaker dependency in patients with new left bundle branch block and new first degree atrioventricular block after transcatheter aortic valve implantation.

Conduction disorders with need for permanent pacemaker (PPM) implantation remain frequent complications after transcatheter aortic valve implantation (TAVI). Up to 22% of PPM after TAVI are implanted for new onset left bundle branch block (LBBB) and atrioventricular block (AVB) I. However, clinical benefit and predictors of ventricular pacing in TAVI patients receiving PPM for this indication remain unclear. We retrospectively evaluated pacemaker interrogation data of patients who received a PPM post TAVI for new LBBB and new AVB I. The primary endpoint of this study was relevant ventricular pacing (ventricular pacing rate: Vp ≥ 1%) at the first outpatient pacemaker interrogation. Secondary endpoints were predictors for relevant ventricular pacing. At the first pacemaker interrogation (median follow up at 6.23 [2.8-14.8] months), median ventricular pacing frequency was 1.0% [0.1-17.8]. Out of 61 patients, 36 (59%) had Vp rates ≥ 1%. Patients with frequent ventricular pacing showed longer QRS duration (155 ms ± 17 ms vs. 144 ms ± 18 ms, p = 0.018) at the time of PPM implantation and were less likely treated with a balloon-expandable Edwards Sapiens Valve (39% vs. 12%, p = 0.040). Our findings suggest that the majority of patients with new LBBB and new AVB I after TAVI show relevant ventricular pacing rates at follow up. Further prospective studies are necessary to identify patients at higher risk of pacemaker dependency.

Survival after left ventricular assist device implantation correlates with a novel device-based measure of heart rate variability: the heart rate score.

OBJECTIVES: The heart rate score (HRS) serves as a device-based measure of impaired heart rate variability and is an independent predictor of death in patients with heart failure and a cardiac implantable electrical device. However, no data are available for predicting death from the HRS in patients with end stage heart failure and a left ventricular assist device. METHODS: From November 2011 to July 2018, a total of 56 patients with a pre-existing cardiac implantable electrical device underwent left ventricular assist device implantation at our 2 study sites. The ventricular HRS was calculated retrospectively during the first cardiac implantable electrical device follow-up examination following the index hospitalization. Survival during follow-up was correlated with initial HRS. RESULTS: During the follow-up period, 46.4% of the patients (n = 26) died. The median follow-up period was 33.2 months. The median HRS after the index hospitalization was 41.1 ± 21.8%. More patients with an HRS >65% died compared to patients with an HRS <30% (76.9% vs 14.4%; P = 0.007). CONCLUSIONS: In our multicentre experience, survival of patients after an left ventricular assist device implant correlates with the HRS. After confirmation of our findings in a larger cohort, the effect of rate-responsive pacing will be within the scope of further investigation.

Infection with SARS-CoV-2 in primary care health care workers assessed by antibody testing.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused a pandemic threat of public health during the last month causing more than 10 million infections and 500 000 deceased patients worldwide. Nevertheless, data about risk of infection for health care workers are sparse. METHODS: In a large primary care facility, 151 workers underwent SARS-CoV-2 immunoglobulin G (IgG) testing. In addition, participants had to complete a survey regarding symptoms and their individual risk of infection. RESULTS: Symptoms suspicious for COVID-19 occurred in 72%, fever in 25% of all subjects. Four workers (2.6%, 95% confidence interval 0.8-7.1%) had a positive SARS-CoV-2 antibody testing. None of these was free from COVID-19 suspicious symptoms. Source of infection was presumably professional in three of four individuals. CONCLUSION: Our systematic analysis of SARS-CoV-2 infection in a cohort of health care workers in a large outpatient centre revealed an apparently low rate of 2.6% past SARS-CoV-2 infections. Relative risk for infection following health care profession cannot be derived as data about infection rates in the corresponding general population are lacking.

Security millimetre wave body scanner safe for patients with leadless pacemakers or subcutaneous implantable cardioverter-defibrillators.

PURPOSE: This study was designed to evaluate the electromagnetic interference (EMI) effects and safety of the new security screening millimetre wave body scanners (MWBSs) for patients with rare cardiac implantable electronic devices (CIEDs). METHODS: We identified 73 patients with either entirely subcutaneous implantable cardioverter-defibrillators (S-ICD) or leadless pacemakers (LPM) attending routine device follow-up. CIED programming was optimised for the detection of EMI occurrence, and high-voltage therapy was disabled. Patients then underwent millimetre wave body scans under continuous ECG monitoring. Scanning was performed at the recommended distance as well as in close proximity to the scanner emulating accidental exposure. CIED function was observed for EMI effects. RESULTS: There were no episodes of inhibition of pacing in the leadless pacemaker subgroup, no oversensing in the S-ICD subgroup and no spontaneous device reprogramming in any group. There was no change in pacing or sensing thresholds, and S-ICD vector eligibility remained unchanged after scanning with the MWBS. No CIEDs were identified by the MWBS during the study. CONCLUSION: No EMI events were detected during the use of MWBSs by patients with either S-ICDs or LPMs. This data should be reassuring for patients suggesting that they can undergo security body scans without worries or disclosure of their CIED status.