Evaluation of Ventricular Repolarization in Patients Undergoing Cardiac Resynchronization Therapy (CRT) Using Two Modalities: Conventional Biventricular Pacing vs. His-Bundle Pacing

Introduction: Permanent His-bundle pacing (HBP) is being used as an alternative to biventricular pacing (BiVP) for CRT. HBP preserves the physiologic pattern of ventricular activation and markedly reduces ventricular dyssynchrony. While ventricular depolarization with HBP vs. BiVP has been studied, the effects of the 2 modalities on repolarization have not been compared. The purpose of this study was to compare ventricular repolarization in patients with HBP and BiVP. We hypothesize that HBP provides more physiologic repolarization as compared to BiVP. Methods: ECG repolarization parameters were analyzed in patients who underwent HBP and BiVP using the first available ECG post implant. Parameters included: 1) T Peak – T End (Tp-TeApical): Tp-Te in lead V5, and if not measurable, then in V4/V6 2) Tp-TeTotal: Earliest T peak to the latest T end across all precordial leads 3) T Peak Dispersion: Absolute difference between the earliest and latest T peaks across all precordial leads. Data was compared using a two-tailed unequal variance Student’s t-test. Results: Data from 23 HBP patients and 23 BiVP patients was analyzed. The average HBP Tp-TeApical of 74 ± 7ms was less than the BiVP Tp-TeApical of 112 ± 15ms (p\u3c0.01). Similarly, average HBP Tp-TeTotal of 106 ± 11ms was smaller than the BiVP Tp-TeTotal of 145 ± 17ms (p\u3c0.01). The difference between Tpeak dispersion between the two groups was not significant. Conclusion: Tp-Te interval, a known measure of dispersion of repolarization and marker of arrhythmic risk, is more physiologic (lower) with HBP as compared to BiVP. These data suggest that in addition to physiologic depolarization, HBP also provides physiologic repolarization and potentially lower arrhythmic risk compared to BiVP

Cryo vs RF p-wave Characteristics Comparative Analysis

Introduction: Atrial fibrillation (AF) is the leading cause of stroke. Patients with drug-refractory AF are managed with Radiofrequency (RF) or Cryoballoon (Cryo) pulmonary vein isolation (PVI). Approximately 30% of PVIs result in AF recurrences. There is clinical utility in identifying patients at higher risk of AF recurrence with readily available ECG parameters. Methods: This retrospective study analyzed the ECG characteristics and AF recurrence of 86 paroxysmal AF patients who underwent PVI. Baseline characteristics were collected by chart review and p-wave parameters were measured with electronic calipers in the MUSE (GE) ECG database. AF recurrence was defined as any documented atrial tachyarrhythmia. Statistical analyses performed in SPSS included t-tests and ROC curves to compare group means and to select parameter cutoffs to predict AF recurrence, respectively. Results: There were no differences in % AF recurrences (Cryo: 26% vs RF: 37%; P = 0.25) or Dp-wave parameters (pre-PVI values - post-PVI values) except for DPwD(III) (Cryo: 11ms vs RF: -3ms; P = 0.023). Patients with AF recurrences had greater CHA2DS2-VASc scores (P = 0.014), Left atrial volume (P = 0.031), Pre-PR-intervals (P = 0.006), Pre-PwD(III) (P = 0.013), Pre-PwD(V1) (P = 0.001), Pre-PwD(V2) (P = 0.02), Pre-PwD-terminal (P = 0.0002), Post-PR-intervals (P = 0.038), Post-PwD(III) (P = 0.002), and Post-PwD(aVF) (P = 0.009). Patients whose p-wave duration (PwD) increased in V1 were less likely to have a recurrence (P = 0.01). Pre-PwD(V1) \u3e 120ms yielded a sensitivity of 68.4% and specificity of 67.6% for predicting AF recurrence. Discussion: Cryo is non-inferior to RF regarding AF recurrence. This finding is further supported by similar PVI-induced Dp-wave parameters between the two modalities. Pre-PwD(V1), along with other parameters can be used in combination to reasonable predict recurrence and to guide clinical management of AF

Validation of a Novel, Non-Invasive System for Autonomic Profiling in Healthy Volunteers

Noninvasive profiling of the autonomic nervous system has been shown to have prognostic value in patients with myocardial infarction, CHF and diabetes. The ANSAR system (ANX 3.0, Philadelphia, PA) is a new commercially available system that utilizes respiratory rate, HR and BP to assess on-going sympathovagal modulation during various maneuvers known to evoke autonomic perturbations. Instead of using conventional Fast Fourier Transform for frequency domain analysis, a Continuous Wavelet Transform (CWT) is used to generate numerical and graphical data. The system calculates Low Frequency Area (LFA, analogous to LF Power) and Respiratory Frequency Area (RFA, analogous to High Frequency Power.) A time domain index (pNN50 is also calculated

Safety of Adenosine for the Treatment of Supraventricular Tachycardia in Hospitalized Patients with COVID-19 Pneumonia

Coronavirus disease 2019 (COVID-19) is associated with pulmonary involvement and cardiac arrhythmias, including supraventricular tachycardia (SVT). Adenosine is commonly used to treat SVT and is generally safe, but is rarely associated with bronchospasm. There are no data regarding the safety of adenosine use in patients with COVID-19 pneumonia and physicians may hesitate to use it in such patients. We surveyed resident physicians and cardiology attendings regarding their level of comfort in administering adenosine to hospitalized COVID-19 patients. We compared a study group of 42 COVID-19 hospitalized patients who received adenosine for SVT to a matched (for age, sex, and co-morbidities) control group of 42 non-COVID-19 hospitalized patients during the same period, all of whom received IV adenosine for SVT. Escalation of care following intravenous adenosine administration was defined as increased/new pressor requirement, need for higher O2 flow rates, need for endotracheal intubation, new nebulizer therapy, or transfer to intensive care unit within 2 h of adenosine administration. Survey results showed that 82% (59/72) of residents and 62% (16/26) of cardiologists expressed hesitation/significant concerns regarding administering adenosine in hospitalized COVID-19 patients. Adenosine use was associated with escalation of care in 47.6% (20/42) COVID-19 as compared to 50% (21/42) non-COVID-19 patients (odds ratio 0.95, 95% CI 0.45-2.01, p = NS). Escalation of care was more likely in patients who were on higher FiO2, on prior nebulizer therapy, required supplemental oxygen, or were already on a ventilator. In conclusion, we identified significant hesitation among physicians regarding the use of adenosine for SVT in hospitalized COVID-19 patients. In this study, there was no evidence of increased harm from administering adenosine to patients with SVT and COVID-19. This finding needs to be confirmed in larger studies. Based on the current evidence, adenosine for treatment of SVT in this setting should not be avoided. Key Points: Question: Given the known bronchospastic effects of adenosine, is the use of adenosine safe for treatment of supraventricular tachycardia in hospitalized patients with COVID-19? Findings: A survey of residents and cardiology attending identified that a majority expressed some level of apprehension in using adenosine for SVT in COVID-19 patients. In our matched cohort study, we found adenosine use to be comparably safe in COVID-19 and non-COVID-19 hospitalized patients. Meaning: Based on current evidence, adenosine for treatment of SVT in this setting should not be avoided

A Shocking Case of Far-Field Atrial Oversensing in Giant-Cell Myocarditis

We report a unique case of delivery of inappropriate implantable cardioverter-defibrillator therapies related to a “perfect storm”: presence of an integrated lead, insufficient lead slack related to right heart dilation resulting in shock coil misplacement, myocarditis with loss of R waves, and the concomitant occurrence of an incessant atrial tachycardia. (Level of Difficulty: Advanced.

16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008.

OBJECTIVES: We analyzed the infection burden associated with the implantation of cardiac implantable electrophysiological devices (CIEDs) in the United States for the years 1993 to 2008. BACKGROUND: Recent data suggest that the rate of infection following CIED implantation may be increasing. METHODS: The Nationwide Inpatient Sample (NIS) discharge records were queried between 1993 and 2008 using the 9th Revision of the International Classification of Diseases (ICD-9-CM). CIED infection was defined as either: 1) ICD-9 code for device-related infection (996.61) and any CIED procedure or removal code; or 2) CIED procedure code along with systemic infection. Patient health profile was evaluated by coding for renal failure, heart failure, respiratory failure, and diabetes mellitus. The infection burden and patient health profile were calculated for each year, and linear regression was used to test for changes over time. RESULTS: During the study period (1993 to 2008), the incidence of CIED infection was 1.61%. The annual rate of infections remained constant until 2004, when a marked increase was observed, which coincided with an increase in the incidence of major comorbidities. This was associated with a marked increase in mortality and in-hospital financial charges. CONCLUSIONS: The infection burden associated with CIED implantation is increasing over time and is associated with prolonged hospital stays and high financial costs

Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures.

OBJECTIVES: This study sought to define contemporary trends in permanent pacemaker use by analyzing a large national database. BACKGROUND: The Medicare National Coverage Determination for permanent pacemaker, which emphasized single-chamber pacing, has not changed significantly since 1985. We sought to define contemporary trends in permanent pacemaker use by analyzing a large national database. METHODS: We queried the Nationwide Inpatient Sample to identify permanent pacemaker implants between 1993 and 2009 using the International Classification of Diseases-Ninth Revision-Clinical Modification procedure codes for dual-chamber (DDD), single-ventricular (VVI), single-atrial (AAI), or biventricular (BiV) devices. Annual permanent pacemaker implantation rates and patient demographics were analyzed. RESULTS: Between 1993 and 2009, 2.9 million patients received permanent pacemakers in the United States. Overall use increased by 55.6%. By 2009, DDD use increased from 62% to 82% (p \u3c 0.001), whereas single-chamber ventricular pacemaker use fell from 36% to 14% (p = 0.01). Use of DDD devices was higher in urban, nonteaching hospitals (79%) compared with urban teaching hospitals (76%) and rural hospitals (72%). Patients with private insurance (83%) more commonly received DDD devices than Medicaid (79%) or Medicare (75%) recipients (p \u3c 0.001). Patient age and Charlson comorbidity index increased over time. Hospital charges ($2011) increased 45.3%, driven by the increased cost of DDD devices. CONCLUSIONS: There is a steady growth in the use of permanent pacemakers in the United States. Although DDD device use is increasing, whereas single-chamber ventricular pacemaker use is decreasing. Patients are becoming older and have more medical comorbidities. These trends have important health care policy implications

The Pulmonary Venous Ridge Length to Stratify Stroke Risk in Atrial Fibrillation

Purpose of Study: To evaluate the left superior pulmonary venous ridge length (RL) and the left atrial appendage fractal dimension (LAA FD) as predictors of cardioembolic ischemic stroke (CVA) and transient ischemic attack (TIA) in patients with atrial fibrillation (AF). Materials, Methods and Procedures: A multicenter, retrospective multicenter study was conducted on patients with AF who underwent cardiac CT prior to catheter ablation between 01/01/2010 and 12/31/2015. Patients were grouped by the presence or absence of prior CVA/TIA. Patients with mitral stenosis, prior mechanical aortic valve replacement, ascending aortic arch atheroma, highrisk patent foramen ovale, history of atrial septal repair or device, preexisting LAA thrombus or intra-cardiac tumor, or prior open-heart surgery were excluded. Further exclusion was performed for patients with sub-optimal or unavailable cardiac CT imaging by investigators blinded to clinical data. Blinded investigators obtained RL by measuring the distance between the left superior pulmonary venous ostium and the internal ostium of the left atrial appendage. LAA FD was calculated using semi-automated volume rendering and processing software (ImageJ, Bethesda, MD) [1] and LAA FD are presented as means (95% confidence interval) and were compared between groups using unpaired t-tests. Logistic regression analysis was used to construct receiver operating curves and to assess the abilities of RL and LAA FD to predict prior CVA/TIA. Results: 225 patients met inclusion criteria. Mean RL were 4.32 (3.80-4.93) and 5.20 (4.93-5.48) for patients with (n=24; mean age: 59.4; 70.8% male) and without (n=165; mean age: 59.3; 75.4% male) prior CVA/TIA, respectively(p=0.033). Mean LAA FD were 2.29 (95% CI: 2.24-2.34) and 2.33 (2.32-2.34) for patients with (n=22; mean age: 60.3; 68.2% male) and without (n=171; mean age: 59.3; 74.9% male) prior CVA/TIA, respectively (p=0.052). In a regression model including LAA FD, RL, and established predictive markers, only RL predicted prior CVA/TIA (OR 0.73; 0.54 to 0.98; p=0.034). Discussion: Lower RL values were associated with prior CVA/TIA, whereas LAA FD values were similar between patients with AF with and without prior CVA/TIA. RL is a novel marker that may refine clinical decision-making regarding anticoagulation goals and treatment decisions for patients with AF. Future studies with larger samples should investigate the clinical utility of RL to improve CVA/TIA risk stratification of patients with AF and prospectively reduce the incidence of CVA/TIA in this population

MK-0448, a Specific Kv1.5 Inhibitor: Safety, Pharmacokinetics and Pharmacodynamic Electrophysiology in Experimental Animal Models and in Humans.

BACKGROUND: -We evaluated the viability of I(Kur) as a target for maintenance of sinus rhythm in patients with a history of atrial fibrillation through the testing of MK-0448, a novel I(Kur) inhibitor. METHODS AND RESULTS: -In vitro MK-0448 studies demonstrated strong inhibition of I(Kur) with minimal off-target activity. In vivo MK-0448 studies in normal anesthetized dogs demonstrated significant prolongation of the atrial refractory period compared with vehicle controls without affecting the ventricular refractory period. In studies of a conscious dog heart failure model, sustained AF was terminated with bolus intravenous MK-0448 doses of 0.03 and 0.1 mg/kg. These data led to a two-part first-in-human study: Part I evaluated safety and pharmacokinetics, and Part II was an invasive electrophysiologic (EP) study in healthy subjects. MK-0448 was well-tolerated with mild adverse experiences, most commonly irritation at the injection site. During the EP study, ascending doses of MK-0448 were administered, but no increases in atrial or ventricular refractoriness were detected despite achieving plasma concentrations in excess of 2 μM. Follow-up studies in normal anesthetized dogs designed to assess the influence of autonomic tone demonstrated that prolongation of atrial refractoriness with MK-0448 was markedly attenuated in the presence of vagal nerve simulation, suggesting that the effects of I(Kur) blockade on atrial repolarization may be negated by enhanced parasympathetic neural tone. CONCLUSIONS: -The contribution of I(Kur) to human atrial electrophysiology is less prominent than in preclinical models and therefore is likely to be of limited therapeutic value for the prevention of atrial fibrillation

Adverse Outcomes of Atrial Fibrillation Ablation in Heart Failure Patients With and Without Cardiac Amyloidosis: A Nationwide Readmissions Database Analysis (2015-2019)

AIMS: Atrial fibrillation (AF) in patients with cardiac amyloidosis (CA) has been linked with a worse prognosis. The current study aimed to determine the outcomes of AF catheter ablation in patients with CA. METHODS AND RESULTS: The Nationwide Readmissions Database (2015-2019) was used to identify patients with AF and concomitant heart failure. Among these, patients who underwent catheter ablation were classified into two groups, patients with and without CA. The adjusted odds ratio (aOR) of index admission and 30-day readmission outcomes was calculated using a propensity score matching (PSM) analysis. A total of 148 134 patients with AF undergoing catheter ablation were identified on crude analysis. Using PSM analysis, 616 patients (293 CA-AF, 323 non-CA-AF) were selected based on a balanced distribution of baseline comorbidities. At index admission, AF ablation in patients with CA was associated with significantly higher adjusted odds of net adverse clinical events (NACE) [adjusted odds ratio (aOR) 4.21, 95% CI 1.7-5.20], in-hospital mortality (aOR 9.03, 95% CI 1.12-72.70), and pericardial effusion (aOR 3.30, 95% CI 1.57-6.93) compared with non-CA-AF. There was no significant difference in the odds of stroke, cardiac tamponade, and major bleeding between the two groups. At 30-day readmission, the incidence of NACE and mortality remained high in patients undergoing AF ablation in CA. CONCLUSION: Compared with non-CA, AF ablation in CA patients is associated with relatively higher in-hospital all-cause mortality and net adverse events both at index admission and up to 30-day follow-up