Safety of Sports for Patients with Subcutaneous Implantable Cardioverter Defibrillator (SPORT S-ICD): study rationale and protocol.

Background: Recent studies suggest that participation in recreational and even competitive sports is generally safe for patients with implantable cardioverter-defibrillators (ICDs). However, these studies included only patients with implanted transvenous ICD (TV-ICD). Nowadays, subcutaneous ICD (S-ICD) is a safe and effective alternative and is increasingly implanted in younger ICD candidates. Data on the safety of sport participation for patients with implanted S-ICD systems is urgently needed. Objectives: The goal of the study is to quantify the risks (or determine the safety) of sports participation for athletes with an S-ICD, which will guide shared decision making for athletes requiring an ICD and/or wishing to return to sports after implantation. Methods: The SPORT S-ICD (Sports for Patients with Subcutaneous Implantable Cardioverter Defibrillator) study is an international, multicenter, prospective, noninterventional, observational study, designed specifically to collect data on the safety of sports participation among patients with implanted S-ICD systems who regularly engage in sports activities. Results: A total of 450 patients will undergo baseline assessment including baseline characteristics, indication for S-ICD implantation, arrhythmic history, S-ICD data and programming, and data regarding sports activities. LATITUDE Home Monitoring information will be regularly transferred to the study coordinator for analysis. Conclusion: The results of the study will aid in shaping clinical decision making, and if the tested hypothesis will be proven, it will allow the safe continuation of sports for patients with an implanted S-ICD.

Electromechanical Window and Spontaneous Ventricular Tachyarrhythmias in Takotsubo Syndrome.

QT interval prolongation is common in patients hospitalized with Takotsubo syndrome (TTS), however, only a minority experience ventricular tachyarrhythmias. Our aim was to characterize the electromechanical window (EMW) in patients with TTS and to evaluate its association with ventricular tachyarrhythmias. We preformed aretrospective analysis of 84 patients hospitalized with TTS in the Tel-Aviv Medical Center between 2013 and 2022. All patients underwent a comprehensive echocardiographic evaluation and the EMW was calculated by subtracting the QT interval from the QRS onset to the aortic valve closure obtained from a continuous-wave Doppler for the same beat. Of the 84 patients with TTS, 74 (88%) were female and the mean age was 70 ± 11 years. The mean left ventricular ejection fraction was 42 ± 8%. The EMW was negative in 81 patients (96%), and the mean EMW was -69 ± 50 ms. Ventricular tachyarrhythmias occurred in 7 patients (8%). The EMW of patients who experienced ventricular tachyarrhythmias was more negative than patients who did not (-133 ± 23 ms vs -63 ± 48 ms, p = 0.001). In the univariate analysis, EMW and QT were associated with ventricular tachyarrhythmias (univariate odds ratio [OR]EMW 1.03, 95% confidence interval [CI] 1.01 to 1.05, p = 0.003 and univariate ORQTc 1.02, 95% CI 1.01 to 1.03, p = 0.02); however, only EMW remained significant in the multivariate analysis (OREMW 1.03 95% CI 1.03 to 1.05, p = 0.023). EMW was more effective than corrected QT interval in identifying patients who had ventricular tachyarrhythmias (AUCEMW: 0.89, 95% CI 0.82 to 0.97 vs AUCQTc 0.77, 95% CI 0.61 to 0.93, p = 0.02), and a cut-off value of -108 ms was predictive of ventricular tachyarrhythmias with a sensitivity of 86% and a specificity of 79%. In conclusion, EMW is negative in patients with TTS and is associated with increased risk for ventricular tachyarrhythmias. The role of EMW in the risk stratification of patients with TTS warrants further investigation.

Left Atrial Appendage Occlusion versus Novel Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation-One-Year Survival.

Aim To compare the 1-year survival rate of patients with atrial fibrillation (AF) following left atrial appendage occluder (LAAO) implantation vs. treatment with novel oral anticoagulants (NOACs). METHODS: We have conducted an indirect, retrospective comparison between LAAO and NOAC registries. The LAAO registry is a national prospective cohort of 419 AF patients who underwent percutaneous LAAO between January 2008 and October 2015. The NOACs registry is a multicenter prospective cohort of 3138 AF patients treated with NOACs between November 2015 and August 2018. Baseline patient characteristics were retrospectively collected from coded diagnoses of hospitalization and outpatient clinic notes. Follow-up data was sorted from coded diagnoses and the national civil registry. Subjects were matched according to propensity score. Baseline characteristics were compared using Chi-Square and student's t-test. Survival analysis was performed using Kaplan-Meier survival curves, log-rank test, and multivariable Cox regression, adjusting for possible confounding variables. RESULTS: This study included 114 subjects who underwent LAAO implantation and 342 subjects treated with NOACs. The mean age of participants was 77.9 ± 7.44 and 77.1 ± 11.2 years in the LAAO and NOAC groups, respectively (p = 0.4). The LAAO group had 70 (61%) men compared to 202 (59%) men in the NOAC group (p = 0.74). No significant differences were found in baseline comorbidities, renal function, or CHA2DS2-VASc score. One-year mortality was observed in 5 (4%) patients and 32 (9%) patients of the LAAO and NOAC groups, respectively. After adjusting for confounders, LAAO was significantly associated with a lower risk for 1-year mortality (HR 0.38, 95%CI 0.14-0.99). In patients with impaired renal function, this difference was even more prominent (HR 0.21 for creatinine clearance (CrCl) < 60 mL/min). CONCLUSIONS: In a pooled analysis of two registries, we found a significantly lower risk for 1-year mortality in patients with AF who were implanted with LAAO than those treated with NOACs. This finding was more prominent in patients with impaired renal function. Future prospective direct studies should further investigate the efficacy and adverse effects of both treatment strategies.

Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections.

BACKGROUND: Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES: The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS: The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS: A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS: CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).

Arrhythmogenic Effects of Cardiac Memory.

Cardiac memory is the term used to describe an interesting electrocardiographic phenomenon. Whenever a QRS complex is wide and abnormal, such as during ventricular pacing, the T waves will also be abnormal and will point to the opposite direction of the wide QRS. If the QRS then normalizes, such as after cessation of ventricular pacing, the T waves will normalize as well, but at a later stage. The period of cardiac memory is the phase between the sudden normalization of the QRS and the eventual and gradual return of the T waves to their baseline morphology. Cardiac memory is assumed to be an innocent electrocardiographic curiosity. However, during cardiac memory, reduction of repolarizing potassium currents increases left ventricular repolarization gradients. Therefore, when cardiac memory occurs in patients who already have a prolonged QT interval (for whatever reason), it can lead to a frank long QT syndrome with QT-related ventricular arrhythmias (torsades de pointes). These arrhythmogenic effects of cardiac memory are not generally appreciated and are reviewed here for the first time.

Reconstruction of the left atrium for atrial fibrillation ablation using the machine learning CARTO 3 m-FAM software.

PURPOSE: Atrial fibrillation (AF) ablation requires a precise reconstruction of the left atrium (LA) and pulmonary veins (PV). Model-based FAM (m-FAM) is a novel module recently developed for the CARTO system which applies machine learning techniques to LA reconstruction. We aimed to evaluate the feasibility and safety of a m-FAM-guided AF ablation as well as the accuracy of LA reconstruction using the cardiac computed tomography angiography (CTA) of the same patient LA as the gold standard, in 32 patients referred for AF ablation. METHODS: Consecutive patients undergoing AF ablation. The m-FAM reconstruction was performed with the ablation catheter (group 1) or a Pentaray and ablation catheters (group 2). The reconstruction accuracy was confirmed prior to the ablation by verification of pre-specified landmarks of the LA and PVs by an intracardiac echocardiogram (ICE) visualization and fluoroscopy. A cardiac CTA performed before the ablation was used as the gold standard of LA anatomy. For each patient, the m-FAM reconstruction was compared to his/her cardiac CTA. RESULTS: The m-FAM reconstruction was accurate in all patients regardless of the catheter used for mapping. Twelve percent re-acquisition of the LA landmarks was necessary to improve the accuracy. m-FAM time was shorter in group 2 while the M-Fam fluoroscopy time was similar. Pulmonary vein isolation was achieved in 100% of patients without major complications. The m-FAM reconstructions accurately resemble the cardiac CTA of the same patients. CONCLUSIONS: The m-FAM module allows for rapid and precise reconstruction of the LA and PV anatomy, which can be safely used to guide AF ablation.

Radial strain imaging-guided lead placement for improving response to cardiac resynchronization therapy in patients with ischaemic cardiomyopathy: the Raise CRT trial.

AIMS: To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. METHODS AND RESULTS: We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. CONCLUSION: Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.

QT interval dynamics in patients with ST-elevation MI.

Background: An association between excessively prolonged QT and ventricular arrhythmia in patients with ST-elevation myocardial infarction has been described; however, the QT dynamics, characterization, and long-term predictive value are not well known. Objective: To characterize QT interval dynamics in patients undergoing ST elevation myocardial infarction (STEMI) and determine its association with mortality. Methods: A retrospective analysis of 4,936 consecutive patients, hospitalized for STEMI between 01/2013-12/2021. Patients with less than three electrocardiograms (ECGs) during index hospitalization were excluded. Baseline demographics, cardiovascular history, clinical risk factors, treatment measures, laboratory results, and mortality data were retrieved from the hospital's electronic medical records. Results: We included 1,054 patients and 5,021 ECGs in our cohort with a median follow-up of 6 years [interquartile range (IQR) 4.3-7.4 years]. The QT was longer in women in comparison to men (428.6 ms ± 33.4 versus 419.8 ms ± 32.52, P-value = 0.001). QT prolongation was greater in females, elderly patients, and patients with STEMI caused by occlusion of the left anterior descending (LAD) coronary artery. We determined QT cutoff to be 445 ms. This value of QT divided our cohort upon arrival into a long QT group (217 patients, 26% of the cohort) and a "normal" QT group (835 patients, 74% of the cohort). The long QT group experienced an increase in combined short and long terms all-cause mortality. The QT upon arrival, on day 2 of hospitalization, and before discharge from the hospital, correlated with long-term mortality. Conclusion: QT duration is often prolonged during STEMI; this prolongation is associated with increased mortality and adverse events. Gender is an important mediator of QT dynamics.

Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy.

Polymorphic ventricular tachyarrhythmias are highly lethal arrhythmias. Several types of polymorphic ventricular tachycardia have similar electrocardiographic characteristics but have different modes of therapy. In fact, medications considered the treatment of choice for one form of polymorphic ventricular tachycardia, are contraindicated for the other. Yet confusion about terminology, and thus diagnosis and therapy, continues. We present an in-depth review of the different forms of polymorphic ventricular tachycardia and propose a practical step-by-step approach for distinguishing these malignant arrhythmias.

Continuous Heart Rate Monitoring for Automatic Detection of Life-Threatening Arrhythmias With Novel Bio-Sensing Technology.

Aims: Assessing the effectiveness of novel bio-sensing technology (CardiacSense), for accuracy and reliability of automatic detection of life-threatening arrhythmias. Methods and Results: This prospective study consisted of Eighteen patients (13 males and 5 females, mean age 59.4 ± 21.3 years) undergoing induction of ventricular tachycardia/fibrillation or provocation of transient ventricular asystole. We tested the detection of provoked ventricular arrhythmias by a wrist-worn watch-like device which uses photoplethysmography (PPG) technology to detect the cardiac rhythm. We used simultaneous electrocardiographic (ECG) recordings as gold standard for arrhythmia definition and confirmation of beat-to-beat detection. A total of 1,527 QRS complexes were recorded simultaneously by ECG and PPG. The overall correlation between the ECG (R-R intervals) and the PPG (G-G intervals) was high, with a correlation coefficient of R = 0.949 (p < 0.001). The device accurately detected all events of mimicked life endangering arrhythmias, including five events of transient (adenosine-induced) ventricular asystole as well as seven episodes of monomorphic ventricular tachycardia and 6 events of ventricular fibrillation. Conclusion: This proof-of-concept study suggests that wearable devices using PPG technology, currently used to detect atrial fibrillation, may also have a role as automatic detectors of life-threatening arrhythmias.

Comparison of permanent pacemaker implantation rate after first and second generation of transcatheter aortic valve implantation-A retrospective cohort study.

OBJECTIVES: This study aimed to compare permanent pacemaker implantation (PPMI) rates among patients undergoing Trans-catheter Aortic Valve Implantation (TAVI) with first generation (G1) versus second generation (G2) valves and the impact of PPMI on long-term mortality. BACKGROUND: PPMI is a known adverse event after TAVI. Recently, two novel iterations of valve designs of both the balloon expandable valves (BEV) and self-expanding valves (SEV) were introduced as a second generation valves. METHODS: All patients included in the Israeli multicenter TAVI registry were grouped according to valve type (BEV vs. SEV) and generation (G1 vs. G2). A comparison was made for clinical and outcome indices of patients undergoing TAVI with G1 and G2 in each of the valve systems. RESULTS: A total of 1377 patients were included. The incidence of PPMI did not differ between G1-BEV versus G2-BEV (15.3% vs. 17.4%; p = 0.598) nor between G1-SEV versus G2-SEV (23.4% vs. 20.3%; p = 0.302). Depth of implantation and complete right bundle branch block were independently associated with PPMI post-TAVI in both valve systems. PPMI was not associated with an increased risk for 2-year mortality. CONCLUSIONS: The incidence of PPMI remains a relevant adverse event post-TAVI even when the newer generation valves are used. Since the predictors for PPMI are well established, a standardized approach for the management of conduction disorders is much needed.

Arrhythmic storm from ischemic ventricular fibrillation treated with intravenous quinidine.

We present a case who developed an acute right ventricular infarction. The leads demonstrating ST-segment elevation were different than those expected based on previous publications. We explain why this happened with the aid of 3-dimentional imaging. Our case then developed an arrhythmic storm caused by ischemic ventricular fibrillation (VF). Emergency revascularization failed and the VF-storm failed to respond to sedation, lidocaine and amiodarone but responded to intravenous quinidine.

Clinically Significant High-Grade AV Block as a Reversible Cause for Acute Kidney Injury in Hospitalized Patients-A Propensity Score Matched Cohort.

Background. High-grade AV block (HGAVB) is a life-threatening condition. Acute kidney injury (AKI) which is usually caused by renal hypo-perfusion is associated with adverse outcomes. We aimed to investigate the association between AKI and HGAVB. Methods. This is a retrospective cohort comparing the incidence of AKI among patients with HGAVB requiring pacemaker implantation compared with propensity score matched controls. Primary outcome was the incidence of AKI at admission. Secondary outcomes were change in creatinine levels, AKI during stay, recovery from AKI, mortality and major adverse kidney events (MAKE). Results. In total, 80 HGAVB patients were compared to 400 controls. HGAVB patients had a higher proportion of admission AKI compared to controls (36.2% versus 21.1%, RR = 1.71 [1.21-2.41], p = 0.004). Creatinine changes from baseline to admission and to maximum during hospitalization, were also higher in HGAVB (p = 0.042 and p = 0.033). Recovery from AKI was more frequent among HGAVB patients (55.2% vs. 25.9%, RR = 2.13 [1.31-3.47], p = 0.004) with hospitalization time, MAKE and crude mortality similar (p > 0.158). Conclusions. AKI occurs in about one third of patients admitted with HGAVB, more frequent compared to controls. Patients with AKI accompanying HGAVB were likelier to recover from AKI. Further studies to explore this relationship could aid in clinical decision making for HGAVB patients.

Pulmonary Vein Isolation With Ablation Index via Single Transseptal Crossing: Critical Role of Carina Isolation.

AIM: Reconnection of the pulmonary veins (PVs) is the most common reason for the recurrence of atrial fibrillation (AF). The ablation index is a marker of ablation lesion quality that achieves high percentages of first-pass isolation and improved AF ablation results. Most operators use a double transseptal approach with confirmation of PV isolation with a circular mapping catheter. In the present study we aimed to show that an ablation index-guided procedure using a single transseptal approach and ablation catheter only would achieve adequate PV isolation while demonstrating the critical role of the carina in PV isolation. METHOD: Sixty-six (66) consecutive patients with paroxysmal AF were included. Thirty-four (34) patients underwent wide antral circumferential ablation (WACA-only) and 32 underwent WACA+ (WACA + empiric carina isolation). All procedures were performed via single transseptal approach. Pulmonary vein isolation was confirmed with the use of a circular mapping catheter in both groups. RESULTS: Compared to WACA-only, WACA+ increased the odds of PV isolation from 65% to 94% (p=0.011). In the WACA-only procedure, ablation of the carina was needed to achieve PV isolation. At the 18-month follow-up (interquartile range 15.2-20.8 months), freedom from AF was 84% for the entire cohort. CONCLUSIONS: Our study confirmed the high success rate of PV isolation using the ablation index and showed that this can be achieved via a single transseptal crossing. Our study confirmed the role of the carina in PV isolation.