Tuesday 1 September 2015

Tuesday 1 September 2015

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Novelties in cardiac resynchronisation therapy NOVELTIES IN CARDIAC RESYNCHRONISATION THERAPY

4856 | BEDSIDE Transseptal endocardial left ventricular lead implantation after failed CRT implantation- long term results L.A. Geller, L. Molnar, S.Z. Szilagyi, E. Zima, G. Szeplaki, V.K. Nagy, E.E. Ozcan, A. Apor, Z. Sallo, B. Merkely on behalf of Bolyai Janos Hungarian Academic Research Fund (GL, SzG). Semmelweis University, Heart and Vascular Center, Budapest, Hungary

4858 | BEDSIDE Cardiac resynchronization therapy in the elderly - is there an indication for a defibrillator? M. Doering, J. Lucas, K. Bode, A. Muessigbrodt, T. Heine, H. Knopp, G. Hindricks, S. Richter. Heart Centre, Department of Electrophysiology, Leipzig, Germany Introduction: Cardiac resynchronization therapy (CRT) is an effective treatment option for heart failure in elderly patients, but the additional benefit of an implantable defibrillator (ICD) in these patients is not evidenced. Purpose: To evaluate the impact of an ICD on all-cause mortality in elderly patients undergoing a CRT device implantation. Methods: Patients at the age of ≥75 years who underwent implantation of either a CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) were identified out of hospital records. Only patients with a Class I or IIa indication for CRT and the primary prophylactic implantation of an ICD due to a severe impairment of the left ventricular ejection fraction (LV-EF) were included in the analysis. Patient characteristics, procedural data and all-cause mortality were compared between the two groups. Results: Between January 2008 and August 2014 two-hundred forty-five seniors were implanted with a CRT device in our centre, whereof 80 patients with CRT-P and 97 patients with CRT-D represent the two study groups. Patients in the CRTP group were more often females (44 vs. 25%; p35% and 130 ms, and left bundle branch morphology. Patients were randomized 2:1 to treatment with CRT-P vs. Control (implanted, LV lead turned OFF). In addition to clinical assessments, echocardiograms were obtained at baseline and at 6 months. Results: Twenty-six patients were successfully implanted with a CRT pacemaker

Kaplan-Meier survival probability

Conclusion: An additional ICD has no impact on survival in elderly patients implanted with a CRT device.

4859 | BEDSIDE Relationship between indices of left ventricular lead electrical position in spontaneous rhythm and right ventricular pacing: implications for optimization of cardiac resynchronization therapy D. Wichterle, K. Sedlacek, H. Jansova, L. Kryze, V. Vancura, R. Cihak, J. Kautzner. Institute for Clinical and Experimental Medicine, Prague, Czech Republic

Cardiac volumes

Purpose: Left ventricular (LV) electrical delay measured from the beginning of the QRS complex to the local LV lead electrogram (EGM), normalized by QRS duration (Q-LV ratio), was found to be a strong and independent predictor of shortterm response to cardiac resynchronization therapy (CRT), heart failure events and mortality. We investigated relationship between Q-LV ratio and similar index obtained during right ventricular pacing (RVP-LV ratio).


Introduction: CRT implantation is a well estabilished therapy in chronic heart failure patients. Transvenous left ventricular (LV) lead positioning might be challenging or in some cases impossible. Objectives: The aim of this study was to investigate the effectiveness and safety of transseptal endocardial left ventricular lead implantation (TELVLI) in severe heart failure patients, and evaluate the long term follow-ups of the patients. Methods: TELVLI was performed in 35 patients (30 men, 64±6 years, NYHA III-IV stage). Transseptal (TS) puncture was performed via the femoral vein. Intracardiac ulrasound was used to guide the puncture in 25 pts. The site of the puncture was dilated with a 6mm (3 pts), later with an 8 mm balloon (32 pts). After the puncture of the left subclavian vein, an electrophysiological deflectable CS catheter was introduced into the CS sheath. The CS catheter was used to reach the left atrium and the left ventricle through the dilated transseptal puncture hole. At the latest LV activation site 65 cm active fixation bipolar lead was screwed into the LV wall, at the site of the latest activation. Results: The lead was fixed in the left ventricle in all cases with good pacing threshold (0,84±0,4 V;0,4 ms). Puncture complication, pericardial effusion was not observed. Because of intraoperatively started anticoagulation, pocket haematoma was observed in three (9%) and needed evacuation in one case (3%). Follow-up was longer than one month in 34 patients [38 (22–49) months]. Significant improvement of NYHA was observed in all but one case (97%), at the first month control LV EF was 30±9% vs 38±6%. Early lead dislocation was noticed in two cases (6%), reposition was performed using the original puncture site in one, and transvenous implantation was succesfully carried out in the other case. Explantation of the system was necessary because of pocket infection in four cases (11%), in two of these cases TELVLI was carried out succesfully 3 months later, in one patient 22 months later. All patients were maintained on anticoagulation therapy with INR between 2–3. No thromboembolic complication was noticed during the follow up. 13 patients were lost, one of them died five years after the implantation in renal failure, the other patient died in malignant tumor 4 years after the implantation, 11 patients died due to the progression of the heart failure in average 16 months after the implantation. Conclusion: TELVLI approach might be a very promising alternative technique of the surgical epicardial procedure when transvenous implantation could not be applied.

and randomized (19 CRT, 7 Control). Of these patients, 10 (7 CRT, 3 Control) completed the 6-month visit with paired echocardiographic data. The median LVEF at baseline was 45% in CRT and 46% in Control. No significant increases in LVEF over time were observed. The CRT patients, however, showed reductions in median LVESV (28% decrease) and LVESVi (25% decrease). (Figure) In contrast, the Control patients showed no changes in LVESV (4% increase) or LVESVi (8% decrease). Similar data are seen with average values. The change in LVESV over time was significantly different between groups (p=0.05) but the change in LVESVi was not (p=0.11). Conclusions: In a small sample of patients with HF symptoms, LBBB and LVEF between 36 and 50%, CRT-P appeared to reduce LV volumes compared with control. The hypothesis that CRT can benefit selected HF patients with LVEF >35% should be tested.

Novelties in cardiac resynchronisation therapy Methods: We prospectively collected ECGs and EGMs in 133 consecutive patients (aged 66±10 years; 72% males; 56% nonischemic cardiomyopathy; LVEF 26±5%, 81% true-LBBB) with native non-RBBB QRS morphology undergoing CRT implant. Recordings of spontaneous rhythm and RV midseptum paced rhythm were edited, signal-averaged and measured by electronic calipers. Results: The LV lead position was characterized by the Q-LV ratio of 0.73±0.11 and RVP-LV ratio of 0.77±0.11. Native QRS width (180±21 ms) was shortened by 14±28 ms during biventricular pacing. There was significant but weak correlation between Q-LV and RVP-LV ratios (r2 =0.23, p0.70, defining adequate electrical LV lead positioning, 67% of patients with suboptimal Q-LV ratio had optimal RVP-LV ratio and 13% of patients with optimal Q-LV ratio had suboptimal RVP-LV ratio.

Conclusions: While observational studies found association between Q-LV ratio and CRT outcome, this measure may not be optimal for LV lead positioning because intrinsic atrioventricular conduction is not maintained during biventricular pacing. Therefore, RVP-LV ratio may better reflect the interlead electrical distance and deserves further evaluation.

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Purpose: The aim of the study was to assess the prognostic impact of heart rhythm (sinus rhythm – SR/ atrial fibrillation – AF) with and without low biventricular pacing percentage (CRT%) in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT). Methods: A single centre cohort of 304 consecutive patients implanted with CRTD and subsequently monitored via remote monitoring was divided into four groups depending on rhythm type (SR – sinus rhythm vs AF – atrial fibrillation) and the mean CRT%: – Group 1 – SR and CRT%≥95% (n=132; 43.4%) – Group 2 – SR and CRT%A promoter polymorphism. 1164 consecutive patients who were admitted for assessment of coronary artery disease were tested by allele specific


Conclusions: In our experience, with advanced NYHA class patients, the acute optimization of LV lead target site, by means of a systematical screening of local electrical delay and LV dP/dtmax, resulted in 74% of patients who responded clinically to CRT. A subanalysis in patients with higher QLV reported 83% of responders.

4865 | BEDSIDE Ventricular antitachycardia pacing therapy in heart failure patients with cardiac resynchronization therapy defibrillator: efficacy, safety and impact on heart failure hospitalizations and mortality

Haemodynamics in hypertension

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multiplex PCR. Individuals carrying the VKORC1(−1639) A variant showed significantly elevated invasively measured systolic, diastolic and mean arterial blood pressures compared with carriers of the G allele. The (3730) SNP showed only a borderline significance for the diastolic blood pressure. No association with vascular calcification could be observed. Conclusions: The VKORC1 (−1639) A allele is associated with elevated systemic arterial blood pressure. This suggests a novel concept of blood pressure regulation through pathways involving vitamin K epoxide reductase and calcium binding proteins.

4867 | BEDSIDE Lack of regression of left ventricular hypertrophy is accompanied by increased incidence of stroke and combined cardiovascular disease in essential hypertensives D. Tsiachris, C. Tsioufis, V. Antonakis, K. Dimitriadis, D. Flessas, F. Lagiou, S. Galanakos, A. Milkas, D. Roussos, D. Tousoulis. First Cardiology Clinic, University of Athens,Hippokration Hospital, Athens, Greece

4868 | BEDSIDE Prognostic implications of left ventricular strain and strain risk score in patients with hypertensive heart disease M. Saito 1 , F. Khan 2 , T. Stoklosa 2 , A. Iannaccone 1 , K. Negishi 1 , T. Marwick 1 . 1 Menzies Research Institute, Hobart, Australia; 2 Royal Hobart Hospital, Hobart, Australia Background: Major adverse cardiovascular events (MACE) in pts with hypertensive heart disease (HHD) are associated with LV geometry, but their association with LV function is unclear. Purpose: We sought to investigate the associations of LV strain and its serial change with MACE in HHD, independent of and incremental to clinical and LV geometric parameters, and to develop a risk score for predicting MACE. Methods: We studied 697 non-ischemic patients with hypertension who had abnormal LV geometry at baseline echo examination from 2005–2014. Global longitudinal and circumferential strain (GLS, GCS) were measured using speckle tracking. Echocardiographic follow-up was performed after 3 years and pts were followed for MACE (death and admission due to heart failure, myocardial infarction, and stroke) over 3.9 years. A Cox proportional hazards model was used to examine the association of baseline parameters with MACE. Results: MACE (n=147, 21%) were associated with increased LV mass index (LVMI) and impaired GLS and GCS (all, p75, AF, COPD, anaemia, abnormal LVMI, and baseline GLS>-15% from the derivation cohort (c-statistic = 0.74). A validation cohort showed it to have good discrimination for MACE (c-statistic = 0.73). Conclusion: GLS and its deterioration are independently associated with MACE in HHD. Strain risk score was useful for predicting risk of MACE.

Abstract 4868 – Figure 1. Sequential model

4869 | BEDSIDE Predictive role of hypertension related organ damage and blood pressure control patterns for the incidence of new-onset atrial fibrillation in essential hypertensives D. Tsiachris, C. Tsioufis, V. Antonakis, K. Dimitriadis, D. Flessas, E. Andrikou, D. Aragiannis, A. Kefala, C. Stefanadis, D. Tousoulis. First Cardiology Clinic, University of Athens,Hippokration Hospital, Athens, Greece Purpose: Hypertension is one of the key factors in the pathogenesis of atrial fibrillation (AF) with further implications in both hypertension and AF management. The aim of our study was to compare the predictive role ofhypertension related organ damage and blood pressure control patterns for the incidence of new-onset AF. Methods: We studied 2.280 hypertensive patients (aged 57.7±11 years, 50% males) without history of AF episodes for a median period of 3.3 years (IQR 2.3–5 years). All subjects had at least one visit annually and at entry underwent complete echocardiographic study and additional workup for exclusion of secondary causes of resistant hypertension (RH). Four groups were identified depending on presence or absence of RH (office-based uncontrolled hypertension under at least 3 drugs including a diuretic or controlled hypertension under 4 or more drugs) at baseline and follow-up: 1.494 patients (65.7%) never having RH, 185 (8.1%) with resolved RH, 230 (10.1%) with incident RH and 365 (16.1%) with persistent RH. Endpoint of interest was new-onset AF. Results: The incidence rate of new-onset AF over the whole follow-up period was 7.06/1000 persons-years. In the univariate analysis age (HR=1.08, p