Sergio Thal

Prognostic Value of Electrocardiographic Measurements Before and After Cardiac Resynchronization Device Implantation in Patients With Heart Failure due to Ischemic or Nonischemic Cardiomyopathy

Postimplant QRS narrowing may predict clinical response after cardiac resynchronization therapy (CRT), but identification of nonresponders remains difficult. We studied the predictive value of electrocardiographic characteristics for mortality or cardiac transplantation in patients after CRT. Patients who had electrocardiograms available for review from before and after CRT device implantation were identified from a clinical database. Bivariate and multivariate Cox regression analyses were performed for the end point of death or transplantation. Of 337 patients (age 65+/-12 years, 76% men, left ventricular ejection fraction 22+/-12%, pre-QRS 175+/-30 ms), 84 died and 7 underwent transplantation during a follow-up of 27+/-15 months. Variables predictive of death or transplantation included QRS increase after CRT (45% vs 32%, p=0.03), older age, higher New York Heart Association class, lower left ventricular ejection fraction, and higher tertile of postimplant QRS (p=0.04), but not preimplant rhythm, QRS duration, or QRS morphology. After adjusting for confounding variables, independent predictors of mortality were older age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.00 to 1.05, p=0.04), lack of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (HR 2.17, 95% CI 1.16 to 4.08, p<0.02), and longer postimplant QRS by tertile (HR 1.50, 95% CI 1.09 to 2.05, p=0.01). In conclusion, wider QRS after CRT device implantation is an independent predictor of mortality or transplantation. In patients with increased QRS durations despite CRT, closer follow-up or reassessment for alternative management strategies may be warranted.

Novel applications in catheter ablation.

Catheter based treatment of arrhythmia has gained significant attention during the last two decades. Due to the explosive development in ablation treatment of atrial fibrillation, huge interest in new tools was born to help in the atrial fibrillation ablation procedures. The aim of this review is to describe the role of these novel techniques and tools aimed at improving the implementation of catheter based ablations of atrial arrhythmias by focusing on the use of intra-cardiac echocardiogram and robotic navigation.

Is there an association between external cardioversions and long-term mortality and morbidity? Insights from the Atrial Fibrillation Follow-up Investigation of Rhythm Management study.

Background— Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. Methods and Results— We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P<0.0001). Conclusions— In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.Background —Cardiac electrical therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardiac defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regards to cardiovascular mortality and morbidity. Methods and Results —We analyzed the data of the 4,060 patients from the AFFIRM trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality and hospitalizations post ECVe were studied. Over an average follow-up of 3.5 years, 660 patients (16.3%) died, 331(8.2%) from cardiovascular causes. A total of 207(5.1%) and 1697(41.8%) patients had low ejection fraction (EF) and non-paroxysmal atrial fibrillation (AF) respectively. 2460 patients received no ECVe; while 1600 experienced ≥1 ECVe. Death occurred in 412(16.7%), 196(16.5%), 39(13.5%), and 13(10.4%) of patients with 0, 1, 2, and ≥3 ECVe respectively. There was no significant association between ECVe and mortality within any of the four subgroups defined by EF and AF type, although myocardial infarction (MI), coronary artery bypass graft (CABG), and digoxin were significantly associated with death (Estimated hazard ratios: 1.65; 1.59 and 1.62 respectively, p<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% vs. 5.8%; Estimated odds ratio: 1.39, p<0.0001). Conclusions —In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, MI, and CABG were significantly associated with mortality.

Is there an Association Between External Cardioversions and Long Term Mortality and Morbidity - Insights from the AFFIRM Study

Background— Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. Methods and Results— We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P<0.0001). Conclusions— In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.Background —Cardiac electrical therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardiac defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regards to cardiovascular mortality and morbidity. Methods and Results —We analyzed the data of the 4,060 patients from the AFFIRM trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality and hospitalizations post ECVe were studied. Over an average follow-up of 3.5 years, 660 patients (16.3%) died, 331(8.2%) from cardiovascular causes. A total of 207(5.1%) and 1697(41.8%) patients had low ejection fraction (EF) and non-paroxysmal atrial fibrillation (AF) respectively. 2460 patients received no ECVe; while 1600 experienced ≥1 ECVe. Death occurred in 412(16.7%), 196(16.5%), 39(13.5%), and 13(10.4%) of patients with 0, 1, 2, and ≥3 ECVe respectively. There was no significant association between ECVe and mortality within any of the four subgroups defined by EF and AF type, although myocardial infarction (MI), coronary artery bypass graft (CABG), and digoxin were significantly associated with death (Estimated hazard ratios: 1.65; 1.59 and 1.62 respectively, p<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% vs. 5.8%; Estimated odds ratio: 1.39, p<0.0001). Conclusions —In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, MI, and CABG were significantly associated with mortality.

Impact of Right Ventricular Pacing in Patients Who Underwent Implantation of Permanent Pacemaker After Transcatheter Aortic Valve Implantation

Atrioventricular conduction disturbances requiring implantation of permanent pacemaker (PPM) are a common complication following transcatheter aortic valve implantation (TAVI). Previous registry data are conflicting but suggestive of an increased risk in heart failure admissions in the post-TAVI PPM cohort. Given the expanding use of TAVI, the present study evaluates the effects of chronic right ventricular pacing (RV pacing) in post-TAVI patients. This is a single-center study of 672 patients who underwent TAVI from 2011 to 2017 of which 146 underwent PPM. Follow-up 1-year post-TAVI outcome data were available for 55 patients and were analyzed retrospectively. Patients who underwent PPM were more likely to have heart failure admissions (17.1% vs 10.1%; hazard ratio [HR] 1.70; 95% confidence interval [CI] 1.10 to 2.64; p 0.019) and a trend toward increased mortality (21.9% vs 15.4%; HR 1.42; 95% CI 0.99 to 2.05; p 0.062). At 1-year follow-up, 30 of 55 (54.5%) patients demonstrated >40% RV pacing. Compared with patients who had <40% RV pacing, those with >40% RV pacing were more likely to have heart failure admissions (8% vs 40%; HR 5.0; 95% CI 1.23 to 20.27; p 0.007) and demonstrated a trend toward increased mortality (12% vs 33.3%; HR 2.78; 95% CI 0.86 to 9.00; p 0.064). This is suggestive that the post-TAVI PPM cohort is particularly sensitive to chronic RV pacing.

Is There an Association Between External Cardioversions and Long-Term Mortality and Morbidity?Clinical Perspective: Insights From the Atrial Fibrillation Follow-Up Investigation of Rhythm Management Study

Background— Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. Methods and Results— We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P<0.0001). Conclusions— In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.Background —Cardiac electrical therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardiac defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regards to cardiovascular mortality and morbidity. Methods and Results —We analyzed the data of the 4,060 patients from the AFFIRM trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality and hospitalizations post ECVe were studied. Over an average follow-up of 3.5 years, 660 patients (16.3%) died, 331(8.2%) from cardiovascular causes. A total of 207(5.1%) and 1697(41.8%) patients had low ejection fraction (EF) and non-paroxysmal atrial fibrillation (AF) respectively. 2460 patients received no ECVe; while 1600 experienced ≥1 ECVe. Death occurred in 412(16.7%), 196(16.5%), 39(13.5%), and 13(10.4%) of patients with 0, 1, 2, and ≥3 ECVe respectively. There was no significant association between ECVe and mortality within any of the four subgroups defined by EF and AF type, although myocardial infarction (MI), coronary artery bypass graft (CABG), and digoxin were significantly associated with death (Estimated hazard ratios: 1.65; 1.59 and 1.62 respectively, p<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% vs. 5.8%; Estimated odds ratio: 1.39, p<0.0001). Conclusions —In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, MI, and CABG were significantly associated with mortality.

Is There an Association Between External Cardioversions and Long-Term Mortality and Morbidity?Clinical Perspective

Background— Cardiac electric therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardioverter-defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regard to cardiovascular mortality and morbidity. Methods and Results— We analyzed the data of the 4060 patients from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality, and hospitalizations after ECVe were studied. Over an average follow-up of 3.5 years, 660 (16.3%) patients died, 331 (8.2%) from cardiovascular causes. A total of 207 (5.1%) and 1697 (41.8%) patients had low ejection fraction and nonparoxysmal atrial fibrillation, respectively; 2460 patients received no ECVe, whereas 1600 experienced ≥1 ECVe. Death occurred in 412 (16.7%), 196 (16.5%), 39 (13.5%), and 13 (10.4%) of patients with 0, 1, 2, and ≥3 ECVe, respectively. There was no significant association between ECVe and mortality within any of the 4 subgroups defined by ejection fraction and atrial fibrillation type, although myocardial infarction, coronary artery bypass graft, and digoxin were significantly associated with death (estimated hazard ratios, 1.65, 1.59, and 1.62, respectively; P<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% versus 5.8%; estimated odds ratio, 1.39; P<0.0001). Conclusions— In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, myocardial infarction, and coronary artery bypass graft were significantly associated with mortality.Background —Cardiac electrical therapies effectively terminate tachyarrhythmias. Recent data suggest a possible increase in long-term mortality associated with implantable cardiac defibrillator shocks. Little is known about the association between external cardioversion episodes (ECVe) and long-term mortality. We sought to assess the safety of repeated ECVe with regards to cardiovascular mortality and morbidity. Methods and Results —We analyzed the data of the 4,060 patients from the AFFIRM trial. In particular, associations of ECVe with all-cause mortality, cardiovascular mortality and hospitalizations post ECVe were studied. Over an average follow-up of 3.5 years, 660 patients (16.3%) died, 331(8.2%) from cardiovascular causes. A total of 207(5.1%) and 1697(41.8%) patients had low ejection fraction (EF) and non-paroxysmal atrial fibrillation (AF) respectively. 2460 patients received no ECVe; while 1600 experienced ≥1 ECVe. Death occurred in 412(16.7%), 196(16.5%), 39(13.5%), and 13(10.4%) of patients with 0, 1, 2, and ≥3 ECVe respectively. There was no significant association between ECVe and mortality within any of the four subgroups defined by EF and AF type, although myocardial infarction (MI), coronary artery bypass graft (CABG), and digoxin were significantly associated with death (Estimated hazard ratios: 1.65; 1.59 and 1.62 respectively, p<0.0001). ECVe were associated with increased cardiac hospitalization reported at the next follow-up visit (39.3% vs. 5.8%; Estimated odds ratio: 1.39, p<0.0001). Conclusions —In the AFFIRM study, there was no significant association between ECVe and long-term mortality, even though ECVe were associated with increased hospitalizations from cardiac causes. Digoxin, MI, and CABG were significantly associated with mortality.

P.1. Supraventricular Arrhythmias

Objectives We report the first clinical experiences with the CARTO-Merge (Biosense-Webster, Diamond Bar, CA, USA) combined with intracardiac ultrasound (ICE) (Acuson, Mountain View, CA, USA) both used for navigation and catheter ablation of atrial fibrillation (AF). Methods 18 patients (15 men, 61±10 years) underwent pulmonary vein antrum isolation for symptomatic, drug-resistant AF using Lasso catheter, ICE and CARTO-Merge. The latter system integrated 3D CTA images of the left atrium and pulmonary veins with virtual CARTO maps. Firstly, 3-4 points (Landmarks) were registered on CTA scan according to the real-time position on the electroanatomical map, than 20-40 surface points of the CARTO map were added to finish the registration of the CT scan. Subsequently, the 3D CT anatomical map was used for catheter navigation. Correlation between this reconstruction, ICE and fluoroscopy was documented. Accuracy of the system was evaluated by the software statistical analysis. Results The mean surface inaccuracy was: 2.1±1.6 mm and the mean Landmarks inaccuracy was 8.9±3.0 mm, which reaches the recommended range. Conclusion This novel system appears to have a reliable correlation between CTA and real-time CARTO maps.

P.1. Supraventricular ArrhythmiasP.1.25 First Clinical Experience with CARTO Merge and Intracardiac Ultrasound

Objectives We report the first clinical experiences with the CARTO-Merge (Biosense-Webster, Diamond Bar, CA, USA) combined with intracardiac ultrasound (ICE) (Acuson, Mountain View, CA, USA) both used for navigation and catheter ablation of atrial fibrillation (AF). Methods 18 patients (15 men, 61±10 years) underwent pulmonary vein antrum isolation for symptomatic, drug-resistant AF using Lasso catheter, ICE and CARTO-Merge. The latter system integrated 3D CTA images of the left atrium and pulmonary veins with virtual CARTO maps. Firstly, 3-4 points (Landmarks) were registered on CTA scan according to the real-time position on the electroanatomical map, than 20-40 surface points of the CARTO map were added to finish the registration of the CT scan. Subsequently, the 3D CT anatomical map was used for catheter navigation. Correlation between this reconstruction, ICE and fluoroscopy was documented. Accuracy of the system was evaluated by the software statistical analysis. Results The mean surface inaccuracy was: 2.1±1.6 mm and the mean Landmarks inaccuracy was 8.9±3.0 mm, which reaches the recommended range. Conclusion This novel system appears to have a reliable correlation between CTA and real-time CARTO maps.