Long-Term Survival After Implantable Cardiac Defibrillator Therapy According to Sex: A Propensity Matched Study.

Background: Whether the sex factor influences the benefit of the implantable cardioverter-defibrillator (ICD) for the prevention of sudden death remains a subject of debate. Using a prospective registry, we sought to analyze the survival and time to first ICD therapy according to sex. Materials and Methods: Retrospective analysis of a prospective cohort of patients undergoing an ICD implant from 2008 to 2019. Data about time to first appropriate therapy, type of therapy administered, and incidence and causes of mortality were collected. Results: Among 756 ICD patients, 150 (19.8%) were women. Women were younger (51 ± 15 years vs. 61 ± 14 years; p < 0.001) and showed a lower rate of ischemic cardiomyopathy (23% vs. 54%; p < 0.001) and atrial fibrillation (12% vs. 19%; p = 0.05). Women had higher left ventricular ejection fraction (39% ± 17% vs. 35% ± 13%) and showed more frequently left bundle branch block (39% vs. 28%, p = 0.027). The rate of primary prevention (68% vs. 59.6%; p = 0.058) and cardiac resynchronization therapy (27% vs. 19%, p = 0.02) were higher in women. After a median follow-up of 46 months (3382 patient-years), the incidence of both the primary combined endpoint of mortality/transplant (20% vs. 29%; logrank = 0.031) and ICD therapies (27% vs. 34%; p = 0.138) were lower in women. According to the propensity score-matching analysis, no differences were observed between both sexes with respect to the incidence of mortality/transplant (24.8% vs. 28.6%; logrank = 0.88), ICD therapies (28% vs. 27%; logrank = 0.17), and main cause of death (heart failure [HF]). Conclusions: The clinical characteristics at the moment of ICD implant are different between sexes. After adjusting them, both sexes equally benefit from the ICD. HF is the main cause of mortality both in men and women.

Resultados en España de la encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) / Spanish results of the Second European Cardiac resynchronization therapy survey (CRT-Survey II)

Introducción y objetivos: Se describen los resultados en España de la segunda encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) y se comparan con los de los demás países participantes. Métodos: Pacientes a los que se implantó un dispositivo de terapia de resincronización cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las características basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados: La tasa de éxito del implante fue del 95,9%. La mediana [intervalo intercuartílico] de implantes anuales/centro en España fue significativamente menor que en los demás países participantes: 30 [21-50] frente a 55 [33-100] implantes/año (p=0,00003). En los centros españoles hubo una menor proporción de pacientes de edad ≥ 75 años (el 27,9 frente al 32,4%; p=0,0071), una mayor proporción de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p <0,00001) y un mayor porcentaje de pacientes con criterios electrocardiográficos de bloqueo de rama izquierda (el 82,9 frente al 74,6%; p <0,00001). La media de la estancia hospitalaria fue menor en los centros españoles (5,8+/-8,5 frente a 6,4+/-11,6; p <0,00001) y una mayor proporción de pacientes recibieron un cable de ventrículo izquierdo cuadripolar (el 74 frente al 56%; p <0,00001) y fueron seguidos a distancia (el 55,8 frente al 27,7%; p <0,00001). Conclusiones: La encuesta CRT-Survey II muestra que en España hay una menor proporción de pacientes de 75 o más años que reciben un dispositivo de terapia de resincronización cardiaca, una mayor proporción de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores

Introduction and objectives: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. Methods: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. Results: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in NYHA class II (46.9% vs 36.9%, P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8+/-8.5 days vs 6.4+/-11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%, P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). Conclusions: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring

Spanish Results of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II).

INTRODUCTION AND OBJECTIVES: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. METHODS: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. RESULTS: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in New York Heart Association functional class II (46.9% vs 36.9%; P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8±8.5 days vs 6.4±11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%; P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). CONCLUSIONS: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring.

Implante de un marcapasos sin cables en un paciente con deformidad torácica grave / Leadless pacemaker implantation in a patient with a severe thoracic deformity

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Repeated procedures at the generator pocket are a determinant of implantable cardioverter-defibrillator infection.

BACKGROUND: Rates of cardiac-device infections have increased in recent years, but the current incidence and risk factors for infection in patients with implantable cardioverter-defibrillators (ICDs) are not well known. HYPOTHESIS: The increasing number of ICD infections is related to accumulated pocket manipulations over time. METHODS: This single-center, prospective study included patients that underwent ICD implantation from 2008 to 2015. The endpoint was time to infection. Multivariate analysis was performed to identify independent risk factors related to infection. RESULTS: The study included a total of 570 patients, of whom 419 (73.5%) underwent a first implantation. Mean age was 59 ± 14 years, and 80% were male. During a median follow-up of 36 months (interquartile range, 18-61 months; 1887 patient-years), infection was identified in 26 patients (4.56%), an incidence of 14.9 × 1000 patient-years. Median time to infection was 9.7 months (interquartile range, 1.35-23.4 months), and 38.5% were late infections (beyond 12 months of follow-up). In patients with replacement implants, the incidence was 3-fold higher than in first implantations (27.7 vs 9.1 × 1000 patient-years; P = 0.002). Cox regression identified 2 independent predictors of ICD infection: cumulative number of interventions at the generator pocket (hazard ratio: 1.92, 95% confidence interval: 1.42-2.6, P < 0.001) and pocket hematoma (hazard ratio: 7.0, 95% confidence interval: 2.7-17.9, P < 0.0001). CONCLUSIONS: The incidence of infection in ICD patients is greater than previously reported, largely due to late infections. Each new cumulative intervention at the same generator pocket nearly doubles the risk of infection.

Impact of Contact Force Monitoring in Acute Pulmonary Vein Isolation Using an Anatomic Approach. A Randomized Study.

BACKGROUND: The impact of contact force (CF) monitoring in pulmonary vein (PV) isolation after a circumferential anatomic ablation (CAA) is unknown. We analyze the usefulness of CF monitoring in acute PV isolation and procedure parameters using a CAA. METHODS: Fifty patients with paroxysmal atrial fibrillation were randomized into CF-on (CF >10 grams; n = 25) or CF-off (CF blinded; n = 25) groups. We performed a first round of CAA with a ThermoCool(®) SmartTouch(®) catheter blinded to the LASSO(®) catheter (Biosense Webster, Diamond Bar, CA, USA), with radiofrequency (RF) lesions tagged with the VisiTag(™) Module. After the CAA, each PV was reviewed with the LASSO(®) catheter recording the segments with gaps. RESULTS: All the PVs were isolated with a CAA in 20 patients of the CF-on versus eight of the CF-off (P = 0.001). Of the 45 segments with gaps in the left PVs, 38 were from the CF-off (P = 0.0001). Of the eight segments with gaps in the right PVs, seven were from the CF-off (P = 0.06). The CF in the left PVs was higher in the CF-on (16.3 ± 3.2 grams vs 10.5 ± 4.3 grams; P = 0.0001) and similar in the right PVs (17.6 ± 3.6 grams vs 15.2 ± 5.3 grams; P = 0.08). All of the gaps were closed with additional RF LASSO(®) -guided touch-up. Procedure and fluoroscopy times were shorter in the CF-on (139 ± 24 minutes vs 157 ± 32 minutes and 20 ± 6 minutes vs 24 ± 7 minutes; both P = 0.039). At 12 months the patients free of AF recurrence was 84% CF-on versus 75% CF-off (log-rank P = 0.4) [corrected]. CONCLUSIONS: In paroxysmal atrial fibrillation, a CAA guided by CF reduces PV gaps and shortens the procedure parameters at the expense of the left PVs.

A simple surgical technique to prevent atrial reentrant tachycardia in surgery for congenital heart disease†.

OBJECTIVES: To present and test a simple surgical technique that may prevent atrial reentrant tachycardia following surgery for congenital heart disease. This arrhythmia is one of the commonest long-term complications of such a surgery. It may occur many years (even decades) after the operation. It is usually explained as a late consequence of right atriotomy, which is an inherent component of many operations for congenital heart disease. Right atriotomy results in a long scar on the right atrial myocardium. This scar, as any scar, is a barrier to electrical conduction, and macro-reentrant circuits may form around it, causing reentrant tachycardia. However, this mechanism may be counterchecked and neutralized by our proposed method, which prevents reentrant circuits around right atriotomy scars. METHODS: The proposed method is implemented after termination of cardiopulmonary bypass and tying the venous purse-strings. It consists of constructing a full-thickness suture line on the intact right atrial wall from the inferior vena cava (IVC) (a natural conduction barrier) to the atriotomy incision. This suture line is made to cross the venous cannulation sites if these are on the atrial myocardium (rather than being directly on the venae cavae). Thus, the IVC, atriotomy and cannulation sites are connected to each other in series by a full-thickness suture line on the atrial wall. If this suture line becomes a conduction barrier, it would prevent reentrant circuits around right atrial scars. This was tested in 13 adults by electroanatomical mapping. All 13 patients had previously undergone right atriotomy for atrial septal defect closure: 8 of them with the addition of the proposed preventive suture line (treatment group) and 5 without (control group). RESULTS: In all 13 cases, the atriotomy scar was identified as a barrier to electrical conduction with electrophysiological evidence of fibrosis (scarring). In the 8 patients with the proposed suture line, this had also become a scar and a complete conduction barrier. In the 5 patients without this suture line, there was free electrical conduction between the IVC and atriotomy scar. CONCLUSIONS: The proposed suture line becomes a scar and conduction barrier. Therefore, it would prevent reentrant circuits around atrial scars and their consequent arrhythmias.

Utilidad del fragmento N-terminal del péptido natriurético cerebral en el seguimiento de la ablación de venas pulmonares / Clinical value of N-terminal pro-B-type natriuretic peptide measurement in the follow up of pulmonary vein ablation

Fundamento y objetivo: En pacientes con fibrilación auricular (FA), los valores del N-terminal pro-B-type natriuretic peptide (NT-proBNP, «fragmento N-terminal del péptido natriurético cerebral») guardan relación directa con la carga arrítmica. Pretendemos validar la utilidad del NT-proBNP como marcador del éxito de la ablación de FA a largo plazo. Pacientes y método: Estudio prospectivo observacional de 75 pacientes con función sistólica conservada (81% varones; edad media [DE] de 52 [9] años; 58,7% paroxísticos) sometidos a aislamiento circunferencial de venas pulmonares. Se realizó determinación de NT-proBNP basal y al año tras el procedimiento. Se relacionaron los valores y la variación del NT-proBNP con el éxito del procedimiento. Resultados: Al año de seguimiento 53 (70,7%) pacientes permanecieron sin recidivas. Una disminución > 30% de NT-proBNP identificó el éxito con una sensibilidad del 79,2%, una especificidad del 81,8%, un valor predictivo positivo del 91,3% y negativo del 62% (área bajo la curva ROC 0,84, intervalo de confianza del 95% 73-95,6). Esta reducción se asoció a una disminución del volumen y de la presión en la aurícula izquierda y a la presencia de disfunción diastólica (todos p < 0,05). Conclusiones: La disminución del NT-proBNP en pacientes sometidos a ablación de FA es útil como marcador del éxito en el seguimiento y de la mejoría hemodinámica asociada (AU)

Background and objective: N-terminal pro-B-type natriuretic peptide (NT-proBNP) correlates with burden of arrhythmia in atrial fibrillation (AF) patients. Our objective is to validate the usefulness of the measurement of NT-pro-BNP to determine the success of AF ablation in a long term follow up. Patients and methods: Prospective observational study in which 75 patients with preserved systolic function (81% men; mean age (SD) 52 (9) years; 58.7% paroxysmal) underwent circumferential pulmonary vein isolation. Determination of NT-proBNP baseline and one year after the procedure was performed. The relation between NT-proBNP levels and the success of the procedure is analyzed. Results: In the follow up 53 (70.7%) patients remained free of recurrences. A > 30% decrease of NT-proBNP levels identified success with a sensitivity of 79.2%, specificity 81.8%, positive predictive value 91.3% and negative 62% (area under ROC curve 0.84, 95% confidence interval 73-95.6). This reduction was associated with a decrease in left atrial volume and pressure and the presence of diastolic dysfunction (allP < .05). Conclusions: The decrease of NT-proBNP levels in patients undergoing AF ablation is useful as a marker of success in the follow up and is associated with hemodynamic improvement (AU)

[Clinical value of N-terminal pro-B-type natriuretic peptide measurement in the follow up of pulmonary vein ablation]. / Utilidad del fragmento N-terminal del péptido natriurético cerebral en el seguimiento de la ablación de venas pulmonares.

BACKGROUND AND OBJECTIVE: N-terminal pro-B-type natriuretic peptide (NT-proBNP) correlates with burden of arrhythmia in atrial fibrillation (AF) patients. Our objective is to validate the usefulness of the measurement of NT-pro-BNP to determine the success of AF ablation in a long term follow up. PATIENTS AND METHODS: Prospective observational study in which 75 patients with preserved systolic function (81% men; mean age (SD) 52 (9) years; 58.7% paroxysmal) underwent circumferential pulmonary vein isolation. Determination of NT-proBNP baseline and one year after the procedure was performed. The relation between NT-proBNP levels and the success of the procedure is analyzed. RESULTS: In the follow up 53 (70.7%) patients remained free of recurrences. A>30% decrease of NT-proBNP levels identified success with a sensitivity of 79.2%, specificity 81.8%, positive predictive value 91.3% and negative 62% (area under ROC curve 0.84, 95% confidence interval 73-95.6). This reduction was associated with a decrease in left atrial volume and pressure and the presence of diastolic dysfunction (all P<.05). CONCLUSIONS: The decrease of NT-proBNP levels in patients undergoing AF ablation is useful as a marker of success in the follow up and is associated with hemodynamic improvement.

Reverse atrial remodeling following pulmonary vein isolation: the importance of the body mass index.

BACKGROUND: Pulmonary vein isolation (PVI) causes a reduction in left atrium size that is attributable to reverse atrial remodeling (RAR). The objective of this study was to identify predictors of RAR and determine its association with other parameters of improvement in cardiac function. METHODS: It is a prospective study with 74 patients (52 ± 9 years old, 81% male), and 51% of patients had paroxysmal atrial fibrillation. Patients were serially assessed with transthoracic echocardiography; plasma N-terminal B-type natriuretic peptide (NT-proBNP); and high-sensitivity C-reactive protein levels at baseline and 3, 6, and 12 months following the PVI. RAR was defined as a reduction in the left atrial volume index (LAV-index) >10% from baseline at the end of follow-up. A multivariate analysis was conducted to identify predictors of RAR. RESULTS: The LAV-index decreased significantly during follow-up in the entire population (P = 0.0005). RAR (experienced by 63.5% of the patients) was more frequent (76% vs. 42%; P = 0.004) and pronounced (reduction 16.65 ± 14% vs. 8 ± 14%; P = 0.015) in patients with a successful ablation (46 of 74 patients, 62.2%). Only patients with RAR showed significant improvement in NT-proBNP levels (P = 0.0001), systolic function (P = 0.035), and diastolic function (P = 0.005). Multivariable analysis revealed that a successful ablation (odds ratio [OR] = 4.6; 95% confidence interval [CI] 1.46-14.68; P = 0.009), LAV-index (OR = 1.15; 95% CI 1.03-1.2; P = 0.021), and patient's body mass index (OR = 0.84; 95% CI 0.74-0.96; P = 0.012) were independent predictors of RAR. CONCLUSIONS: Successful PVI ablation is the main predictor of RAR that is associated with other parameters of improvement in cardiac function. The patient's body mass index may have a negative effect on RAR.

Implante de un desfibrilador totalmente subcutáneo en un niño con cardiopatía congénita compleja e infección del sistema endovenoso previo / Totally subcutaneous implantable cardioverter-defibrillator in a child with complex congenital heart disease and infection in a previous transvenous system

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Paroxysmal atrial fibrillation burden before and after pulmonary veins isolation: an observational study through a subcutaneous leadless cardiac monitor.

AIMS: Data on the success rate of ablation in atrial fibrillation (AF) are controversial. Our hypothesis is that the efficacy must be evaluated considering the AF burden (AFB) before the procedure. Moreover, the clinical significance of early recurrence (ERAT) of AF or atrial tachyarrhythmias (AT) is debatable. The aim is to describe the outcome of pulmonary vein isolation in paroxysmal AF through a subcutaneous cardiac monitor (ICM) implanted before the procedure. METHODS: Using CARTO 3, circumferential lesions around the pulmonary veins were placed. The study endpoint was the first documented recurrence of AF/AT by ICM after the blanking period (3 months). AFB (percentage of time in AF/AT) was collected every month before and after the procedure during the 12-month follow-up. RESULTS: The ICM was implanted 94 ± 23 days before the procedure in 35 patients with paroxysmal AF (54 ± 11 years, refractory to 1.8 ± 0.6 antiarrhythmic drugs). Cumulative AFB before the procedure and after the blanking period was 2.5% (1-5%) versus 0% (0-0.25%), P < 0.001. Twenty patients (57.1%) were free of documented AF/AT recurrence, 5 patients (14.2%) reduced the AFB 90%, 6 patients (17.1%) continued the same, and 4 patients (11.4%) increased the AFB 90% for AT. The success rate with second procedure was 71.4%. All 13 patients with ERAT had recurrence after the blanking period. CONCLUSIONS: The outcome of pulmonary vein isolation in patients with paroxysmal AF is well documented by an ICM. The success rate is dependent of the previous AFB that can be randomly variable and lower than expected. ERATs predict late recurrence.

Electroanatomical mapping of the esophagus in circumferential pulmonary vein isolation.

A virtual reconstruction of the geometry of the esophagus was produced using an electroanatomical mapping system and a specially designed catheter in 20 consecutive patients undergoing circumferential pulmonary vein isolation. The course of the esophagus, its motion and its proximity to the predicted lines of application of radiofrequency energy to the left atrium were evaluated. Thirteen (65%) were located centrally (i.e. >10 mm from the ostium), 69 (30%) laterally (i.e. <10 mm from the ostium) and 1 (5%) obliquely. No movements larger than 10 mm occurred during the procedure. Conventionally, the radiofrequency ablation lines are configured such that, in 50% of patients, radiofrequency energy is applied to areas adjacent to the esophagus. In order to decrease the potential risk associated with this procedure, either the position of the ablation lines was altered to bring them closer to the ostium (by 15%) or the power was reduced (by 35%). Although there was no significant movement of the esophagus during the ablation procedure, its course was variable. Consequently, the ablation strategy was altered in a substantial number of cases.

Cartografía electroanatómica del esófago en el aislamiento circunferencial de venas pulmonares / Electroanatomical mapping of the esophagus in circumferential pulmonary vein isolation

Realizamos una reconstrucción virtual de la geometría del esófago con un sistema de cartografía electroanatómica utilizando un catéter específico en 20 pacientes consecutivos sometidos a aislamiento circunferencial de venas pulmonares. Monitorizamos el trayecto esofágico y sus movilizaciones, valorando la proximidad a las líneas de aplicación de radiofrecuencia previstas en la aurícula izquierda. Trece (65%) fueron centrales (> 10 mm de los ostia), 6 (30%) laterales ( < 10 mm) y 1 (5%) oblicuo. No hubo movilizaciones > 10 mm durante el procedimiento. La disposición convencional de las líneas de ablación suponía la aplicación de radiofrecuencia en zonas adyacentes al esófago en el 50% de los pacientes. Intentando reducir el riesgo potencial de estas aplicaciones, se modificó su posición aproximándolas a los ostia (15%) o se disminuyó la potencia (35%). El esófago demuestra una disposición variable sin desplazamientos significativos durante el procedimiento de ablación. Esto implica modificar la estrategia de ablación en un número considerable de casos (AU)

A virtual reconstruction of the geometry of the esophagus was produced using an electroanatomical mapping system and a specially designed catheter in 20 consecutive patients undergoing circumferential pulmonary vein isolation. The course of the esophagus, its motion and its proximity to the predicted lines of application of radiofrequency energy to the left atrium were evaluated. Thirteen (65%) were located centrally (i.e. >10 mm from the ostium), 69 (30%) laterally (i.e. <10 mm from the ostium and 1 5 obliquely no movements larger than 10 occurred during procedure conventionally radiofrequency ablation lines are configured such that in 50 of patients energy is applied to areas adjacent esophagus order decrease potential risk associated with this either position was altered bring them closer by 15 or power reduced 35 although there significant movement its course variable consequently strategy a substantial number cases (AU)

Unusual tachycardia association in a patient without structural heart disease.

We report an unusual association of persistent atrial flutter and bundle branch re-entrant ventricular tachycardia in a young patient without structural heart disease. Atrial flutter masked the infra-Hisian conduction disease, was fundamentally dependent on a long PR interval, and could be a possible trigger of ventricular tachycardia.