Left atrial strain is a good predictor of atrio‐ventricular synchrony in leadless pacemaker pacing

IntroductionThe importance of atrio-ventricular synchrony pacing in sinus rhythm patients is known. To identify patients in whom leadless pacemakers are able to guarantee this atrio-ventricular synchrony, we explored correlations among echocardiographic measures of left atrial (LA) size and function (doppler parameter and strain) with A4 amplitude in patients implanted with new generation Micra-AV device.MethodsAfter implantation with Micra-AV system, patients underwent device interrogation to evaluate AV synchrony based on the sensing of atrial mechanics and echocardiographic exam to assess LA morphology and LA function.ResultsIn the 21 studied patients (14 males, 72 +/- 13 years), the A4 wave amplitude values inversely correlated with LA antero-posterior diameter, LA volume, LA contraction strain and LA conduit strain, while they were positively related with LA reservoir strain.DiscussionOur results indicate a statistically significant relationship between morphological echocardiographic LA parameters and atrial contraction signal (A4), detected by leadless pacemakers and used to synchronize ventricular pacing with the atrium. Instantaneous LA function assessment obtained with LA strain provides incremental information over morphological parameters. LA strain evaluates atrial myocardial deformation during the whole cardiac cycle. We found higher value of A4 in patients that have grater absolute value of LAsr, LAscd and LAsct, that are simple and measurable parameters of LA functional capacity.ConclusionPreimplant echocardiographic evaluation of the atrial contractility may be useful in predicting adequate A4 sensing and consequently a good atrio-ventricular synchrony pacing. Echocardiography LA strain study seems promising in Micra-AV patient selection

Preliminary experience with the multisensor HeartLogic algorithm for heart failure monitoring: a retrospective case series report

Aims In the Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients study, a novel algorithm for heart failure (HF) monitoring was implemented. The HeartLogic (Boston Scientific) index combines data from multiple implantable cardioverter defibrillator (ICD)-based sensors and has proved to be a sensitive and timely predictor of impending HF decompensation. The remote monitoring of HF patients by means of Heartlogic has never been described in clinical practice. We report post-implantation data collected from sensors, the combined index, and their association with clinical events during follow-up in a group of patients who received a HeartLogic-enabled device in clinical practice.Methods and results Patients with ICD and cardiac resynchronization therapy ICD were remotely monitored. In December 2017, the Heartlogic feature was activated on the remote monitoring platform, and multiple ICD-based sensor data collected since device implantation were made available: Heartlogic index, heart rate, heart sounds, thoracic impedance, respiration, and activity. Their association with clinical events was retrospectively analysed. Data from 58 patients were analysed. During a mean follow-up of 5 +/- 3 months, the HeartLogic index crossed the threshold value (set by default to 16) 24 times (over 24 person-years, 0.99 alerts/patient-year) in 16 patients. HeartLogic alerts preceded five HF hospitalizations and five unplanned in-office visits for HF. Symptoms or signs of HF were also reported at the time of five scheduled visits. The median early warning time and the time spent in alert were longer in the case of hospitalizations than in the case of minor events of clinical deterioration of HF. Heartlogic contributing sensors detected changes in heart sound amplitude (increased third sound and decreased first sound) in all cases of alerts. Patients with Heartlogic alerts during the observation period had higher New York Heart Association class (P = 0.025) and lower ejection fraction (P = 0.016) at the time of activation.Conclusions Our retrospective analysis indicates that the HeartLogic algorithm might be useful to detect gradual worsening of HF and to stratify risk of HF decompensation

Circadian periodicity affects the type of ventricular arrhythmias and efficacy of implantable defibrillator therapies

Introduction Factors influencing malignant arrhythmia onset are not fully understood. We explored the circadian periodicity of ventricular arrhythmias (VAs) in patients with implantable cardioverter and cardiac resynchronization defibrillators (ICD/CRT-D). Methods Time, morphology (monomorphic/polymorphic), and mode of termination (anti-tachycardia pacing [ATP] or shock) of VAs stored in a database of remote monitoring data were adjudicated. Episodes were grouped in six 4-h timeslots from 00:00 to 24:00. Circadian distributions and adjusted marginal odds ratios (ORs), with 95% confidence interval (CI), were analyzed using mixed-effect models and logit generalized estimating equations, respectively, to account for within-subject correlation of multiple episodes. Results Among 1303 VA episodes from 446 patients (63% ICD and 37% CRT-D), 120 (9%) self-extinguished, and 842 (65%) were terminated by ATP, 343 (26%) by shock. VAs clustered from 08:00 to 16:00 with 44% of episodes, as compared with 22% from 00:00 to 08:00 (p < .001) and 34% from 16:00 to 24:00 (p = .005). Episodes were more likely to be polymorphic at night with an adjusted marginal OR of 1.66 (CI, 1.15-2.40; p = .007) at 00:00-04:00 versus other timeslots. Episodes were less likely to be terminated by ATP in the 00:00-04:00 (success-to-failure ratio, 0.67; CI, 0.46-0.98; p = .039) and 08:00-12:00 (0.70; CI, 0.51-0.96; p = .02) timeslots, and most likely to be terminated by ATP between 12:00 and 16:00 (success-to-failure ratio 1.42; CI, 1.06-1.91; p = .02). Conclusion VAs did not distribute uniformly over the 24 h, with a majority of episodes occurring from 08:00 to 16:00. Nocturnal episodes were more likely to be polymorphic. The efficacy of ATP depended on the time of delivery

One-year mortality after implantable defibrillator implantation: do risk stratification models help improving clinical practice?

none30The purpose of this study was to assess the available mortality risk stratification models for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients.noneCalvi, Valeria; Zanotto, Gabriele; D'Onofrio, Antonio; Bisceglia, Caterina; Iacopino, Saverio; Pignalberi, Carlo; Pisanò, Ennio C; Solimene, Francesco; Giammaria, Massimo; Biffi, Mauro; Maglia, Giampiero; Marini, Massimiliano; Senatore, Gaetano; Pedretti, Stefano; Forleo, Giovanni B; Santobuono, Vincenzo E; Curnis, Antonio; Russo, Antonio Dello; Rapacciuolo, Antonio; Quartieri, Fabio; Bertocchi, Patrizia; Caravati, Fabrizio; Manzo, Michele; Saporito, Davide; Orsida, Daniela; Santamaria, Matteo; Bottaro, Giuseppe; Giacopelli, Daniele; Gargaro, Alessio; Bella, Paolo DellaCalvi, Valeria; Zanotto, Gabriele; D'Onofrio, Antonio; Bisceglia, Caterina; Iacopino, Saverio; Pignalberi, Carlo; Pisanò, Ennio C; Solimene, Francesco; Giammaria, Massimo; Biffi, Mauro; Maglia, Giampiero; Marini, Massimiliano; Senatore, Gaetano; Pedretti, Stefano; Forleo, Giovanni B; Santobuono, Vincenzo E; Curnis, Antonio; Russo, Antonio Dello; Rapacciuolo, Antonio; Quartieri, Fabio; Bertocchi, Patrizia; Caravati, Fabrizio; Manzo, Michele; Saporito, Davide; Orsida, Daniela; Santamaria, Matteo; Bottaro, Giuseppe; Giacopelli, Daniele; Gargaro, Alessio; Bella, Paolo Dell

Prognostic significance of remotely monitored nocturnal heart rate in heart failure patients with reduced ejection fraction

BACKGROUND Elevated resting heart rate is a risk factor for cardio-vascular events.OBJECTIVE The purpose of this study was to investigate the clinical significance of nocturnal heart rate (nHR) and 24-hour mean heart rate (24h-HR) obtained by continuous remote monitoring (RM) of implantable devices.METHODS We analyzed daily-sampled trends of nHR, 24h-HR, and physical activity in patients on b-blocker therapy for chronic heart failure and with implantable cardioverter-defibrillators or cardiac resynchronization therapy defibrillators (CRT-Ds). Patients were grouped by average nHR and 24h-HR quartile during follow-up to es-timate the respective incidence of nonarrhythmic death and device -treated ventricular tachycardia/fibrillation (VT/VF).RESULTS The study cohort included 1330 patients (median age 69 years [interquartile range 61-77 years]; 41% [n = 550] with CRT-D; median follow-up 25 months [interquartile range 13-42 months]). Compared with patients in the lowest nHR quartile (<57 beats/min) group, patients in the highest quartile group (>65 beats/min) had an increased risk of nonarrhythmic death (adjusted hazard ratio [AHR] 2.25; 95% confidence interval [CI] 1.13-4.50; P = .021) and VT/VF (AHR 1.98; 95% CI 1.40-2.79; P < .001) and were characterized by the lowest level of physical activity (P < .0004 vs every other nHR quartiles). The highest 24h-HR quartile group (>75 beats/min) showed an increased risk of VT/VF (AHR 2.13; 95% CI 1.52-2.99; P < .001) and a weaker though significant asso-ciation with nonarrhythmic mortality (AHR 1.80; 95% CI 1.00-3.22; P = .05) as compared with the lowest 24h-HR quartile group (<65 beats/min).CONCLUSION In remotely monitored patients with implantable cardioverter-defibrillator/CRT-D on 0-blocker therapy for heart fail-ure, elevated heart rates (nHR >65 beats/min and 24h-HR >75 beats/min) were associated with increased mortality and VT/VF risk. nHR showed a stronger association than 24h-HR with worst prognosis and lowest physical activity

Multiparametric Implantable Cardioverter-Defibrillator Algorithm for Heart Failure Risk Stratification and Management: An Analysis in Clinical Practice

BACKGROUND: The HeartLogic algorithm combines multiple implantable cardioverter-defibrillator sensors to identify patients at risk of heart failure (HF) events. We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events.METHODS: The HeartLogic feature was activated in 366 implantable cardioverter-defibrillator and cardiac resynchronization therapy implantable cardioverter-defibrillator patients at 22 centers. The median follow-up was 11 months [25th-75th percentile: 6-16]. The HeartLogic algorithm calculates a daily HF index and identifies periods IN alert state on the basis of a configurable threshold.RESULTS: The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients. The time IN alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations, and 8 patients died of HF during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (hazard ratio, 24.53 [95% CI, 8.55-70.38], P<0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with less HF events (hazard ratio, 0.37 [95% CI, 0.14-0.99], P=0.047). No differences in event rates were observed between in-office and remote alert management.CONCLUSIONS: This multiparametric algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required to effectively manage HeartLogic alerts. Registration: URL: ; Unique identifier: NCT02275637