Heart Failure

AP19‐­00042

Autonomic nervous system optimized fixed delay left‐­ventricular cardiac resynchronization

Toan Nguyen‐Duy, Dat Tran ‐Tat, Tran Thong

Northwest Signal Processing, United States

Introduction:

Cardiac Resynchronization Therapy (CRT) is used to treat heart failure patients with left bundle branch block (LBBB). With good right ventricular (RV) conduction (RVc), adaptive atrioventricular delay (AVD) using left‐­ventricular (LV) pacing, no RV pacing, is used to extend device longevity. Simpler fixed AVD LV‐­only is discussed here.

Methods:

Three LBBB CRT pacemaker (CRT‐­P) patients with good RVc were reprogrammed to fixed AVD LV‐­only to extend device longevity utilizing intrinsic RVc. With the RVs triggering feature when an early RVs is detected (before LVp) an LVp is immediately triggered, forcing resynchronization. An RVs arriving after the LVp is not detected. The patients were implanted with 3 different CRT‐­P models from a manufacturer. Follow‐­up (FU) durations: 4 years, 8 & 8 months. FUs are performed every 2‐­12 months to increase data collection, we initiated home remote monitoring (RM) for nightly statistics.

Result:

Extending daily the LV AVD to 300 ms, the CRT‐­Ps measure the intrinsic atrial sense/pace to ventricular sense (Ax‐­Vs) intervals. At the start of LV‐­only, from prior biventricular pacing, the intervals were found to be spread over the 0‐­300 ms range. With fixed AVD LV‐­only, autonomic nervous system, ANS, optimization is recognized when the intervals coalesce into ≤2 adjacent 10 bpm bins from then on. In the late model CRT‐­P, we were able to aggressively remote schedule the full FUs with electrogram (EGM). Each full FU includes 10 seconds each for normal rhythm, enhanced sensing with LV AVD to 300 ms, fast atrial pacing. EGMs were also received for atrial fibrillation (AF) episodes. Over 4 months of RM, 18 reports with 3 channel EGMs were received: 11 periodic FUs, 7 short 12 seconds AF records. In this abstract we focus on this patient. The paper will discuss the other 2 patients from whom we received 5 + 19 and 3 + 0 EGM records. The daily RM data include %As‐­Vs, and atrial rate. The Vs are actually RVs. With LV AVD of 125 ms, the histogram of the daily %As‐­Vs (Ap = 0%) with early RVs and triggered LVp is shown in Figure 1. The median daily %As‐­Vs is 11%. The 13 times the daily %As‐­Vs are >30% cannot be random, since each corresponds to >7 hours. The associated atrial rates are also high. This shows active dromotropic RVc modulation. Figure 2 shows the distribution of the %As‐­Vs vs the daily atrial rate. Dromotropic RVc shortening allows more early RVs at high atrial rates, increasing %As‐­RVs. From the 18 EGM records, As‐­RVs intervals are measured. Figure 3 summarizes the results. All 3 regression curves exhibit dromotropic shortening at increased atrial rates.

Conclusion:

In fixed AVD LV‐­only CRT, dromotropy is shown to modulate the RVc to optimize hemodynamics. The other ANS functions will similarly be recruited to optimize hemodynamics using the RV timing with a fixed LVp reference time. Thus this is ANS optimized LV‐­only CRT, superior to device driven adaptation.

FIGURE 1 Histogram of daily As‐­RVs. Full database (117 records), and first 57 records

FIGURE 2 Distribution of daily As‐­RVs vs average daily atrial rate

FIGURE 3 As‐­RVs measured from IEGM records: pre Mode‐­Switch, normal, enhanced sensing with LV AVD 300 ms

AP19‐­00125

Left ventricular endocardial pacing: a direct comparison of the second generation of the novel wireless CRT system (WiSE‐­CRT) with the original system

Simon James, Andrew Turley, Michael Chapman

James Cook University Hospital, United Kingdom

Introduction:

The WiSE‐­CRT system is a leadless endocardial pacing system for cardiac Resynchronization therapy. It uses ultrasound technology to transfer energy from a subcutaneously pulse generator (transmitter) to a receiver‐­electrode implanted on the Left Ventricle (LV) endocardial wall. This converts acoustic energy to an electrical pulse. The original hardware has been revised and Generation 2 system (Gen2) now contains the Model 4100 transmitter. (see Table 1). Early data for generation 2 of the system suggested greater efficiency and reduced battery energy requirement to achieve LV capture. A small number of patients have had the generation 1 transmitter explanted and replaced with generation 2 system. We compare and describe energy requirement for LV capture for the 2 systems in these patients

Methods:

Patients studied were those who underwent removal of the original system and replacement with Gen 2 at the same intercostal location. Electrode‐­transmitter distance and pacing parameters were measured post Gen 2 implant and compared with the parameters of the original system immediately prior to explanation.

Result:

16 patients underwent removal of the original system /replacement with Gen 2 at the same intercostal location. Parameters are shown in Table 1. There is no conventional direct voltage threshold ‐­ Energy requirement for electrical capture is calculated via function of amplitude/ pulse width/ aperture of sound beam, power required per transmit level of the transmitter and efficiency of conversion of battery energy to transmitter energy. Energy required for capture with gen 2 was less for all cases. Mean (SD) was 1.97 (0.98) mJ original vs 0.62 (0.36) mJ for Gen 2 (P = .000048). When corrected for the improved conversion efficiency of Gen 2 transmitter (0.75 vs 0.55) this difference remains significant 1.08 vs 0.48 mJ, P = .00037). This demonstrates that the reduced energy requirement for capture is not due to improved energy conversion within the transmitter alone. There was no difference in distance from transmitter to electrode or in superior/inferior angle of beam. However medial‐­lateral beam angle was reduced by mean 12.9° (P = .0003). This reduced angulation of the ultrasound beam results in far greater efficiency of energy delivery to the endocardial LV electrode

Conclusion:

Generation 2 of the Wise‐­CRT system requires far less energy to achieve capture than original system when compared head to head. This increased efficiency exceeds that due solely to improved efficiency of conversion of battery energy to transmitter energy and is likely to reflect other improvements within the 4100 model, including the angulation of the transmitter head that results in a reduction medial‐­lateral beam angle.

Table 1 Mean (standard deviation) for pacing parameters

Column 1	Generation 1 4000 system	Generation 2 4100 system	P value
Battery energy required (mJ)	1.97 (0.98)	0.62 (0.35)	.0005
Transmitter energy required (mJ)	1.08 (0.54)	0.46 (0.26)	.00037
Distance to electrode (cm)	8.53 (1.67)	8.23 (1.57)	.103
Superior/Inferior angulation (degrees)	−17.2 (12.9)	−16.9 (11.2)	.847
Medial‐­lateral angulation (degrees)	−25.4 (12.4)	−12.6 (16.6)	.0002

AP19‐­00126

Does a trans‐­septal approach for implantation of the wise‐­CRT leadless Endocardial left ventricular pacing system reduce the incidence of vascular complications?

Simon James, Andrew Turley, Chrostopher Rinaldi, Martin Arnold, Raymond Sy, Kim Chan, Prash Sanders, Giovanni Rovaris, James DeVille

James Cook University Hospital, United Kingdom

Introduction:

WiSE‐­CRT is a leadless CRT endocardial pacing system. It uses ultrasound technology to transfer energy from a subcutaneous pulse generator to a receiver implanted directly into the Left Ventricle (LV) endocardial wall. To date this procedure has been performed via a retrograde aortic route which necessitates large gauge femoral arterial access. This is a potential risk to a population of patients with potential vascular disease. A trans‐­septal access route for implant has been used in a small number of patients in whom retrograde access for implantation is either not feasible or not safe. We compare the efficacy and safety of implanting the WiSE‐­CRT system via a trans‐­septal approach vs the standard retrograde aortic route.

Methods:

WiSE‐­CRT was implanted via a trans‐­septal route in cases where retrograde access was either unfeasible or unsafe. Procedural outcome data, site of implant and complication data were collected and compared with a contemporaneous cohort of implants performed using a retrograde aortic approach.

Result:

20 patients (15 male/5 female) underwent trans‐­septal implant at 7 centres. Mean age was 69.7 ± 9.4 years. The electrode was succesfully implanted in all 20 cases. Locations of each implant are summarised in Figure 1. Contraindications to a retrograde approach were: severe peripheral vascular disease‐­12, mechanical AVR — 4, morbid obesity — 2, TAVR — 1, Aorto‐­bifemoral graft — 1. In the trans‐­septal group there were no acute vascular or thromboembolic complications, no incidence of perforation/tamponade. In the retrograde aortic comparator group of 80 cases there were the following: Vascular complications‐­5 (haematoma‐­1, pseudoaneyrysm‐­3, reduced flow necessitating removal of closure sutures‐­1), tamponade‐­1, perforation with sheath‐­1.

FIGURE 1 Site of electrode deployment within the left ventricle anterior

Conclusion:

Leadless endocardial LV pacing utilising a trans‐­septal approach is both feasible and safe. It is possible to access a wide range of target sites for implant successfully. This technique removes the incidence of vascular complication that is associated with large gauge arterial access.

AP19‐­00135

Modified electrocardiographic scoring to predict left ventricular ejection fraction in chronic heart failure

Wiza Erlanda, Hauda El Rasyid, Masrul Syafri, Ricvan Nindrea

Indonesian heart association, Indonesia

Introduction:

Heart failure (HF) are divided into HF with reduced ejection fraction (EF < 40), mid range (EF 40%‐­49%), and preserved (EF ≥ 50%). Echocardiography is used as gold standard examination, but it is limited only in several health care. Preliminary examination tools are needed. Previously there was ECG scoring to predict LVEF in HF patients, but still divided into two categories. This study make a new modified ECG scoring which dividing HF into three categories and also adding new variables like age and sex.

Methods:

An observational approach with cross sectional study design. The data were taken from patients’ medical record with chronic heart failure (CHF) who went to the Department of Cardiology at Dr. M. Djamil Padang Hospital in January‐­August 2018. Bivariate analysis was performed on each ECG variable then correlated with LVEF by chi‐­square method. Multivariate analysis with logistic binary regression test was conducted to obtain variables that would go into the score calculation stage with the Hosmer‐­Lameshow test (P < .25). The sensitivity, specificity test and receiver operating curve (ROC) analysis were performed.

Result:

283 subjects of CHF who had been divided into three groups. Obtained variables that met the requirements for calculating scores were left atrial enlargement (LAE) (OR = 6.36; P = .000) score was 6, wide QRS (OR = 13.06; P = .000) score was 9, prolonged QTc interval (OR = 2.18; P = .065) score was 2, ST‐­T change (OR = 5.05; P = .000) score was 6, male patient (OR = 1.78; P = .018) score was 1, and age ≥60 (OR = 1.34; P = .000) score was 1. Subjects with HFpEF if the scored were <9, HFmrEF if the scored were 9‐­10, and HFrEF if the scored were >10. It has sensitivity 89.3%, specificity 85.6% with AUC 88.4%.

Conclusion:

Modified Electrocardiography scoring system in this study can be used as an initial tool to determine LVEF in patients with CHF.

AP19‐­00140

Comparison of the clinical backgrounds and electrocardiographic findings of fulminant and non‐­fulminant groups in patients with myocarditis

Chatani Ryuki, Tada Takeshi, Kawase Yuichi, Tasaka Hiroshi, Kadota Kazushige

Kurashiki Central Hospital, Japan

Introduction:

Myocarditis is a fatal disease, and the mortality is high in fulminant cases.

Methods:

There were 38 patients who were admitted to our hospital with a diagnosis of myocarditis from January 2012 to February 2018. We divided patients into fulminant (N = 10) and non‐­fulminant groups (N = 28), and retrospectively examined the clinical backgrounds, Electrocardiographic findings and outcomes. We defined fulminant as a case requiring mechanical support circulation.

Result:

The mean age was 45.8 ± 23.9 years, and 55.3% of patients were male. The causative disease was viral in 84.2% of cases and eosinophil in 7.9%. As for the patient background, women were more frequent in the fulminant group, but there was no significant difference (70.0% vs 35.7%, P = .08). In electrocardiographic findings on admission, complete right leg blocks and complete leg blocks tended to be more common in the fulminant group, but there was no significant difference (30.0% vs 7.1%, P = .10, 40.0% vs 10.7%, P = .06). The pulse rate was significantly faster in the fulminant group (123 ± 46 vs 86 ± 24 bpm, P = .002), and the QRS width was significantly wider in the fulminant group (144 ± 75.6 vs 104 ± 21.2 ms, P = .02). There were 3 cases of ventricular tachycardia during hospitalization only in the fulminant group. In blood test findings on admission, CK and CK‐­MB at admission were significantly higher in the fulminant group, and CRP, CK and CK‐­MB in Peak were also significantly higher in the fulminant group. In the fulminant group there were 7 cases of IABP, 4 cases of PCPS, 1 case of Impella, and 3 cases of combined IABP and PCPS. 4 patients died in the hospital and all were all from the fulminant group.

Conclusion:

Electrocardiogram findings at admission to myocarditis are important, and in fulminant myocarditis, the QRS width was significantly wider and the pulse rate was faster. The prognosis for fulminant myocarditis is poor.

AP19‐­00191

CLINICAL response with adaptive CRT algorithm compared with CRT with echocardiography‐­optimized

Takashi Sasou, Yusaku Nishikawa, Takehiro Gotou, Masahiro Tomita, Yuma Tsumagari, Kou Takahama, Masako Yamada

Mie University Hospital, Japan

Introduction:

Cardiac resynchronization therapy improves left ventricular (LV) structure and function and clinical outcomes in NYHA functional class III and IV HF with prolonged QRS.

Objectives:

We aimed to compare the clinical response between adaptive cardiac resynchronization therapy (ACRT) and standard CRT.

Methods:

Fifteen patients with NYHA functional class III or IV heart failure with A QRS > OR = 120 ms and a LV ejection fraction < OR = 35% received a CRT device and were ACRT (N = 8) or standard CRT (N = 7). The primary END point was the HF clinical composite response, which scores patients as improved, unchanged, or worsened. the retrospective powered secondary end point was LV end‐­systolic volume index.

Result:

The HF clinical composite response end point, which compared only the percent worsened, indicated 13% worsened in ACRT compared with 43% IN standard CRT (N.S.). Patients assigned to ACRT experienced a improvement in LV end‐­systolic volume index (−15.8 ± 16.5 ML/M2 vs 10.8+/40.8 ML/M2, P = .08) and other measures oF LV remodeling.

Conclusion:

The ACRT algorithm is safe and at least as effective as BIV pacing with standard CRT.

AP19‐­00323

Increased effective pacing is associated with improved survival in cardiac resynchronization therapy patients

April Bond, Mark Silver, Edward Schloss, Jagmeet Singh, Brett Atwater, Yong‐Mei Cha, Eugene Chung, David O'Donnell, Maurizio Lunati, Shufeng Liu, Thomas Xie

Medtronic, United States

Introduction:

Higher percentages of ventricular pacing are known to enhance the clinical benefit of cardiac resynchronization therapy (CRT). Conventional device‐­reported ventricular pacing reports on pulse delivered rather than actual ventricular capture. A novel CRT diagnostic, EffectivCRT, assesses left ventricular capture after each pace to accurately quantify the percentage of effective ventricular pacing (%eCRT). The objective is to evaluate the association between %eCRT and clinical outcomes in a real‐­world Heart Failure (HF) patient population.

Methods:

The Personalized CRT Study is a multi‐­center, single arm prospective observational study of real‐­world HF patients with CRT devices. Enrolled patients with the EffectivCRT diagnostic were included in this analysis, and their lifetime averages of %eCRT were obtained from device data. The clinical outcomes of the patients with %eCRT ≥ 95 were compared to the patients with %eCRT < 95.

Result:

A total of 1207 patients (71% male, average age 70.1 ± 10.7 years) were included in this analysis, with an average follow‐­up duration of 8.7 ± 6.6 months. The group of patients with ≥95% eCRT (n = 822) had a 54% relative reduction in mortality over the group with <95 %eCRT (n = 385) (hazard ratio 0.46, P = .004, Figure 1). The patient group with ≥95 %eCRT also had significantly decreased risk of HF related hospitalizations (hazard ratio 0.47, P = .014) and lower probability of having atrial fibrillation (AF) burden ≥5.5 hours in any day (hazard ratio 0.66, P < .001).

FIGURE 1 Total survival by %eCRT subgroups

Conclusion:

In a real‐­world cohort of HF patients, ≥95 %eCRT was associated with reduced mortality, less HF hospitalizations, and lower probability of having AF burden ≥5.5 hours in any day.

AP19‐­00324

Effect of right ventricular pacing on mortality in a real‐­world population

April Bond, Mark Metzl, Robert Canby, Ethan Fruechte, Derek Exner, Manoj Duggal, Eugene Chung, Jagmeet Singh, David O'Donnell, Yong‐Mei Cha, Maurizio Lunati, Yan Zhong

Medtronic, United States

Introduction:

The implantable cardioverter defibrillator (ICD) is a proven lifesaving therapy. Chronic right ventricular (RV) pacing may lead to dyssynchrony that may be detrimental for ICD recipients with left ventricular systolic dysfunction, leading to increased mortality. Long term outcomes among ICD patients with a high degree of RV pacing in the real‐­world have not been examined. Aim: To estimate the 5‐­year survival probability for patients receiving the ICD therapy stratified by >40% RV pacing (High RVP%) vs ≤40% RV pacing (Low RVP%) based on prior studies.

Methods:

Patients prospectively enrolled in the Medtronic Product Surveillance Registry (PSR) implanted with an ICD from 2010 to 2019 with a minimum of 30 days of device data were included. The medians of the first year RV pacing were used to determine patient cohort assignment (High RVP% vs Low RVP%). The Kaplan‐­Meier method was used to assess the 5‐­year survival probability. Hazard ratios (HR) were estimated adjusting for clinical covariables using the Cox‐­regression method.

Result:

A total of 4969 patients with ICD implanted between 2010 to 2019 were included in the analysis with a mean age of 63.1 ± 13.3 years. Baseline characteristics are shown in Table 1. As of April 2019, among 4969 patients, 283 (5.7%) had a High RVP%. The 5‐­year survival probability for those with High RVP% was 63.3%, vs 80.4% for Low RVP% (P < .0001, Figure 2). The Cox regression analysis was conducted to adjust for clinical covariables including age. This difference remained statistically significant in the Cox model (adjusted HR 0.71; 95% CI 0.56 to 0.91, P = .007).

FIGURE 1 Patient survival at 5 years after ICD implant

Conclusion:

In this real‐­world cohort of ICD patients, high RV pacing percentage was independently associated with higher mortality. Patients with more frequent RV pacing may derive benefit from more aggressive treatments, including resynchronization therapy.

AP19‐­00325

Attain performa lead performance

April Bond, Archana Rao, Timothy Simmers, Tillman Dahme, Daniel Gras, Mehran Firouzi, Jay Schloss, Dwayne Campbell, Jon Hays, Robert Schwartz, Anwer Dhala, Azlan Hussin, Erika Pouliot

Medtronic, United States

Introduction:

Quadripolar left heart leads provide electrical re‐­position as a post‐­operational non‐­ invasive treatment option. The Medtronic Attain Performa™ Quadripolar Lead includes three shapes of leads (model 4298 – canted, model 4398‐­straight & model 4598‐­S shape) designed to address a variety of patient anatomies. A previous premarket clinical study demonstrated safety and effectiveness of the Attain Performa Family of quadripolar left ventricular (LV) leads in the clinical environment. A multi‐­ center post‐­approval study (PAS) is being conducted to continuously monitor lead performance in the real‐­world setting. The objective is to monitor and report the long‐­term safety and reliability of the Medtronic Attain Performa Model 4298, 4398 and 4598 leads when implanted with a compatible CRT‐­D system.

Methods:

The Attain Performa PAS is a cohort of the Personalized CRT Registry and includes patients implanted with an Attain Performa lead. The Medtronic Personalized CRT study is conducted under the Product Surveillance Registry (PSR) platform enrolling patients in the United States, Canada, Europe, and Central Asia. Patients implanted with Attain Performa leads are followed per standard of care. Lead complication‐­free probability is characterized using the Kaplan‐­Meier survival method. Pacing threshold data were summarized.

Result:

Study enrollment of the Attain Performa PAS is complete with a total of 1923 Attain Performa leads (in 1902 patients) at 114 clinical sites. Of those, 1118 were Model 4298, 283 were Model 4398, and 522 were Model 4598 leads. There have been 10, 3, and 5 lead‐­related complications in the Model 4298, 4398, and 4598 leads, respectively. The most common complications are lead dislodgement 10 (0.5%) and extracardiac stimulation 4 (0.2%). The overall lead‐­related complication‐­free survival is 99.1% (95% CI: 98.2%, 99.5%), 98.8% (95% CI: 94.6%, 99.7%), and 99.0% (95% CI: 97.5%, 99.6%), at 3 years post‐­implant for Model 4298, 4398 and 4598 leads, respectively (see Figure). Lead pacing thresholds at 0.4‐­0.6 ms were stable over time, with a median 1.00 V at 3 years.

FIGURE 1 Kaplan Meier estimate of attain performa complication free survival stratified by model

Conclusion:

These results confirm the long‐­term safety and reliability of the Medtronic Attain Performa models 4298, 4398 and 4598 Quadripolar LV Leads, when implanted with a compatible Medtronic CRT‐­D system. Safety and reliability performance will continue to be evaluated through 5 years post‐­implant.

AP19‐­00326

CRT response in real world patients: evaluation methods and actions taken to optimize response

April Bond, Kevin Vernooy, Bobbi Hoppe, Danny Pierce, Jagmeet Singh, David O'Donnell, Yong‐Mei Cha, Maurizio Lunati, Eugene Chung, Shufeng Liu, Lenore Marcotte

Medtronic, United States

Introduction:

Although multiple, randomized, double‐­blind trials have confirmed the benefits of cardiac resynchronization therapy (CRT), a proportion of patients continue to be considered non‐­responders. It remains largely unknown how physicians are evaluating for CRT response outside of prospective interventional trials and what methods they are taking to optimize CRT response in real‐­life practice. Objective: We aimed to characterize evaluation methods and treatments used to optimize CRT response in a real‐­world population.

Methods:

Routine CRT response assessments were collected for a subset of patients enrolled in the Medtronic Personalized CRT Registry implanted with a Medtronic CRT system since April 2017. Data capture was reflective of real‐­world clinical practice in terms of how physicians assess CRT response and what actions were taken to improve CRT response.

Result:

A total of 957 Patients have been enrolled and 444 have completed at least 3 months of follow‐­ up. Of the 336 patients (70.7 ± 10.5 years, 73.2% male) who had a completed CRT response assessment, 271 (80.7%) were CRT responders based on the initial CRT response assessment by physicians following implant. Assessment of CRT response was primarily based on heart failure (HF) symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, flight of stairs, city block walk) (82.7%), followed by NYHA Class (58.9%), LVEF (30.1%), and LVESV (6.0%). Actions to improve CRT response were taken (or scheduled) in nearly half (46.2%) of non‐­responders, whereas actions were taken in 25.5% of responders. In both non‐­responders and responders these actions mostly involved additions (or changes) in medications (46.7% and 55.1%) followed by changes in device programming (30.0% and 37.7%) and diet changes/fluid restrictions (16.7% and 26.1%).

Conclusion:

These preliminary results demonstrate that HF symptoms are the primary criteria used to assess CRT response. Actions to improve CRT response are more often taken in non‐­responders and most frequently included changes in medications followed by changes in device programming.

AP19‐­00384

Machine learning‐­based models predict long‐­term outcomes of heart failure patients implanted cardiac resynchronization therapy

Shengwen Yang, Shangyu Liu, Zhimin Liu, Yiran Hu, Ran Jing, Wei Hua

Fuwai Hospital, CAMS&PUMC, China

Introduction:

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in drug‐­ refractory heart failure patients with ventricular dyssynchrony delay. However, up to one‐­third of individuals do not benefit from CRT. We assessed the utility of machine learning (ML) algorithms to develop and validate models for predicting long‐­term outcomes using variables collected before the implantation.

FIGURE 1 Workflow used to develop and validation machine learning‐­based predictive model for prediction and risk stratification.

FIGURE 2 Receiver operation characteristics curve for best models. Six machine learning algorithms, [i.e. support vector machine, decision tree, random forest, gradient boosting decision tree, neural network and logistic regression (GBDT)], were evacuated by area under curve (AUC) for all‐­cause death and heart transplantation. Models were developed and validated with all 53 variables.

FIGURE 3 Feature selection. Information gain ranking was used to evaluate the worth of each variable by measuring the entropy gain with respect to the outcome, and then rank the attributes by their individual evaluations (top to bottom). Top 15 variables in Random Forest model derived with all 53 variables.

FIGURE 4 Kaplan‐­Meier curves for primary endpoint. Random Forest model with all variables sub‐­divided into quartiles. Quartile 4 expected to have the best outcomes and Quartile 1 the worst.

Methods:

Models were developed with six machine learning algorithms to predict all‐­cause mortality and heart transplantation from January 2010 to December 2017 in Fuwai hospital. Ten‐­fold cross‐­ validation was used for evaluation each ML model's performance.

FIGURE 5 Kaplan‐­Meier curves for HF hospitalization. Random Forest model with all variables sub‐­divided into quartiles. Quartile 4 expected to have the best outcomes and Quartile 1 the worst.

Result:

The best performing model was the Random Forest model with all 53 variables collected before the implantation [the receiver operating characteristic area under the curve (AUC): 0.75 ± 0.09]. The model could significantly discriminate the risk of all‐­cause mortality or heart failure hospitalization (log‐­rank P < .001, respectively).

Conclusion:

A machine learning algorithm, by integrating multiple pre‐­implantation parameters, can produce a good model for meaningful stratification of long‐­term outcomes in heterogeneous heart failure patients following CRT.

AP19‐­00400

Characteristics of Asia‐­Pacific heart failure patients with cardiac resynchronisation therapy: data from the adaptresponse trial

Kengo Kusano, David Birnie, Michael R. Gold, Ahmad S. Hersi, Christophe Leclercq, Wilfried Mullens, Balbir Singh, Seung‐Jung Park, Min‐Tsun Liao, Bart Gerritse, Sandra Jacobs, Gerasimos Filippatos, Bruce L. Wilkoff

Medtronic, Netherlands

Introduction:

CRT response rates vary significantly with limited clinical improvement in at least 20%‐­30% of device recipients. Multiple clinical factors are associated with CRT response, including QRS duration and morphology, age, gender, height, HF etiology, dyssynchrony, and scar burden. HF patient characteristics vary between regions and countries. The AdaptResponse trial is a large CRT trial well represented with women that enrolled worldwide and the present analysis was designed to compare patient characteristics of randomized Asia‐­Pacific patients (pts) with pts from other regions.

Methods:

The AdaptResponse trial enrolled CRT indicated pts with NYHA Class II‐­IV HF, LBBB (QRS ≥ 140 ms in men, ≥130 ms in women), and baseline PR interval ≤200 ms. Pts from Japan, Republic of Korea, Taiwan, India and Australia are included in the Asia‐­Pacific cohort. Statistical analyses were done to assess differences in patient characteristics.

Result:

There were 3620 pts randomized in 226 centers worldwide, including 1569 (43.3%) women. In the Asia‐­Pacific cohort of 245 pts, 37.1% were women. The table below shows that Asia‐­Pacific patients had a comparable age, were shorter, had lower BMI, tended to have worse baseline status (57.6% in NYHA III/IV), reported significant less depression (4.1% vs 14.2%) and received more often CRT‐­P (15.1 % vs 3.7% in the other regions). Moreover, more pts reported HF hospitalizations (62.9% vs 47.1%) prior to randomization. Medication included significantly more loop diuretics and aldosterone antagonists (MRA), less Angiotensin Converting Enzyme (ACE) inhibitors and β‐­Blockers. Renal dysfunction was more frequently present in Asia‐­Pacific patients and chronic lung disease less; however, incidence of other comorbidities such as AF, diabetes, or ischemic cardiomyopathy was not significantly different.

Conclusion:

Patient characteristics differ between patients from Asia‐­Pacific compared to other regions and Asia‐­Pacific patients have different medication treatment patterns. Their KCCQ overall summary score is comparable, although less Asia‐­Pacific patients reported to be depressed. The impact of these differences on clinical outcomes will be evaluated in the AdaptResponse trial.

Percentage or mean ± s.d. * p<0.05, ** p<0.001	Other regions (N=3375)	Asia Pacific (N=245 )	Other regions (N=3375)	Asia Pacific (N=245 )
Age (years)	64.9 ± 11.0	65.4 ± 11.7	Renal Dysfunction*	16.5%	22.4%
Female *	1478 (43.8%)	91 (37.1%)	Diabetes	34.5%	37.1%
Height (cm) **	169.5 ± 10.3	162.0 ± 9.8	Chronic Lung Disease**	15.3%	7.8%
BMI (kg/m2) **	29.2 ± 6.5	24.7 ± 4.8	Hypothyroidism	9.2%	6.5%
NYHA Class III/IV	51.3%	57.6%	Anemia * Depression **	6.8%	3.3%
LVEF (%) *	25.5 ± 6.3	24.7 ± 5.7	β‐­Blocker **	14.2%	4.1%
QRS interval (ms)	163 ± 17	164 ± 17	ACE inhibitor *	90.0%	80.8%
KCCQ Overall Summary Score	62.4 ± 24.0	63.5 ± 21.2	ARB	52.1%	43.3%
Previous HF hospitalization **	47.1%	62.9%	MRA **	33.7%	32.2%
Ischemic Cardiomyopathy	31.9%	27.8%	Loop Diuretic **	46.1%	59.6%
Mitral Valve Dysfunction **	16.7%	7.8%	CRT‐­P **	58.7%	73.5%
Atrial Fibrillation	12.9%	10.2%	3.7%	15.1%

AP19‐­00437

Performance of a novel active fixation quadripolar left ventricular lead: results from the Attain Stability Quad clinical trial

Azlan Hussin, George H Crossley, Svein Faerestrand, Francois Philippon, Raymond Yee, Melissa H. Kong, Axel Kloppe, Maria Grazia Bongiorni, Shelby Li, Sheikh Mohammad Norhafiz Abdul Aziz, Jessica Lukken, Kevin Jackson

Institut Jantung Negara, Malaysia

Introduction:

Dislodgements of left ventricular (LV) leads are still a challenging problem in cardiac resynchronization therapy (CRT). The Attain Stability Quad (ASQuad) MRI SureScan Model 4798 steroid‐­eluting, quadripolar LV lead has a side‐­helix to enable the lead to be actively fixated to the vessel wall. The uniquely designed active fixation can be advantageous in vessels that are wide or have short take‐­offs. Further, the helix easily elongates to allow for future extraction.

Methods:

The ASQuad clinical study is a prospective clinical trial from 50 centers in 10 countries aimed at evaluating safety and effectiveness of the Medtronic Attain Stability LV lead. Lead implant related parameters were obtained. Reported adverse events were reviewed by an independent physician panel. Additionally, we compared ASQuad study results against data observed in the Attain Performa 4298 premarket study for implant experience and lead final placement.

Result:

Of 440 enrolled patients (74.8% male, average age 70 ± 11 years) who underwent an implant procedure, 426 (96.8%) were successfully implanted. The side‐­helix was mostly affixed in the mid to basal lateral position (62.0%), followed by mid to basal posterior position (29.0%). The lead tip placement was 90.6% non‐­apical; most often mid‐­lateral or mid‐­posterior (76.5%), and in a vein with diameter greater than the pacing electrode diameter (>5.1 French) in the majority (60.4%) of procedures, which was 2X as that of the Medtronic Quadripolar Attain Performa Model 4298 (P < .0001). The overall handling of the LV lead was rated as acceptable by implanters in 99.3% of cases. During implant, incidences of dislodgement during slitting was very low (0.45% vs 1.96% in Model 4298, P = .0145). The mean PCT for all subjects at the final selected LV pacing vector was 1.15 ± 0.70 V at 0.5 ms pulse width at implant and 1.07 ± 0.68 V at 6 months. Overall lead related complication free survival at 6 months was 97.6% (Figure 1). Three patients (0.7%) experienced LV lead dislodgement post implant, and these complications were resolved by repositioning of the lead (0 and 1‐­day post implant) in two and by lead replacement when noted at 90 days follow‐­up in one.

Conclusion:

The Attain Stability Quad 4798 lead was implanted with a high rate of success (96.8%) and very low rate of dislodgment (0.7%), with lead placement mostly (90.6%) at non‐­apical locations. Lead safety and effectiveness were demonstrated by 97.6% lead‐­related complication‐­free probability and low and stable PCTs. The active fixation mechanism enabled precise placement of the pacing electrodes at the desired target region. The novel fixation mechanism may further enhance the implanting physician's ability to deliver safe and effective CRT, and to potentially achieve desired CRT response in more heart failure patients.

AP19‐­00455

How useful are anatomic M mode, mitral VTI index and radial strain in assessment of dyssynchrony and response to CRT?

Chetan Rathi, Neeta Bachani, Yash Lokhandwala

Holy Family Hospital, Mumbai, India

Introduction:

The benefits of CRT in a select population of heart failure patients with LBBB is beyond question. However, despite numerous parameters assessed over the years, up to 30% of patients still do not respond to this therapy. To overcome some of the limitations of standard parameters, we evaluated newer indices

Methods:

We prospectively evaluated 43 patients who were to undergo CRT out of which 32 patients follow up done. During the evaluation, we assessed AMM septal to lateral (S‐­L) wall and septal to posterior (S‐­P) wall delays and mitral valve velocity time integral (MVVTI) index and radial strain.

Result:

QRS duration, Anatomical M mode delays and PLAX septal to posterior delay in pre and on follow up were statistically significant.

Conclusion:

As expected, there was marked narrowing of the QRS after CRT. While the Anatomic M Mode parameters improved, the Radial Strain and the MV VTI did not show significant change.

Parameter	Pre‐­CRT (n=43)	Post‐­ CRT (n=43)	Follow up (n=32)	P‐­value (T‐­test)*
QRS	162.5±18.9	137.1±19.1	138.5±20.8	0.0001
LVIDD	62.7±12.3	58.3±12.0	58.2±13.1	0.1379
LVIDS	49.8±13.5	46.8±12.9	45.3±13.6	0.16481
EDV	163.0±70.8	158.2±77.8	147.2±75.5	0.44923
ESV	122.0±62.5	112.4±61.5	102.1±58.1	0.25497
Visual EF	22.3±6.6	26.9±8.2	30.9±9.6	0.0001
PLAX – Basal	195.7±60.3	90.9±68.4	69.5±58.4	0.0001
PLAX – Mid	191.3±55.0	84.6±57.9	71.7±48.2	0.0001
DFT	387.4±124.5	379.3±137.8	431.8±114.3	0.26162
DFT/RR	0.41±0.07	0.44±0.08	1.80±7.46	0.25462
Mitral VTI	16.2±3.6	16.4±4.8	18.1±5.6	0.10583
VTI/RR	0.0195±0.006	0.0193±0.0043	0.0213±0.0061	0.30914
SAX‐­MID‐­A to P	192.0±67.2	63.2±75.5	51.1±69.1	0.0001
SAX‐­MID‐­S to L	195.1±60.0	76.4±81.7	52.6±56.4	0.0001
SAX‐­MID‐­S to P	221.2±73.0	95.0±85.3	59.3±53.5	0.0001
Radial Strain ‐­ S to L ‐­ Mid	−19.4±202.7	87.4±218.6	88.6±220.7	0.28519
Radial Strain ‐­ S to L – Basal	−67.1±246.7	14.1±240.6	81.9±192.6	0.04011
Radial Strain ‐­ S to P – Mid	−12.7±217.1	20.1±199.0	67.2±218.2	0.25368
Radial Strain ‐­ S to P – Basal	−88.8±179.5	−32.3±219.5	26.3±140.2	0.03384

*Pre‐­CRT vs follow‐­up

AP19‐­00489

Short‐­term clinical outcomes in left bundle branch pacing in patients with heart failure and complete left bundle branch block

chen yang

the Second Affiliated Hospital of Nanchang University, China

Introduction:

Bi‐­ventricular pacing (Bivpacing) for cardiac synchronization therapy (CRT) effectively corrects indoor conduction block, especially complete left bundle branch block (CLBBB)‐­induced ventricular systolic dyssynchrony, reducing patients Morbidity and mortality. However, 30% of patients with Bivpacing showed complete non‐­response status. His Bundle pacing (HBP) can achieve complete physiological pacing, shorten the QRS width, and even correct the patient's indoor conduction and improve the patient's heart function, but HBP still has an acute threshold. Significant shortcomings such as low perception and long‐­term threshold increase. The new technique of levitation of left bundle branch area pacing (LBBAP) penetrates the ventricular septum through the electrode at the right ventricular septum, reaching the LBB region of the left ventricular surface, thereby pacing the LBB region. Fiber can achieve a similar physiological pacing effect analogous to HBP. LBBAP has better parameters such as perception and pacing than HBP, and it is a safe and effective physiological pacing technique. For the first time, we performed permanent LBBAP in patients with CLBBB complicated with heart failure to further evaluate the clinical efficacy and safety of LBBAP.

Methods:

This was a prospective study of pacing therapy in patients with typical heart failure and CLBBB who were consecutively enrolled from a single center. Follow‐­up parameters were measured after implantation of the pacemaker: QRS wave width, left ventricular ejection fraction, left ventricular end diastolic diameter, and New York cardiac function grading.

Result:

A total of 16 patients (mean 64.56 ± 6.45 years, 12 males) were registered. Eleven patients successfully corrected CLBBB (67.85%), 5 patients did not completely rectify CLBBB, and 16 patients completed more than 3 months of follow‐­up. The average follow‐­up was 6.94 ± 3.91. Months after LBBAP, the QRS width of 16 patients narrowed from baseline 174.63 ± 13.12 to 123.81 ± 29.52 ms (P = .000), and left ventricular ejection fraction increased from baseline 31.00 ± 7.17% to 44.50 ± 12.25% (P = .000), left ventricular end diastolic diameter decreased from baseline 66.81 ± 7.24 to 57.06 ± 8.58 mm (P = .000) and New York heart function grade improved from 2.88 ± 0.72 at baseline to 1.94 ± 0.77 (P = .002). The CLBBB correction threshold remained stable and showed a decreasing trend from 0.79 ± 0.28 to 0.54 ± 0.14 V/0.4 ms, (P < .01).

Conclusion:

LBBAP can improve QRS width, left ventricular ejection fraction, left ventricular end diastolic diameter, and New York cardiac function grading in patients with heart failure and type CLBBB.

AP19‐­00498

Case of intractable NYHA class 4 heart failure treated with leadless endocardial left ventricular pacing

Simon JAMES, Andrew Turley, Michael Chapman

James Cook University Hospital, United Kingdom

Introduction:

We present a 54 years old man with dilated cardiomyopathy (DCM) / severe left ventricular impairment that failed to respond to conventional CRT. He presented with refractory class 4 heart failure and underwent implantation of leadless endocardial LV pacing system (WiCS®‐­LV system) resulting in marked improvement in NYHA class, Echo and ECG parameters.

Methods:

A 54 years old man with history of severe LV impairment due to DCM and AF with persistent high ventricular rates underwent AV node ablation and attempted upgrade of his dual chamber ICD to a Biventricular implantable cardioverter defibrillator in 2018. An LV lead was sited in the only vein branch of the coronary sinus that was present. He initially demonstrated an improvement in symptoms but the lead displaced within 4 weeks of implant and it was not possible to re‐­site. Despite optimal medical therapy he was admitted to hospital repeatedly with decompensated heart failure requiring intravenous (IV) diuretic therapy. A further attempt at LV lead implantation resulted in a lead being sited in a lateral branch of the great cardiac vein as there were no other targets. Following this he remained NYHA class 4, ejection fraction was 25% and required IV diuretics to remain stable.

Result:

We elected to implant a leadless endocardial LV pacing system (WiCS®‐­LV system). this system uses ultrasound technology to transfer energy from a subcutaneously implanted pulse generator (transmitter) to a small receiver‐­electrode implanted on the LV endocardial wall, which then converts the acoustic energy to an electrical pacing pulse The site of latest mechanical activation was identified by Speckle‐­tracking 2D radial strain echo analysis (as per protocol used to in the TARGET (2) and STARTER (3) trials). The site of latest LV activation was shown to be the basal posterior segment. Implantation of the system was performed as a 2‐­stage procedure. First the transmitter was surgically anchored in a pre‐­specified intercostal location based on assessment of the acoustic window characteristics. The following day the patient underwent implantation of the LV endocardial receiver‐­ electrode via right femoral venous access and a trans‐­septal approach. We were able to successfully implant the receiver‐­electrode in the LV segment targeted and establish biventricular pacing. Post implant he was successfully weaned off IV diuretics.

Conclusion:

By 4 weeks post implant QRS width had decreased from 190 to 120 ms. Dyssynchrony parameters had normalised. LV end systolic volume reduced from 191 to 157 mL, ejection fraction increased from 25% to 33.5% and GLS from 9% to 11%. NYHA class improved to 2 and Minnesota Living with Heart Failure Questionnaire score reduced by 44%. His 6 minutes walk distance was 330 m. The response has persisted to 6 months post implant

AP19‐­00509

Evaluation of SharpSense algorithm enhancements in patients with heart failure

Simon Beggs, Chunlan Jiang, Fujian Qu, Kevin Davis, Fady Dawoud, Kyungmoo Ryu, Roy Gardner

Golden Jubilee National Hospital, United Kingdom

Introduction:

RHYTHM‐­HF study is a prospective, observational, multi‐­center cohort study, investigating the role of arrhythmias in the rehospitalization and death of patients with heart failure (HF). In all patients, continuous surveillance of arrhythmias is achieved via the implantation of an Abbott Confirm Rx injectable cardiac monitor (ICM) system. In this analysis, we retrospectively evaluated the effectiveness of recent algorithm enhancements (SharpSense™ Technology) using arrhythmic episodes detected by Confirm Rx ICM devices in this patient cohort.

Methods:

We analyzed data from the first 196 subjects with Confirm Rx devices in the RHYTHM‐­HF study who had a successful transmission to Merlin.net. Pause, bradycardia, and atrial fibrillation (AF) episodes triggered by conventional sensing algorithms and transmitted between August 2017 and May 2019 were further analyzed using SharpSense™ technology. SharpSense™ utilizes arrhythmia adjudication parameters additional to conventional sensing algorithms. For pause and bradycardia episodes, the SharpSense™ algorithm adjudicates the episode as false positive if undersensing of R waves contributed to the trigger. For AF, SharpSense™adjudicates the episode as false positive if p waves are detected. Human adjudication combined with supervised adjudication using a machine learning model was used as the reference for assessing the performance of these enhanced algorithms.

Result:

A total of 313 051 episodes from 196 devices were analyzed (pause: 164 227 [52%], brady: 108 100 [35%] and AF: 40 724 [13%]). The follow‐­up duration was 258 ± 159 days. SharpSense™ algorithm enhancements reduced false pause, bradycardia, and AF episodes by 98.5%, 96.1%, and 30.4%, respectively, with 0.7%, 0.5%, and 2.0% reduction in true episodes, respectively. There was a 97.9% reduction in total false positive episodes using SharpSense™; while 99.5% of true positive episodes were preserved. The number of detected pause, bradycardia, and AF episodes that remained after utilizing SharpSense™ technology was 116 691 (63% reduction in EGM review burden).

Conclusion:

Confirm Rx with SharpSense™ technology significantly reduced false positive detections of pause, bradycardia, and AF episodes while maintaining high sensitivity. This may reduce the requirement for human review of arrhythmic episodes by healthcare professionals and thus improve clinic workflow.

AP19‐­00562

The relationship of atrial fibrillation and clinical features with prognosis in patients with acute decompensated heart failure

Reo Hata, Hiroshi Tasaka, Masatomo Ozaki, Mitsuru Yoshino, Yuuichi Kawase, Takeshi Tada, Kazushige Kadota

Kurashiki Central Hospital, Japan

Introduction:

Atrial fibrillation (AF) is a predictor of poor prognosis in patients with acute decompensated heart failure (ADHF). However, little is known its impact of long‐­term prognosis and the subgroups related to a higher risk of poor prognosis.

Methods:

We retrospectively analyzed the consecutive 1318 patients hospitalized for ADHF and discharged alive in the Kurashiki Congestive Heart Failure registry (with a median [IQR] age of 81 [72‐­87] years, and of whom, 587 [44.5%] were women). They divided them into two groups based on the presence of AF (AF group; n = 639 and non‐­AF group; n = 679). The clinical outcome measure is composite endpoint defines as cardiac death and HF hospitalization.

Result:

During follow‐­up period [median 469 days], 362 events were occurred (cardiac death: n = 110, HF hospitalization: n = 311, both: n = 59). The AF group had significantly higher age, female sex, prevalence of patients with previous HF hospitalization, stroke, dementia (AF group vs non‐­AF group: 79.3 ± 11.0 vs 77.1 ± 12.8, P = .001, 48% vs 42%, P = .03, 29% vs 16%, P =< .001, 17% vs 12%, P = .023, 26% vs 19%, P = .003, respectively). The cumulative event rate was significantly higher in the AF group than in the non‐­AF group (P = .004). After multivariate adjustment, the risk of clinical outcome measure was significantly higher in the AF group than in the non‐­AF group (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.11‐­1.71; P = .03). Subgroup analysis in AF group was performed to further stratify the risk. Cox proportional hazards model showed that renal dysfunction (estimated glomerular filtration rate <45 mL/min/m²) (HR, 1.48; 95% CI, 1.07‐­2.03; P = .017), hyponatremia (<135 mEq/L) (HR, 1.77; 95% CI, 1.22‐­2.59; P = .003), and the history of HF hospitalization (HR, 2.20; 95% CI, 1.63‐­2.96; P < .001), hypoalbuminemia (<3.5 g/dL) (HR, 1.48; 95% CI, 1.08‐­2.04; P = .015) were independent predictors of cardiac events.

Conclusion:

AF is associated with worse prognosis in ADHF patients. Renal dysfunction and hyponatremia, and the history of HF hospitalization were independent predictors of cardiac death and HF hospitalization.

AP19‐­00584

A case of heart failure exacerbated after Leadless pacemaker implantation.

Tomoyuki Yaguchi

SUBARU Health Insurance Society Ota Memorial Hospital, Japan

Introduction:

Case: 89 years old, male. He had been in our hospital with atrial flutter since May 2008. In October 2017, he was admitted for surgery for rectal cancer recurrence. Because he was in advanced atrioventricular block, he inserted a temporary pacemaker and performed surgery. We also considered the implantation of permanent pacemaker, but since there were no symptoms and the remaining life was around 6 months, we decided not to implant. However, since heart failure signs were observed in February 2018, a leadless pacemaker was implanted. Although heart failure was improved after implantation, heart failure signs were observed again 2 months after implantation. He was admitted to the hospital in June 2018 due to exacerbation of heart failure.

Methods:

We observed dyssynchrony exacerbation and LVEF decline that may be due to right ventricular pacing. Therefore, we changed the setting of leadless pacemaker to VVI back up rate 50 bpm.

Result:

Echocardiography was performed 3 hours after the setting change. dyssynchrony had disappeared. At the time of discharge, the EF improved from 35% to 40%, and after 1 month it was further improved to 48%.

Conclusion:

We reported that it was rare in cases of dyssynchrony exacerbation and LVEF decline with right ventricular pacing in a leadless pacemaker.

AP19‐­00642

Clinical benefits of left bundle branch pacing in patients with left bundle branch block: a multicenter, prospective study

Weijian Huang, Shengjie Wu, Lan Su, Xueying Chen, Bingni Cai, Jiangang Zou, Rongfang Lan, Guosheng Fu, Guangyun Mao, Pugazhendhi Vijayaraman, Kenneth A Ellenbogen, Zachary I. Whinnett, Roderick Tung

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Chin, China

Introduction:

His bundle pacing (HBP) could correct left bundle branch block (LBBB) and improved the cardiac function, however it often requires high pacing output. To assess the clinical benefis of left bundle branch pacing achieved by capture left conduction system via a novel intraseptal technique (iLCSP) to deliver cardiac resynchronization therapy (CRT).

Methods:

Patients with LBBB indicated for CRT or pacing therapy from multicenters were included. iLCSP was performed by advancing the MDT 3830 lead deep into the septum about 1 cm distal to the His bundle region. Left ventricular eject fraction (LVEF), left ventricular end‐­systolic volume (LVESV) and New York Heart Association (NYHA) functional class were assessed.

Result:

A total of 94 patients aged 68.3 ± 10.7 years were included. Permanent iLCSP was successfully achieved in 92 patients. In patients who completed 1‐­year follow‐­up, LVEF improved from 38 ± 14% to 56 ± 11% (P < .001). In patients with LVEF > 35%, LVEF increased from 51 ± 12% to 60 ± 10% at 1 year (P < .001). In those with baseline LVEF ≤ 35%, a greater magnitude of LVEF improvement was observed from 28 ± 5% to 48 ± 9% at 6 months (n = 42, P < .001,) and from 29 ± 5% to 53 ± 10% at 1‐­year follow‐­up (P < .001). LVESV decreased significantly (P < .001). The NYHA functional class improved significantly from 3.1 ± 0.5 to 1.5 ± 0.6 at 6 months follow‐­up (P < .001). BNP levels improved from 3.0 ± 0.6 to 2.1 ± 0.7 and cardiothoracic ratios also decreased from 0.62 ± 0.06 to 0.56 ± 0.06 at 6 months (All P < .001). There were no other complications such as infections, embolism or stroke associated with the implantation and heart failure related rehospitalization.

FIGURE 1 Paired LVEF and LVESV at baseline and during the follow‐­up. A. total patients; B, patients with baseline LVEF > 35%; C, D. patients with baseline LVEF ≤ 35%. LVEF, Left ventricular ejection fraction; LVESV, LV end‐­systolic volume. N/M, N means the number of patients who had completed the follow‐­up of 6 month/1 y; M means the member of patients who should complete the follow‐­up of 6 month/1 y. **P < .001, *P < .01, compared to baseline LVEF. LVEF, LVESV

Conclusion:

Permanent iLCSP is effective and safe in patients with LBBB. Permanent iLCSP results in an improved cardiac function in patients with LVEF ≤ 35% and preserve cardiac function in those with LVEF > 35%.

AP19‐­00711

Effect of thoracic magnetic resonance imaging (tMRI) scan on implantable cardioverter defibrillator (ICD) system‐­ the ASIA MRI ICD study update

Balbir Singh, Rajesh Vijayvergiya, Praveen Chandra, Upendra Kaul, Aparna Jaswal, Choi Eue Keun, Vinod Sharma, Tarlochan S. Kler, Kim Dongmin, Yong Seog Oh, Sumit Anand, Neha Sharma, Pallavi Singh, Kartikeya Bhargava

Medanta‐­The Medicity, India

Introduction:

Patients implanted with Implantable Cardioverter‐­Defibrillator (ICD) system may require a thoracic MRI (tMRI). However, performance of tMRI raises potential safety concerns since direct exposure of radiofrequency (RF) to ICD can possibly result in tissue heating, arrhythmia induction, or device damage. The purpose of this study is to evaluate safety of ICD system in patients from Asia undergoing an elective tMRI scan.

Methods:

The ASIA MRI ICD study (Clinicaltrials.gov: NCT02877693) is currently enrolling up to 198 subjects across 16 sites from India, Malaysia, and South Korea All enrolled subjects consented for study participation, were previously implanted with a St. Jude Medical MR Conditional ICD system for at least 60 days and had no contraindications for undergoing tMRI. At 30 days post‐­enrollment, subjects underwent a non‐­diagnostic, RF intensive, pre‐­defined, study specific 1.5 Tesla tMRI sequence, designed to reach a whole‐­body specific absorption rate (SAR) of 1.8 to 2.0 W/Kg. Device interrogation was conducted pre‐­/post and 1‐­month post‐­tMRI follow‐­up visit (1‐­M FU).

Result:

To date 194 subjects [average age 58 years, 163 male, Single Chamber ICD: 143; Dual‐­ Chamber ICD: 51], have been enrolled. The majority of subjects (162) were enrolled in India, 28 in South Korea, followed by 4 in Malaysia. One hundred sixty‐­four (164) subjects had tMRI scan performed at 30 days of post‐­study enrollment (26 subjects withdrew from the study prior to tMRI scan). The average scan duration was 24 minutes 40 seconds and average SAR was 1.8 W/kg. One hundred fifty (150) subjects completed the 1‐­M FU visit. There was no change in lead capture threshold (average 0.75 V@0.5 ms), sensing amplitude (average 10.9 mV) & pacing/high voltage impedance (471/65 and 469/67 ohms) reported between pre‐­tMRI and 1‐­M FU visit in 93% (140/150) of the subjects. No clinically significant detection delays for non‐­sustained VT/VF episodes have been reported. There were 2 SAEs (1 death and 1 hospitalization due to ventricular tachycardia storm) reported prior to tMRI scan. 1 ADE was reported for loss of capture prior to tMRI. 2 SAEs were reported post tMRI (1 death due to hypertension and acute pulmonary edema and 1 hospitalization due to breathless). None of the SAEs were related to the MRI scan, or MRI scan procedure. (Results will be updated before publication)

Conclusion:

The data reported so far in ASIA MRI ICD Study of subjects undergoing 1.5 T tMRI is consistent with other 1.5T MRI studies, with no significant MRI related complications or impact on lead electrical performance.

AP19‐­00783

Left ventricular free wall conduction barriers in heart failure and LBBB – differential effect of right‐­ and left‐­ventricular pacing?

Brian Wisnoskey, Gary Cranke, Niraj Varma

Abbott, United States

Introduction:

Left ventricular (LV) pacing sites are optimized by late activation and/or avoidance of conduction barriers attributed to scar. Hypothetically, LV activation may be delayed due to functional conduction barriers, both during intrinsic activation and pacing, but this has been little examined. The goal of this analysis is to assess LV free wall conduction properties described by multipolar LV leads deployed epicardially via the coronary sinus.

Methods:

In pts with LBBB receiving CRT with quadripolar (span 47 mm) LV leads for standard indications, we measured the activation interval between proximal to distal bipoles (delta qLV) during intrinsic conduction (IC). A gradient was defined as a difference of >20 ms. To test for functional conduction barriers, we altered the direction of LV activation by RV (and then LV) pacing. The LV activation time during each pacing mode was recorded. We then compared paced LV activation to IC in each individual patient. A gradient was considered resolved if its magnitude decreased to <20 ms with pacing but exacerbated if it increased vs baseline.

Result:

Among CRT recipients (n = 120, 68 ± 11 years, EF 25 ± 6 %, 63% male, 33% ischemic; QRSd 162 ± 19 ms), intrinsic LV conduction gradients were identified by quadripolar leads in 29% (nearly equally in ischemic (13/40) and non‐­ischemic (22/80) pts). Intrinsic gradients were resolved in 24/35 (69%) during LV pacing and 22/35 (63%) RV pacing. Exacerbation of existing gradients was rare with either pacing mode (17%). However, LV pacing was twice as likely to reverse the direction of LV activation in patients with existing gradients compared to RV pacing and half as likely to create new gradients where they did not exist previously.

Conclusion:

Although intrinsic LV gradients have largely been attributed to scar we found that most have a functional basis since they are resolved by changing direction of LV activation. These effects may have important implications for CRT programming.

LV pacing	Paced effect	RV pacing
24/35 (69%)	Resolved	22/35 (63%)
6/35 (17%)	Exacerbated existing	6/35 (17%)
13/35 (37%)	Reversed LV activation	6/35 (17%)
13/85 (15%)	Created new gradient	34/85 (40%)

AP19‐­00784

Intrinsic vs left ventricular paced activation in heart failure and LBBB ‐­ do they tell the same story…?

Brian Wisnoskey, Gary Cranke, Niraj Varma

Abbott, United States

Introduction:

Left ventricular (LV) pacing sites are optimized by late activation and/or avoidance of conduction barriers attributed to scar. While most operators target the site of latest electrical activation for optimal LV lead placement, some reports suggest that LV paced effects may be a stronger predictor of CRT response. However, little is known about the relationship between intrinsic and paced electrical activation within an individual patient. The goal of the present study is to assess correlation of intrinsic left ventricular conduction gradients with LV paced activation time in heart failure patients with LV electrical dyssynchrony.

Methods:

In pts with LBBB receiving CRT with quadripolar (span 47 mm) LV leads for standard indications, we measured the activation interval (qLV) at both the proximal and distal bipole during intrinsic conduction. Then during left ventricular pacing, the interval between the distal (and proximal) LV pacing stimulus to the RV sensed iEGM (LVp‐­RVs time) was determined. Correlation analysis was performed between the intrinsic and paced activation times at each bipole. Patients with ischemic and non‐­ischemic cardiomyopathy were contrasted.

Result:

Among CRT recipients (n = 120, 68 ± 11 years, EF 25 ± 6 %, 63% male, 33% ischemic; QRSd 162 ± 19 ms) the mean qLV was 129 ± 28 ms or 79 ± 14% of the intrinsic QRS duration suggesting placement at a terminally activated site. LVp‐­RVs time was longer than qLV in both ischemic and non‐­ ischemic patients (178 ± 31 and 160 ± 27 ms, respectively; both P < .05 vs qLV) and showed poor correlation in both ischemic (R ² = .219) and non‐­ischemic (R ² = .322) patients.

Conclusion:

Intrinsic conduction and paced electrical delays are largely unrelated, even in the presence of ischemic scar, and reflect independent electrophysiologic properties. Paced effects are unpredictable and should evaluated independently of qLV, with important implications for programming to improve CRT response.

AP19‐­00802

β‐­adrenergic signaling activates inflammasome promoting pressure overload‐­induced cardiac fibrosis

Shipeng Dang, Ru‐Xing Wang

The Affiliated Wuxi People's Hospital of Nanjing Medical University, China

Introduction:

Heart failure (HF) is an end‐­stage syndrome of all structural heart diseases accompanying the loss of myocardium and cardiac fibrosis. It has been reported that inflammasome plays a role in cardiac fibrosis. However, it is largely unknown how the inflammasome is activated during heart failure.

Methods:

We established rat thoracic aorta constriction (TAC) model and measured inflammasome proteins in sham and TAC rat myocardium. Inflammasome proteins were also investigated in cultured cardiac fibroblasts with stimulation of norepinephrine.

Result:

Our results showed that inflammasome was activated in cardiac fibroblasts of TAC rats. Stimulation of cultured cardiac fibroblasts with norepinephrine activated inflammasome in vitro, which was abrogated by inhibition of calcium channel and reactive oxygen species (ROS). Activation of inflammasome by norepinephrine promoted cardiac fibrosis, while inhibition of calcium channel/ROS/inflammasome abrogated this effect. Furthermore, blockade of β‐­adrenergic signaling with β‐­blocker suppressed inflammasome with promotion of heart function in TAC rats.

Conclusion:

Our findings indicate that activation of inflammasome by β‐­adrenergic signaling promotes cardiac fibrosis. Therefore, modulation of inflammasome during HF may provide a novel strategy to treat this disease.

AP19‐­00824

Predictive value of q wave in avL in left bundle branch block patients with organic heart disease

Shimeng Zhang, Minglong Chen

the First Affiliated Hospital of Nanjing Medical Universit, China

Introduction:

Aim to determine the prevalence of q wave in avL, prescribe its characteristics and evaluate the correlation between the q wave in avL and organic heart disease (OHD) verified by gated single‐­photon emission computed tomography myocardial perfusion imaging (SPECT‐­MPI) in left bundle branch block (LBBB) patients.

Methods:

1882 LBBB patients were initially involved in the study, and results of SPECT‐­MPI, coronary angiogram (CAG) and Coronary computed tomography angiography (CCTA) were collected. The prevalence, duration and amplitude of q wave as well as duration and amplitude of QRS complex in avL were measured and analyzed. Characteristics of q wave as well as the relationship between q wave and OHD were determined.

Result:

157 subjects were involved in the study finally, OHD were confirmed by SPECT‐­MPI, CAG and CCTA in 122 patients. Septal q waves were present in 56(45.9%) LBBB patients (OHD(+)q(+) group) in the organic heart disease group (OHD(+) group). Specificity and positive predictive value of q wave in avL for OHD were 97.1% and 98.2% respectively. Compare with LBBB patients in OHD(+)q(−) group,LBBB patients in OHD(+)q(+) group have larger end diastolic volume (EDV) (P < .05) and end systolic volume (ESV) (P < .05) as well as lower left ventricular ejection fraction (LVEF) (P < .05). Scatter chart and correlation analysis showed no significant linear correlations between duration, amplitude and areas of q wave with ESV, EDV and LVEF verified by SPECT‐­MPI.

Conclusion:

Q wave in avL in LBBB patients indicated left ventricular disease, and was a predictive factor of serious OHD.

AP19‐­00825

Performance validation of a fluid index derived from intrathoracic impedance in predicting heart failure events in a large real‐­world population of patients with cardiovascular implanted electronic devices

Jodi Koehler, Shantanu Sarkar

Medtronic Plc, United States

Introduction:

Implanted cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) measure intrathoracic impedance and derive a surrogate measure for intravascular and interstitial fluid volume. We validated the performance of a fluid index derived from intrathoracic impedance in predicting impending HF events (HFE) in a large real‐­world cohort of patients.

Methods:

Patients with cardiovascular diseases were included from the Optum® EHR de‐­identified database during 2007‐­2017. In this cohort, we identified patients with Medtronic ICD/CRTD implants with OptiVol2.0 feature. The previously reported OptiVol2.0 fluid index looks for sustained decrease in intrathoracic impedance compared to an expected normal (reference) impedance as a surrogate for increased fluid in intravascular and interstitial space. HFE was defined as an ED or observation unit or inpatient stay with primary diagnosis of HF and IV diuretics administration. Sensitivity was defined as the percentage of HFEs preceded by fluid index exceeding a threshold within the last 30 days. Unexplained detections were fluid index threshold crossing events not followed by an HFE within 30 days. Sensitivity and unexplained detection rate of the fluid index crossing various thresholds is estimated using a generalized estimation equations (GEE) model.

FIGURE 1 Unexplained detection rate (per patient‐year)

Result:

A total of 21 069 patients with 1.5 ± 1.2 years of follow‐­up met inclusion criteria. The average age of patients was 67.8 ± 12.6 years, with 72% being males, 70% with history of HF diagnosis, and 51% (49%) had ICD (CRTD) devices implanted. A total of 1812 patients (8.6%) had 2853 HFEs during follow‐­up. The receiver operating characteristics curve of sensitivity and unexplained detection rate for fluid index based prediction of HFE is shown in figure. In this cohort of patients with all ICD/CRTD devices, at nominal threshold of 60 Ω‐­days, 57% of the HFEs were predicted in the 30 days prior to event with an unexplained detection rate of 1.1 per patient year of monitoring. The performance results underestimate the sensitivity and overestimate the unexplained detection rate as it was derived from a real‐­world cohort of patients and the diagnostic data was not blinded from physicians who may have acted based on the data and prevented HFEs.

Conclusion:

The study validates that the intrathoracic impedance derived fluid index can predict impending HFEs in a large real‐­world population of patients with ICD/CTRD devices.

AP19‐­00891

Eligibility of heart failure patients with sinus rhythm for stroke prevention by antithrombotic in Thailand

Sittinun Thangjui, Aekarach Ariyachaipanich

King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Thailand

Introduction:

Previously reported studies show that oral anticoagulation therapy (OAC) use in patients with heart failure (HF) and sinus rhythm (SR) is nonbeneficial for composite outcomes of death, myocardial infarction, or stroke. Recently in Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease (CAD) Study (COMMANDER‐­HF trial), rivaroxaban has been shown to reduced risk of stroke, especially in patient with CHA2DS2VAS score >4. The aim of this study is to determine the percentage of HF patients who may be a candidate to be enrolled in mentioned study and may benefit from rivaroxaban in a real world practice in Thailand.

Methods:

This is a retrospective, cross‐­sectional study of patients who survived to discharge after HF hospitalization from June 2017 to April 2018 at a single center tertiary care hospital in Thailand. The inclusion and exclusion criteria of COMMANDER‐­HF trial were used to determine the patient who may benefit from rivaroxaban. Patient characteristic including CHA2DS2VAS score were gathered. Data were presented in mean, standard deviation and percentage.

Result:

A total of 197 patients were evaluated. Of these, 23 had inadequate information. Of 174 patients, 32.49%, 61.42% and 39.10% had left ventricular ejection fraction ≤40%, SR and CAD, respectively. When exclude patient with previous intracranial hemorrhage, GFR < 20 or current OAC use, only 9 patients (5.2%) were a candidate to be enrolled in COMMANDER‐­HF trial with 6 patients have a CHA2DS2VAS score of >4.

Conclusion:

Even though COMMANDER‐­HF trial showed benefit of rivaroxaban in patient with HF and CAD in sinus rhythm to reduced risk of stroke. Only minority of patients in real world practice in Thailand could be considered eligible for the study. Nevertheless, OAC use in this setting has to be carefully consider and choose only in the right patient in order to benefit the patients.

AP19‐­00951

The clinical benefit of multipoint pacing in heart failure patients: preliminary results from a randomized and multicenter study in the Middle East

Abdul Mohsen Al‐Musaad, Fayez Boukhari, Raed Sweidan, Yahya Al Hebiashi, Ahmed Al Fagih, Najib Al‐Rawahi, Amjad Al‐Mandalawi, Mohammed Hashim, Ahmad Hersi, Bandar Al‐Ghamdi, Mohammed Amin, Mohammed El Maghawry, Naeem AlShoaibi, Antonio Sorgente, Maria Luisa Loricchio, Ghaliah Al Mohani, Ismail Al Abri, Edmon Khammo, Nazar Sudan, Mohamed Sayed

King Abdulaziz Medical City, Saudi Arabia

Introduction:

Cardiac Resynchronization Therapy (CRT) has been established as adjunctive therapy for heart failure patients with electrical dysynchrony. Despite the improvement of pacing technology and features minimizing the rate of non‐­responders to such therapy remains the goal. MultiPoint™ Pacing (MPP) is one of the latest pacing technologies that provide the opportunity to improve CRT response by pacing the left ventricle (LV) from 2 electrodes along a quadripolar LV lead. Acute and chronic benefits of MPP have been shown in several non‐­randomized clinical studies. In this randomized multicenter trial we evaluated the long‐­term clinical benefits of MPP.

Methods:

In this prospective, randomized, multicenter study, patients with LBBB, meeting an approved indication for CRT‐­D implant according to ESC/EHRA guidelines underwent CRT implantation with St Jude Medical (now Abbott) CRT‐­D device with a quadripolar LV lead. Those with non‐­LBBB or a history of AF within 30 days prior to the enrollment were excluded. Patients were enrolled in 13 centers in 7 countries in the Middle East and randomized to receive either MPP ON (MPP arm) or empirically optimized conventional bipolar pacing (BIV arm) immediate post‐­implant. MPP was programmed based on the RV‐­LV conduction time, assessed by the VectSelect ™ feature. Transthoracic echocardiogram was performed pre‐­implant and at 6 months post‐­implant and analyzed by a core lab to assess CRT response. The primary endpoint was defined as a reduction in LV end‐­systolic volume (ESV) of >15% at 6 months.

Result:

A total of 182 patients were enrolled in the study, successful implantation of LV quadripolar leads were achieved in 174 patients (95.60%) and equally randomized in the two group. Thirty two patients were dropped out (18.39%) because of 20 loss‐­to‐­follow‐­up (11.4%), system explant or lead dislodgment in 3 patients (1.7%), study withdrawal 4 patients (2.2%), 2 patients had no 6 months echocardiography (1.1%) and 3 patients died during follow up due to non‐­cardiac reasons (1.7%). At 6‐­month follow‐­up patients were distributed as following: 73 patients in MPP arm and 69 patients in BIV arm. Final analysis showed significant improvement in the End Systolic Volume (ESV) in MPP group vs BIV group (68% vs 50%, P < .0399).

Conclusion:

The study has been successfully executed and final analyses suggest a positive trend. Additional results will be presented at the conference.

AP19‐­01031

Prognosis significance of atrial fibrillation in patients hospitalized for acute heart failure

Thiratest Leesutipornchai, Pakin Lalitnithi, Thanaporn Ratchataswan, Palapun Waitayangkoon, Aekarach Ariyachaipanich

Faculty of Medicine, Chulalongkorn University, Thailand

Introduction:

Atrial fibrillation (AF) is a common comorbidity observed in patients with acute heart failure (AHF). While chronic heart failure patients with AF have a worse prognosis than those with sinus rhythm, little is known about its prognosis in AHF. The objective of this study is to assess short‐­term outcomes in patients with previously known AF hospitalized for AHF after discharge.

Methods:

This is a retrospective cohort study of patients with AHF who were hospitalized at the tertiary care hospital between July 2017 and March 2018. Patients were divided into two groups by a history of AF from medical records. The co‐­primary outcomes were 30‐­day all‐­cause mortality and 30‐­day readmission rate. The secondary outcome was 180‐­day all‐­cause mortality. The AHF was defined by the Framingham criteria. Survival analysis and Cox regression were used to analyze the association between AF and outcomes.

Result:

A total of 181 patients (aged 68.7 ± 13.5, 51.9% men) with a mean EF of 44.0 ± 19.4 were enrolled. Of these, 64 patients (35.4%) had a history of AF. The 30‐­day mortality, 30‐­day readmission rate, and 180‐­day all‐­cause mortality were 8.8%, 18.2%, and 16.6%, respectively. Kaplan‐­Meier survival analysis demonstrated that there was no statistically significant difference between the group with AF and group without AF. The Cox regression model revealed that, after adjusting for sex and age, the difference between these two groups remained statistically insignificant for all outcomes including 30‐­day mortality (HR 1.55, 95% CI 0.58‐­4.17, P = .383), 30‐­day readmission rate (HR 0.49, 95% CI 0.21‐­1.12, P = .094), and 180‐­day all‐­cause mortality (HR 0.99, 95% CI 0.46‐­2.11, P = .971).

Conclusion:

The previous history AF was not associated with short‐­term prognosis after discharge in patients hospitalized for AHF. However, further prospective studies are needed to confirm these outcomes.

AP19‐­01087

How to chose LV lead duiring CRT implantation: A case of LV lead dislodgment and re‐­implantation

Huan Wang, Lihong Wang

Zhejiang Provincial People's Hospital, China

Introduction:

We hope to discuss how to select suitable LV lead according to different morphologies of coronary veins in a case of LV lead dislodgment and re‐­implantation.

Methods:

A 58‐­year‐­old man complained of “Repeated chest tightness and shortness of breath for 7 years, syncope once” was admitted into our center and diagnosed as “Dilated cardiomyopathy, CRBBB” according to cardiac echocardiography (LVDd/LVDs: 78/64 mm, EF 34%; QRS duration 170 ms). CRTD (St Jude, USA) was implanted during hospitalization. During operation, tiny lateral vein and anterior‐­ lateral vein of CS vein were observed via venography. A quadripolar LV lead (St Jude, USA) was implanted into a tiny branch of lateral vein (threshold: tip1 2.0 V@0.5 ms, tip2 2.5 V@0.5 ms, tip3 and tip4>5 V@0.5 ms), however, LV lead dislodgment happened 1 month after implantation.

Result:

Re‐­implantation was performed. According to venography, a straight quadripolar LV lead (Boston Scientific USA) with Whisper View guiding wire (Boston Scientific USA) was wedged into branch vessels for lead stability and satisfactory threshold (tip1 1.0V@0.5 ms, tip2 1.5V@0.5 ms, tip3 and tip4>5V@0.5 ms).

Conclusion:

CS anatomy could be a limitation of LV lead implantation. Suitable LV lead should be considered according to those situation. Well designed LV lead could meet the needs of various coronary venous anatomies, and could be successfully implanted in most patients and was associated with low acute and chronic complication rates.

AP19‐­01106

Current status of guideline‐­based oral anticoagulant use in thai patients with atrial fibrillation concomitant with heart failure

Pajaree Sriparn, Pakin Lalitnithi, Aekarach Ariyachaipanich

Chulalongkorn University, Thailand

Introduction:

Current guidelines recommend using novel oral anticoagulants (NOACs) to prevent thromboembolism in atrial fibrillation (AF) patients; however, the actual use of NOACs in clinical practice hasn't been well studied. In this study, we focus on AF patients with heart failure (HF) as it's one of the most common co‐­morbidities and recent meta‐­analysis shows more efficacy and safety profile of NOACs over warfarin in this subgroup.

Methods:

In this cross‐­sectional, descriptive study, we enrolled patients with diagnosis of acute HF with concomitant AF who were discharged alive from a single center tertiary care hospital from July 2017 to March 2018. We determined the patient's oral anticoagulant (OAC) need based on CHA2DS2VASc score. Among those who needed, we examined whether they were eligible to NOACs use (not end‐­stage renal disease or liver cirrhosis) and which OAC they received at discharge. Data were presented in mean, SD and percentage.

Result:

From 185 patients who were discharged with HF, a total of 64 patients have HF concomitant with AF (53.1% male, 40.6% HFrEF and a mean age of 69.1 years old). Based on CHA2DS2VASc score, OAC was indicated in 58 patients in which 94.8% were eligible for NOACs. Among these patients, 7.3%, 56.4% and 36.4% were prescribed NOACs, warfarin, and no OAC, respectively (Figure 1).

Conclusion:

According to guideline‐­based recommendation, almost all of HF with AF patients are eligible for NOACs; however, less than one tenth of them are prescribed NOACs.

AP19‐­01108

Characteristics of symptom burden in atrial fibrillation with concomitant heart failure

Sung Joo Cha, Ran Heo, Jin‐Kyu Park

Hanyang University Seoul Hospital, South Korea

Introduction:

Symptom burden is an important factor in determining the treatment of atrial fibrillation (AF). AF is frequently accompanied by heart failure (HF). This study investigated the characteristics of AF symptoms with concomitant HF.

Methods:

A total of 4885 patients with AF were consecutively enrolled through a prospective observational registry (the Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation [CODE‐­AF] registry). Clinically diagnosed HF was divided into 3 categories (preserved, mid‐­range, and reduced ejection fraction [EF]). Symptom severity was assessed using the European Heart Rhythm Association (EHRA) classification.

Result:

The presence of AF‐­related symptoms was comparable irrespective of concomitant HF. Patients with HF with reduced EF demonstrated severe (EHRA class 3 and 4) and atypical symptoms. HF with preserved EF was also associated with atypical symptoms. Female sex and AF type were associated with the presence of symptoms in AF without HF, and non‐­maintenance of sinus rhythm and increased left atrial pressure (E/e`≥15) were factors related to the presence of symptoms in AF with HF.

Conclusion:

AF with concomitant HF presented with more severe and atypical symptoms than AF without HF. Maintaining the sinus rhythm and reducing the E/e’ ratio are important factors for reducing symptoms in AF with concomitant HF.

Table 1 General characteristics according to the presence of heart failure in atrial fibrillation

No. of patients n=4885	No HF n=4322	HF n=563	P value
Age, years	67.2 ± 10.7	69.3 ± 11.0	<.001
Age ≥ 65	2686 (62.1%)	388 (68.9%)	.002
Sex
Female	1579 (36.5%)	212 (37.7%)	.603
Male	2743 (63.5%)	351 (62.3%)
BMI (kg/m2)	24.7 ± 3.4	24.6 ± 3.7	.503
CHA2DS2‐­VASc score ≥2	3141 (72.7%)	525 (93.3%)	<.001
HAS‐­BLED score ≥3	1046 (24.2%)	161 (28.6%)	.025
Hypertension	2964 (68.6%)	401 (71.2%)	.209
Diabetes mellitus	1089 (25.2%)	171 (30.4%)	.009
Dyslipidemia	1590 (36.8%)	205 (36.4%)	.553
Myocardial infarction	93 (2.2%)	44 (7.8%)	<.001*
Stroke history	719 (16.6%)	109 (19.4%)	.107
Cancer	490 (11.3%)	54 (9.6%)	.227
PAD	212 (4.9%)	53 (9.4%)	.002
CKD (eGFR<60)	434 (10.0%)	85 (15.1%)	<.001
ESRD on dialysis	75 (1.6%)	6 (1.1%)	.294*
Permanent pacemaker	278 (6.4%)	48 (8.5%)	.072
ICD	17 (0.4%)	33 (5.9%)	<.001*
Alcohol drinking
Current	945 (22.0%)	106 (18.9%)	.045
Social	340 (7.9%)	34 (6.0%)
Never	3014 (70.1%)	422 (75.1%)
Smoking
Current	363 (8.4%)	64 (11.4%)	.027
Former	1002 (23.2%)	140 (24.9%)
Never	2957 (68.4%)	359 (63.8%)
Systolic blood pressure (mmHg)	122.2 ± 14.7	120.2 ± 16.6	.002
Diastolic blood pressure (mmHg)	74.6 ± 11.1	73.0 ± 12.6	.002
Heart rate (bpm)	74.7 ± 15.6	78.5 ± 17.9	<.001
AF pattern
Paroxysmal	2851 (66.0%)	265 (47.1%)	<.001
Persistent	1290 (29.8%)	240 (42.6%)
Permanent	181 (4.2%)	58 (10.3%)
AF documentation
Newly diagnosed	206 (4.8%)	26 (4.6%)	.840
Within 3 months	353 (8.2%)	50 (8.9%)
Above 3 months	3763 (87.1%)	487 (86.5%)
Echocardiography
EF (%)	63.6 ± 6.2	47.7 ± 13.6	<.001
<40	‐­	163 (29.0%)
40‐­50	‐­	152 (27.0%)
>50	4322 (100%)	248 (44.0%)
LA size (mm)	43.3 ± 7.7	47.3 ± 8.8	<.001
E/e` ratio	11.4 ± 5.0	14.2 ± 6.6	<.001
Electrocardiography
Sinus rhythm	2236 (51.8%)	187 (33.2%)	<.001
QRS duration (ms)	98.6 ± 19.3	103.6 ± 24.7	<.001
Corrected QT interval (ms)	439.7 ± 32.9	452.0 ±40.0	<.001

Note Numerical variables are expressed as mean ± standard deviation, and categorical variables are represented as the absolute value with the percentage in parentheses. Fisher's exact test (*).

Abbreviations: AF, atrial fibrillation; BMI, body mass index; CKD, chronic kidney disease; EF, ejection fraction; ESRD, end‐­stage renal disease; ICD, implantable cardiac defibrillator; LA, left atrium; PAD, peripheral artery disease.

Table 2 Treatment strategies according to the presence of heart failure

No. of patients n=4885	No HF n=4322	HF n=563	P value
Pharmacologic treatment ARB or ACEi	1627 (37.7%)	389 (69.5%)	<.001
Beta blocker	2163 (50.1%)	378 (67.5%)	<.001
Non‐­DHP CCB	1322 (30.6%)	136 (24.3%)	.002
Digoxin	235 (5.4%)	104 (18.6%)	<.001
Statin	1501 (34.7%)	241 (43.0%)	<.001
AF treatment strategy
Rhythm control	2129 (49.3%)	201 (35.7%)	<.001
Rate control only	1564 (36.2%)	317 (56.3%)
None	629 (14.6%)	45 (8.0%)
Non‐­pharmacologic AF treatment
Catheter ablation	809 (18.7%)	83 (14.8%)	.023
Electrical cardioversion	748 (17.3%)	131 (23.3%)	.001
Stroke prevention
CHA2DS2‐­VASc≤1
None	797 (67.5%)	20 (52.6%)	.095*
Anti‐­platelet agents	22 (1.0%)	0 (0.0%)
Oral anticoagulants	362 (30.7%)	18 (47.4%)
CHA2DS2‐­VASc≥2
None	550 (17.5%)	72 (13.7%)	.030*
Anti‐­platelet agents	13 (0.4%)	0 (0.0%)
Oral anticoagulants	2578 (82.1%)	453 (86.3%)

Note Categorical variables are represented as the absolute value with the percentage in parentheses. Fisher's exact test (*).

Abbreviations: ACEi, angiotensin‐­converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin‐­receptor blocker; Non‐­DHP CCB, non‐­dihydropyridine calcium channel blocker.

Table 3 Deterministic factors related to symptoms according to the presence of heart failure in atrial fibrillation

	No HF		HF
	Adjusted OR (95% CI)	P value	Adjusted OR (95% CI)	P value
Age ≥65 years	Not selected		Not selected
Female	1.52 (1.33‐­1.73)		Not selected
BMI ≥ 25 kg/m2	Not selected	<.001	Not selected
CHADS‐­VASc≥2	Not selected		Not selected
PAF vs PmAF	2.18 (1.42‐­3.35)	<.001	Not selected
PeAF vs PmAF	1.75 (1.13‐­2.72)	.013	Not selected
Heart rate ≥100 bpm	1.54 (1.18‐­2.01)	.001	1.92 (1.07‐­3.43)	.028
Sinus rhythm at ECG	Not selected		0.64 (0.43‐­0.97)	.033
QRS duration ≥120 ms	Not selected		Not selected
QTc interval ≥480 ms	Not selected		Not selected
HFmrEF vs HFpEF	Not applicable		Not selected
HFrEF vs HFpEF	Not applicable		Not selected
LA size ≥40 mm	Not selected		Not selected
E/e` ratio ≥15	Not selected		1.47 (1.01‐­2.16)	.047

Note Covariates were age ≥65 years, sex, body mass index (BMI)≥25 kg/m², CHADS‐­VASc≥2, AF pattern, heart rate ≥100 bpm, and parameters of echocardiography and electrocardiography.

Abbreviations: BMI, body mass index; CI, confidence interval; ECG, electrocardiography; EF, ejection fraction; HF, heart failure; LA, left atrium; OR, odds ratio; QTc, corrected QT; PAF, paroxysmal atrial fibrillation; PeAF, persistent atrial fibrillation; PmAF, permanent atrial fibrillation.

AP19‐­01140

Prevalence of patients with QRS 120‐­150 ms and QRS ≥ 150 ms from patients with LVEF ≤ 35% in sinus rhythm and left bundle branch block at St. Luke's Medical Center – Global City, Philippines

Lisa M. Beltejar, Giselle Gervacio

Philippine Heart Rhythm Society, Philippines

Introduction:

This is a pilot study. To date, no study in published Philippine literature has investigated the prevalence of patients with QRS ≥ 120 ms (ESC/EHRA Guidelines) and QRS ≥ 150 ms (ACC/AHA/HRS Guidelines) from patients with LVEF ≤ 35% in SR with LBBB morphology, both said QRS durations were included in the criteria of Class I indication for CRT implantation. The objectives of the study are to determine the prevalence of patients with QRS 120‐­150 ms and QRS ≥ 150 ms from patients with LVEF ≤ 35% in SR and LBBB at St. Luke's Medical Center‐­Global City (SLMC‐­GC), Philippines, to classify these patients to ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM), and to determine their demographics in terms of age, sex, and co‐­morbidities.

Methods:

This is a cross‐­sectional study performed from January to September 2016, with subjects at SLMC‐­GC, Philippines. Data collection was performed which consists of 2‐­D echocardiogram with LVEF ≤ 35% in SR and LBBB, from which 2 groups of QRS 120‐­150 and ≥150 ms with their demographic profiles such as age, sex, and co‐­morbidities will be identified and analyzed using percentage or proportion.

Result:

The sample size in the study period was composed of 10 113 patients, of whom 1% (135) had LVEF ≤ 35% in SR. From 135 patients, 11% (15) had LBBB with QRS ≥ 120 ms. From 135 patients, 7% (9) had QRS 120‐­150 ms and also 7% (9) had QRS ≥ 150 ms. All patients who had QRS 120‐­150 ms were ICM while those with QRS ≥ 150 ms, 56% (5) were ICM and 44% (4) were NICM. Among patients with QRS 120‐­150 ms, youngest age was 50, median age was 67, and oldest age was 84, while among patients with QRS ≥ 150 ms, youngest age was 50, median age was 66, and oldest age was 82. Among those with QRS 120‐­150 ms, 67% (6) were males and 33% (3) were females whereas those with QRS ≥ 150 ms, 78% (7) were males and 22% (2) were females. Both groups of QRS 120‐­150 ms and ≥150 ms had the same identified comorbidities: CAD, HPN, DM, dyslipidemia and ESRD. Those with QRS 120‐­150 ms, 67% (6) had both CAD and DM, 56% (5) had HPN, 22% (2) had dyslipidemia and 11% (1) had ESRD, whereas those with QRS ≥ 150 ms, 78% (7) had CAD, 56% (5) had HPN, 44% (4) had DM, and 11% (1) had both dyslipidemia and ESRD.

Conclusion:

There was both 7% prevalence of patients with QRS 120‐­150 ms and QRS ≥ 150 ms from patients with LVEF ≤ 35% in SR and LBBB at SLMC‐­GC, Philippines. All patients with QRS 120‐­150 ms were ICM while majority of those with QRS ≥ 150 ms were ICM. In both groups of QRS duration, youngest age was 50; median age of QRS 120‐­150 ms was 67 whereas QRS ≥ 150 ms was 66; and with QRS 120‐­150 ms, patients who were affected were older (84 vs 82 years old). Both QRS 120‐­150 ms and ≥150 ms were predominantly males with CAD, HPN, and DM as identified important risk factors.

AP19‐­01224

Single center experience of abbott multipoint pacing devices

Tarlochan Singh Kler, Avinash Verma

Pushpawati Singhania Hospital & Research Institute, India

Introduction:

Cardiac Resynchronization therapy (CRT) with Multipoint pacing (MPP) is an advanced feature which helps to pace Left ventricle at dual‐­sites by using 2 different vectors with a programmable delay. This observation aims to evaluate impact of MPP on non‐­responder patients.

Methods:

A total of consecutive 79 patients were implanted with Abbott CRT‐­pacemaker(P) or defibrillator(D) at Pushpawati Singhania Research Institute (PSRI) Hospital, India. Clinical, functional and hemodynamic parameters {Left Ventricular End Systolic Volume (LVESV)} were evaluated at pre‐­ implant, 6th and 12th month. Patients with LVESV reduction of less than 15% were classified as non‐­responders at 6th month.

Result:

The CRT‐­D (n‐­58) and CRT‐­P (n‐­20) systems were successfully implanted in 78 of 79 attempted implants (99%). There were 26 (33%) Non‐­responder patients at 6th month who were followed up till 12th month. Out of 26 patients MPP was programmed on in 11 patients. Clinical, functional and hemodynamic parameters were evaluated at 12th month. Out of 11, 4 patients completed 12th month follow up, 3 were lost to follow‐­up, in 2 MPP could not be turned on due to lack of vectors and 2 patients are due for 12th month follow up. All 4 patients were responder at 12th month with reduction in LVESV of >15%. New York Heart Failure Association (NYHA) class improvement by 1 class was observed in all patients. QRS narrowed at 12 months to 125 ± 22 ms from 174 ± 18 ms at baseline. Patient global assessment showed markedly better outcome for all patients in comparison to baseline. Out of 4 completed patients, 3 patients had MPP programmed with anatomical separation (AS) and 1 patient with other MPP programming.

Conclusion:

Hence, MPP is beneficial to heart failure patients who do not respond to regular CRT. Further MPP programmed with anatomical separation yielded better results.

AP19‐­01238

Clinical outcome of cardiac resyncronization therapy in patients with heart failure due to valvular cardiomyopathy after corrective surgery

Vickram Vignesh R, Chennapragada Sridevi, David Sampath Kumar Gollapally, Sachin Yalagudri, Daljeet K. Saggu, Narasimhan Calambur

Care Hospital, India

Introduction:

Cardiac resynchronization therapy (CRT) is beneficial and well established therapy in heart failure patients with LVEF ≤ 35% and electrical dyssynchrony. Little data is available about the usefulness of CRT in heart failure due to valvular heart disease. The objective of the present study is to describe the long term follow up of clinical characteristics and effect of CRT on left ventricular remodelling in patients with heart failure of valvular etiology who had undergone prosthetic valve replacement.

Methods:

Between 2008‐­2018, a total 400 underwent CRTs at Care hospital, Hyderabad. Among them 15 consecutive patients with heart failure due to valvular heart disease who had undergone prosthetic valvular replacement were included in this retrospective analysis. The clinical characteristics, implantation data and follow up analysis of electrocardiographic and hemodynamic remodeling following CRT implantation were studied. Response to CRT was defined as improvement in NYHA class by 1 and reduction end systolic volume (ESV) by 15% post CRT.

Result:

The baseline characteristics of the patients are shown in Table 1. The median duration of valvular surgery and CRT implantation was 72 [3‐­312] months. Patients were followed up for 29 (17‐­125) months. CRT–P was performed in 6 patients and remaining underwent CRT‐­D. Acute lead related procedural complications occurred in 2 patients. At the end of 1 year follow up, QRS duration (167.86 + 14.15 vs 135.29 + 10.93, P < .01) ms, NYHA class (3.2 + 0.56 vs 2.13 + 0.51, P < .01), HF related hospitalisation [2 (2‐­3) vs 0 (0‐­1) P < .01] and ESV (121.5 + 29.76 vs 66.5 + 37.38, P < .01) mL showed significant improvement. The non‐­ responders at 1 year follow up was 3 (20%). The following complications occurred on long term follow up, lead related (n = 3, 20%), mortality (n = 1, 6.6%).

Conclusion:

Both clinical and LV remodeling improvement occurs in patients with advanced heart failure due to valvular cardiomyopathy.

TABLE 1

Age, mean (SD), years	54.66 (14.45)
Men n (%)	11 (73.33)
Rheumatic heart disease n (%)	8 (53%)
Replaced valve
Mitral n (%)	5 (33.33%)
Aortic n (%)	7 (46.67%)
Mitroaortic n (%)	3 (20%)
Base line QRS morphology
LBBB n (%)	12 (80%)
Non‐­LBBB n (%)	03 (20%)
Base line QRS duration mean (SD) ms	167.86 (14.15)
Atrial fibrillation n (%)	7 (46.66%)
Atrioventricular junction ablation	5 (33.33%)
Maze procedure	1 (6.6%)
Baseline NYHA
NYHA class III n (%)	11 (73.33%)
NYHA class IV n (%)	04 (26.67%)

AP19‐­01245

Can ‘routine’ cardiac MRI change treatment plan in DCM?

Debabrata Bera, Ayan Kar, Subhajit Das, Suchit Majumder, Sanjeev Mukherjee

Rabindranath Tagore International Institute of Cardiac Sciences, India

Introduction:

Dilated cardiomyopathy (DCM) is a heterogeneous entity with next population of patients sometimes they have underlying disease like cardiac sarcoidosis or tuberculosis or alcoholic cardiomyopathy or they can be simply idiopathic DCM.The management hence difference in different subset of patients. We tried to look at our patients labelled as dilated cardiomyopathy who were referred for ‘routine’ cardiac MRI.

Methods:

Patients with DCM between 15‐­60 years who came for routine cardiac MRI were evaluated. Consecutive 20 patients were analysed retrospectively.

Result:

We found the indication of dilated cardiomyopathy in 20 patients in them eight patients (8/20, 40%) had significant abnormality in cardiac MRI. In three of them (3/20, 15%) the finding could change the diagnosis and management. Of these three patients, two patients (2/20, 10%) had granulomatous myocarditis who were treated with disease specific therapy. One patient had scarring suggesting ischemic etiology, which mimicked idiopathic dilated cardiomyopathy due to triple vessel involvement. In other five patients where it did not change the diagnosis, it could help us to prognosticate them about risk of arrhythmias hence helped for risk stratification.

Conclusion:

We found that routine cardiac MRI is useful to look for underlying etiology and can change treatment plan of patients initially diagnosed with dilated cardiomyopathy. It can also help for risk stratification of subjects with DCM.

AP19‐­01253

Multipoint pacing activation in the patients implanted with cardiac resynchronization therapy

Avinash Verma, T. S Kler

Pushpawati Singhania Research Institute, India

Introduction:

Multipoint left ventricular (LV) pacing [MultiPoint™ Pacing (MPP), modality enables sequential pacing from two LV sites (LV1 and LV2) through a quadripolar LV lead and from one right ventricular (RV) site. It provides benefit to acute LV hemodynamics, dyssynchrony and peak radial strain and to mid‐­term LV function beyond conventional CRT. The positioning of LV quadripolar lead effects the possibility of Multipoint pacing activation. MPP feature can be programmed ‘ON’, in a patient who have at least 2 vectors from different groups (with different Cathodes) that fulfills the following conditions: • At least one vector per electrode (D1, M2, M3 and M4) must be tested. The capture threshold does not exceed 4.5 V at 0.5 ms pulse width (CRT‐­D) or 4.5V @ 0.4 ms (CRT‐­P) • No Phrenic Nerve Stimulation (PNS) at 1 Volt above the pacing capture threshold Patients who met above programming criteria were considered as true candidates for “MPP Activation”. In this study, we evaluated probability of MPP activation in patients implanted with a CRT‐­ pacemaker (P) or defibrillator (D) MPP device.

Methods:

A total of 78 patients implanted with Abbott CRT‐­P /D at Pushpawati Singhania Research Institute (PSRI) Hospital, India were enrolled. All subjects had a routine device interrogation on the day of Implant. To check the possibility of turning MPP feature “On”, device interrogation was conducted within 7 days post implant. It included routine device parameters, RV‐­LV Conduction delays and MPP Vector test. Data collected was evaluated to see how many patients meet the programming criteria for “MPP Activation”.

Result:

Out of 78 patients, 58 patients received CRT‐­D and 20 received CRT‐­P MPP device. Out of 78, 56 subjects had Ischemic while 23 had non‐­ischemic cardiomyopathy. LV lead was positioned at lateral position in 56% patients, posterior lateral in 24%, anterior lateral in 12% and rest were anterior. On the day of implant all subjects had stable device parameters. Out of 78, 73 number of patients met the criteria for MPP activation. Majority of patients had an average capture threshold of 1.5V@0.5 ms pulse width with PNS absent. 5 Patients didn't meet programming criteria due to unavailability of MPP vectors with anatomical separation (4) and death (1).

Conclusion:

Hence, MPP activation is possible in majority of patients.

Table 1 Showing vector possible in number of patients

Vector group	Cathode to anode	Vector possible (No. of patients)
A	D1 → M2	28
	D1 → P4	39
	D1 → RV Coil/Ring	43
	D1 → Can	1
B	M2 → P4	46
	M2 → RV Coil/Ring	46
	M2 → Can	3
C	M3 → M2	24
	M3 → P4	29
	M3 → RV Coil/Ring	40
	M3 → Can	2
D	P4 → M2	23
	P4 → RV Coil/Ring	28
	P4 → Can	2

AP19‐­01255

Effect of coenzyme Q10 administration in the incidence of atrial fibrillation among heart failure patients: The roles of antioxidant

Louisa Fadjri Kusuma Wardhani, Ivana Purnama Dewi, Djoko Soemantri

Universitas Airlangga, Indonesia

Introduction:

Heart Failure (HF) is associated with increased circulating inflammatory cytokines and high oxidative stress state. Several studies have shown inflammation as an independent risk factor for the initiation and maintenance of Atrial Fibrillation (AF). AF, a common coexisting cardiac problem in HF, is marked as a significant increased mortality risk factor. Coenzyme Q10 (CoQ10) is involved in free radical scavenging by reducing TNF, hs‐­CRP, and MDA. Decreasing of CoQ10 level in myocardial found among HF patients and correlated with the severity symptoms. Oral administration of CoQ10 is needed to obtain a positive clinical impact.

Methods:

This study aimed to evaluate the effect of CoQ10 administration in the incident of AF and mortality outcomes among HF patients. We searched Pubmed database using the following keywords: Coenzyme Q10, CoQ10, Ubiquinone, Heart Failure, and Arrhythmia.

Result:

Two good clinical studies met our inclusion criteria with total of 548 patients for analysis. Both studies showed a lower incidence of AF and good outcome in Coenzyme Q10 treatment group. Patients undertake CoQ10 were no significant differences to coexisted with Atrial Fibrillation [OR 0.51 (95% CI 0.15‐­1.77); P = .29] but have lower mortality rates [OR 0.58 (95% CI 0.35‐­0.96); P = .03].

Conclusion:

These conclude that coenzyme Q10 could reduce the mortality rates among heart failure patient without significantly reduce the incidence of AF.

Keywords: Coenzyme Q10, CoQ10, ubiquinone, heart failure, arrhythmia.

Table 1. Description of the study

Author (year)	Country	Method	Patient	Outcome
Mortensen, et al (2014)	17 European, Australian, and Asian centers	Retrospective	420 patients	1. The number of adverse events tended to be lower in the Coenzyme Q10 group compared with placebo group 2. A lower all cause mortality rate was found among Coenzyme Q10 patient
Zhao, et al (2016)	China	Retrospective	128 patients	1. The incidence of Atrial Fibrillation was lower in Coenzyme Q10 group than control group after 12 months 2. Restrospectively, all‐­cause mortality was lower in Coenzyme Q10 patient group within 16 week treatment

TABLE 2 Effect of coenzyme Q10 administration in the incidence of atrial fibrillation among heart failure patients

TABLE 3 Mortality rates among heart failure patient with and without coenzyme Q10 administration

AP19‐­01261

Montreal cognitive assessment is superior to standardized mini‐­mental status exam in detecting mild cognitive impairment in heart failure

Marleen Irwin

University of Alberta, Canada

Introduction:

The incidence and prevalence of mild cognitive impairment (MCI) in patients with heart failure (HF) preserved or reduced ejection fraction is largely unknown. This study compares the utility of Montreal Cognitive Assessment (MoCA) to the Mini‐­Mental Status Exam (MMSE) for diagnosing MCI in a HF population.

Methods:

Participants were recruited from the Alberta HEART study at the Mazankowski Alberta Heart Institute in Edmonton and St. Mary's hospital in Camrose. This study enrolled 54 community dwelling adults; 34 with HF and 20 controls aged >50 years. Participants were assessed using both the MMSE and MoCA for MCI. In all participants, depression and dementia were ruled out using the DSM IV criteria. MCI was diagnosed using the European Consortium Criteria. Sensitivity and specificity analysis, positive and negative predictive values, likelihood ratios and Kappa statistic were calculated.

Result:

The mean age was 72.8 (SD 8.4), 60.4% were females and 34% had underlying ischemic heart disease. Overall, two thirds of patients (22/33, 66%) with HF had MCI. In comparison to Consortium Criteria, the sensitivity and specificity of MoCA were 82% and 91% in identifying individuals with MCI, and MMSE were 9% and 91%, respectively. The positive and negative predictive values for MoCA were 95% and 71%, and for MMSE were 67% and 33%, respectively. Kappa statistics showed good agreement between MoCA and consortium criteria (kappa = 0.68) and a low agreement between MMSE and consortium criteria (kappa = 0.07).

Conclusion:

Cognitive dysfunction is common in patients with HF. Overall, the MoCA is a better screening tool than MMSE for MCI in patients with heart failure.

AP19‐­01262

Arrythmia in myocarditis

Pham Tran Linh, Vu Quoc Oai

Vietnam National Heart Institute, Vietnam

Introduction:

Acute myocarditis must be considered in patients with recent onset of cardiac failure or arrhythmia. Fulminant myocarditis is a distinct entity characterized by sudden onset of severe congestive heart failure or cardiogenic shock, usually following a flu‐­like illness, parvovirus B19, human herpesvirus 6, coxsackie virus and adenovirus being the most frequently viruses responsible for the disease. And virus is also the most common cause of myocarditis. Arrhythmia is frequent in myocarditis especially dangerous arrhythmias like third degree AV block, ventricular fibrillation, ventricular tachycardia, etc. Myocarditis is thought to account for a large proportion of sudden cardiac deaths in young people without prior structural heart disease. However, therapeutic interventions are limited and nonspecific. Identifying those at greatest risk of a life‐­threatening arrhythmia is critical to reducing the mortality. This review summarizes current understanding of this challenging area in which many questions remain.

Methods:

50 research subjects were diagnosed with myocarditis according to the 2013 European Society of Cardiology guidelines. The patients were kept under observation by medical monitor or holder monitor in their acute phase (96 hours since developing symptoms). We summarized all kinds of arrhythmia including supraventricular tachycardia, atrial fibrillation, atrial flutter, AV block, ventricular tachycardia, ventricular fibrillation, torsade de points. Calculate the frequency of arrhythmia.

Result:

We detected that most of the research patients had sinus tachycardia, 42% was found with sustained ventricular tachycardia, 60% with unsustained ventricular tachycardia, 34% with ventricular fibrillation; 52% third degree AV block.

Conclusion:

There was a significant proportion of life threatening arrhythmia was found in acute phase of myocarditis patients, therefore, a close monitoring plan is highly recommended for timely detection and management.

AP19‐­01280

Recovery from heart failure with reduced ejection; HFrEF to HFpEF

Marleen Irwin

University of Alberta, Canada

Introduction:

Patients with heart failure are traditionally categorized into two groups according to size and function of the left ventricle [LV]. The systolic heart failure group with dilated LV diameters and low <45% ejection fraction [EF] or HFrEF, and those with normal EF and no evidence of LV dilation described as HFpEF. An interesting emerging group are those found to be previously HFrEF but with time and optimal medical management are reclassified to HFpEF; “responders”. We evaluated a novel tool which provides endothelial function measurements using peripheral arterial tonometry [PAT] for reactive hyperaemic index [RHI] in this group of LV responders.

Methods:

One hundred and sixty two [162] consecutive patients recruited into a heart failure trail [64 ± 10 years, 98 male], undergoing Echo and CMR were included along with 20 matched controls. The authors investigated the relationship between PAT‐­RHI and clinical characteristics, risk factors, levels of inflammatory biomarkers, and end‐­exercise cardiac output [CO]. Contrast bolus injections were administered for optimal Echo and CMR endocardial definition. Off‐­line RHU as well as LV volume analysis was performed by standard manual tracing of end‐­systolic and end‐­diastolic endocardial borders.

Result:

In HFpEF and HFrEF, RHI, and CO were significantly lower, while significantly higher in the ‘recovered’ HFrEF and controls. Tracing of RHI images was possible in 158 patients. In 158 of 162 patients [97.5%] the RHI followed the myocardial imaging outcomes. The defining parameters obtained correlated well with both standard Echo and CMR for all: EDV (r .93, P < .01: r .91, P < .01) ESV (r .89, P < .01: r .94, P < .01), and EF (r .87, P < .01: r .83, P < .01).

Conclusion:

The authors confirmed a possible link between improved RHI in the HFrEF ‘responders’ by demonstrating an impairment of endothelial function associated with LV dysfunction severity.

AP19‐­01305

Characteristics of Asia‐­Pacific heart failure patients with cardiac resynchronisation therapy: data from the Adaptresponse trial

Kengo Kusano, Sandra Jacobs, David Birnie, Michael R. Gold, Ahmad S. Hersi, Christophe Leclercq, Wilfried Mullens, Balbir Singh, Seung‐Jung Park, Min‐Tsun Liao, Bart Gerritse, Gerasimos Filippatos, Bruce L. Wilkoff

Medtronic, Netherlands

Introduction:

CRT response rates vary significantly with limited clinical improvement in at least 20%‐­30% of device recipients. Multiple clinical factors are associated with CRT response, including QRS duration and morphology, age, gender, height, HF etiology, dyssynchrony, and scar burden. HF patient characteristics vary between regions and countries. The AdaptResponse trial is a large CRT trial well represented with women that enrolled worldwide and the present analysis was designed to compare patient characteristics of randomized Asia‐­Pacific patients (pts) with pts from other regions.

Methods:

The AdaptResponse trial enrolled CRT indicated pts with NYHA Class II‐­IV HF, LBBB (QRS ≥ 140 ms in men, ≥130 ms in women), and baseline PR interval ≤200 ms. Pts from Japan, Republic of Korea, Taiwan, India and Australia are included in the Asia‐­Pacific cohort. Statistical analyses were done to assess differences in patient characteristics.

Result:

There were 3620 pts randomized in 226 centers worldwide, including 1569 (43.3%) women. In the Asia‐­Pacific cohort of 245 pts, 37.1% were women. The table below shows that Asia‐­Pacific patients had a comparable age, were shorter, had lower BMI, trended to have worse baseline status (57.6% in NYHA III/IV), reported significant less depression (4.1% vs 14.2%) and received more often CRT‐­P (15.1 % vs 3.7% in the other regions). Moreover, more pts reported HF hospitalizations (62.9% vs 47.1%) prior to randomization. Medication included significantly more loop diuretics and aldosterone antagonists (MRA), less Angiotensin Converting Enzyme (ACE) inhibitors and β‐­Blockers. Renal dysfunction was more frequently present in Asia‐­Pacific patients and chronic lung disease less; however, incidence of other comorbidities such as AF, diabetes, or ischemic cardiomyopathy was not significantly different.

Conclusion:

Patient characteristics differ between patients from Asia‐­Pacific compared to other regions and Asia‐­Pacific patients have different medication treatment patterns. Their Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score is comparable, although less Asia‐­Pacific patients reported to be depressed. The impact of these differences on clinical outcomes will be evaluated in the AdaptResponse trial.

Percentage or mean ± s.d. * p<0.05, ** p<0.001	Other regions (N=3375)	Asia Pacific (N=245 )		Other regions (N=3375)	Asia Pacific (N=245 )
Age (years)	64.9 ± 11.0	65.4 ± 11.7	Renal Dysfunction *	16.5%	22.4%
Female *	1478 (43.8%)	91 (37.1%)	Diabetes	34.5%	37.1%
Height (cm) **	169.5 ± 10.3	162.0 ± 9.8	Chronic Lung Disease **	15.3%	7.8%
BMI (kg/m2) **	29.2 ± 6.5	24.7 ± 4.8	Hypothyroidism	9.2%	6.5%
NYHA Class III/IV	51.3%	57.6%	Anemia *	6.8%	3.3%
LVEF (%) *	25.5 ± 6.3	24.7 ± 5.7	Depression **	14.2%	4.1%
QRS interval (ms)	163 ± 17	164 ± 17	β‐­Blocker **	90.0%	80.8%
KCCQ overall summary score	62.4 ± 24.0	63.5 ± 21.2	ACE inhibitor *	52.1%	43.3%
Previous HF hospitalization **	47.1%	62.9%	ARB	33.7%	32.2%
Ischemic cardiomyopathy	31.9%	27.8%	MRA **	46.1%	59.6%
Mitral valve dysfunction **	16.7%	7.8%	Loop Diuretic **	58.7%	73.5%
Atrial fibrillation	12.9%	10.2%	CRT‐­P **	3.7%	15.1%

AP19‐­01306

The clinical benefit of multipoint pacing in heart failure patients: Preliminary results from a randomized and multicenter study in the middle east

Abdul Mohsen Al‐Musaad, Fayez Boukhari, Raed Sweidan, Yahya Al Hebaishi, Ahmed Al Fagih, Najib Al‐Rawahi, Amjad Al‐Mandalawi, Mohammed Hashim, Ahmad Hersi, Bandar Al‐Ghamdi, Mohammed Amin, Mohammed El Maghawry, Naeem AlShoaibi, Antonio Sorgente, Maria Luisa Loricchio, Ghaliah Al Mohani, Ismail Al Abri, Edmon Khammo, Nazar Sudan, Mohamed Sayed

King Abdulaziz Medical City, Saudi Arabia

Introduction:

Cardiac Resynchronization Therapy (CRT) has been established as adjunctive therapy for heart failure patients with electrical dysynchrony. Despite the improvement of pacing technology and features minimizing the rate of non‐­responders to such therapy remains the goal. MultiPoint™ Pacing (MPP) is one of the latest pacing technologies that provide the opportunity to improve CRT response by pacing the left ventricle (LV) from 2 electrodes along a quadripolar LV lead. Acute and chronic benefits of MPP have been shown in several non‐­randomized clinical studies. In this randomized multicenter trial we evaluated the long‐­term clinical benefits of MPP.

Methods:

In this prospective, randomized, multicenter study, patients with LBBB, meeting an approved indication for CRT‐­D implant according to ESC/EHRA guidelines underwent CRT implantation with St Jude Medical (now Abbott) CRT‐­D device with a quadripolar LV lead. Those with non‐­LBBB or a history of AF within 30 days prior to the enrollment were excluded. Patients were enrolled in 13 centers in 7 countries in the Middle East and randomized to receive either MPP ON (MPP arm) or empirically optimized conventional bipolar pacing (BIV arm) immediate post‐­implant. MPP was programmed based on the RV‐­LV conduction time, assessed by the VectSelect ™ feature. Transthoracic echocardiogram was performed pre‐­implant and at 6 months post‐­implant and analyzed by a core lab to assess CRT response. The primary endpoint was defined as a reduction in LV end‐­systolic volume (ESV) of >15% at 6 months.

Result:

A total of 182 patients were enrolled in the study, successful implantation of LV quadripolar leads were achieved in 174 patients (95.60%) and equally randomized in the two group. Thirty two patients were dropped out (18.39%) because of 20 loss‐­to‐­follow‐­up (11.4%), system explant or lead dislodgment in 3 patients (1.7%), study withdrawal 4 patients (2.2%), 2 patients had no 6 months echocardiography (1.1%) and 3 patients died during follow up due to non‐­cardiac reasons (1.7%). At 6‐­month follow‐­up patients were distributed as following: 73 patients in MPP arm and 69 patients in BIV arm. Final analysis showed significant improvement in the End Systolic Volume (ESV) in MPP group vs BIV group (68% vs 50%, P < .0399).

Conclusion:

The study has been successfully executed and final analyses suggest a positive trend. Additional results will be presented at the conference.

AP19‐­01308

Lower targeted beta‐­blocker dosage in Asian population: A pilot study in heart failure and coronary artery disease patients

Hans Nuari, Joey Martinus Sidarta, Elizabeth Marcella, Karlina Alferinda, Carol Natasha, Vito Damay, Michael Tanaka, Melisa Aziz, Indah Sukmawati

Udayana University, Indonesia

Introduction:

It is still being discussed regarding up‐­titration of beta‐­blocker as an important therapy of heart failure with reduced ejection fraction (HFrEF) and coronary artery disease (CAD). Up‐­titration of beta‐­blocker was associated with lower morbidity and mortality. Do we need to achieve targeted heart rate (50‐­60 bpm) or maximum dose to obtain desired therapeutic effect? According to high profile studies, bisoprolol was suggested to be up‐­titrated to maximum of 10 mg daily. Difference in patient characteristics, such as race and age, may associate with heart rate response to beta‐­blocker. There are less data regarding this in Asia‐­Pacific, particularly in Indonesia. This preliminary study aims to reveal a real‐­world heart rate response of beta‐­blocker dosage in Asian population, particularly in Indonesia, also to discover association between patient characteristic and beta‐­blocker dosag

Methods:

Samples were outpatient subjects of Siloam hospital (Type‐­B / Regional hospital), Tangerang. Inclusion criteria were HFrEF and CAD patients treated at least 2 months with a tolerated beta‐­blocker (bisoprolol) dose, 20‐­70 years old. Exclusions were fever/systemic infection, respiratory insufficiency, on digoxin/ivabradine therapy, thyroid disease, and pregnancy.

Result:

This study enrolled 150 Asian patients. From 94 patients (56 male; 38 female) with heart rate of 50‐­60 bpm (mean: 56.79 ± 2.90 bpm), 77 patients (81.91%) were treated with less than 5 mg bisoprolol. This result was much lower compared to European studies. There is a significant difference between age and bisoprolol dose by T test (P: .019). Mean age 60.51 ± 9.90 years on bisoprolol <5 mg, compared to 54.12 ± 10.32 years on bisoprolol ≥5 mg. Gender and body measurements, however, are not associated with bisoprolol dose.

Conclusion:

In this study, most patients (81.91%) need lower than daily 5 mg bisoprolol to achieve heart rate reduction target of 50‐­60 bpm. Elderly is significantly associated with lower bisoprolol dosage to achieve heart rate reduction target. Thus should be part of consideration in real world practices, with respect to dose related benefit of beta‐­blocker. More study across Asia‐­Pacific is suggested.