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Factors Associated with New-Onset Atrial Fibrillation in Patients with Implanted Pacemakers
The 10th Annual Scientific Meeting
214 Chronic Performance of a New 4 Fr Left Ventricular Unipolar Lead in the Canine Model Vivek K. Sharma1, Christine Palma1, Peter Fong1, Corey Brown1; 1CHF Leads Development, St. Jude Medical CRMD, Sylmar, CA Background: Relatively large diameter of currently marketed transvenous LV leads rules out optimal pacing site selection in many patients. In these cases the first choice target vein is either too small to accept, or too tortuous to track the available CRT leads. A new smaller 4Fr diameter, left ventricular lead has been developed to help physicians select and track to their first choice target vein. The lead design uses the characteristic QuicksiteÒ S-shape fixation mechanism. This lead has been evaluated in a chronic canine study to evaluate the stability, electrical, mechanical and histological performance. Method: A total of 5 canines were implanted with the new lead. These leads were placed in the anterior branch of the coronary venous anatomy using stylets and /or guidewires. Results: During lead implantation the new leads were found to track farther and into more vein branch locations compared to the currently available leads. No lead dislodgements or other lead related complications occurred in these canines. Table 1 shows the electrical performance of the lead over this time period. These values compare favorably with the currently available transvenous LV leads. Conclusions: The new 4Fr LV lead may allow greater ease in successfully positioning the lead into small and tortuous veins without compromising on handling or tracking. In canine studies this lead has exhibited excellent performance with low, stable pacing thresholds, and excellent lead stability. Further testing is in progress.
HFSA
S67
apical 4-chamber view. Diastolic TDI values (Ew, Aw), peak systolic strain and systolic and diastolic strain rate values were determined. Results. At six months followup after BVP, patients functional status improved by one NYHA class or more and LVEF improved overall from 19.9 6 7.5% to 29.3 6 11.4%. A significant reduction in severity of tricuspid regurgitation and pulmonary artery pressure was also observed. Interventricular dyssynchrony by SRI was reduced from 82.4 6 29 ms to 36.5 6 23.4 ms (p!0.005) and intraventricular dyssynchrony from 77 6 31.2 ms to 23.8 6 15.9 ms (p!0.001). The degree of dyssynchrony correlated significantly with the improvement in LVEF and LV end-diastolic diameter. An increase of Ew at basal RV level from 11.8 6 1.9 cm/s to 15.9 6 1.5 cm/s was shown (p!0.005). Peak systolic strain and systolic and early diastolic strain rate at basal RV level increased, respectively, from 20.3 6 6.5% to 30.5 6 7.4%, 2.8 6 1.9 cm/s to 4.7 6 1.5 sec1, and 4.8 6 1.7 cm/s to 7.9 6 1.4 sec1 (p!0.001). RV reverse remodeling was only observed in patients with highest degrees of LV dyssynchrony at baseline. Conclusions. Thus, by improving temporal LV asynchrony, BVP has a positive hemodynamic impact on LV as well as RV function.
Table 1. Chronic Electrical Performance of new 4 Fr unipolar LV lead in a canine model Parameter (Mean 6 Std Dev) Capture Threshold (V @ 0.5 ms) R-Wave amplitude (mV) Pacing Impedance (Ohms)
Implant
One month
Three months
0.30 6 0.11 15.80 6 5.02 678 6 67.2
1.55 6 0.87 18.40 6 1.56 732 6 95.5
1.05 6 0.37 17.33 6 4.35 770 6 115.1
215 Factors Associated with New-Onset Atrial Fibrillation in Patients with Implanted Pacemakers Maria C. Tentori1, Graciela A. Ruiz1, Raul Chirife1, Elena Sztyglic1, Monica Arrascaite1; 1Cardiology, Hospital Fernandez, Buenos Aires, Argentina Background: Since the incidence of AF in patients with implanted pacemakers is higher than the general population, it was the aim of this retrospective study to assess the factors associated with new-onset AF after PM implantation. The clinical and PM variables included in the analysis were: age, sex, indication for PM implant (SSS or AVB), type of cardiophathy, pacing mode (VVI, DDD), left atrial and left ventricular dimensions. Methods: From a database of 869 Pts, 733 Pts with previous to PM implant and no history of AF were included. The mean follow-up period was 90 þ/ 78 months. Multiple linear regressions and multiple discriminant function analysis (MDF) were done between AF and above clinical/PM variables. Results: There 112 cases of new-onset AF detected during PM follow-up. The individual variables revealing a significant association were SSS and LAD, with LVD revealing only a trend. With MDF the combination of SSS and LAD had a predictive accuracy of AF of 72% (P!0.0001). Predominance of atrial pacing over sensing did not affect the incidence of AF. Conclusion: New-onset AF seems to be determined by the presence of SSS and LA dilatation. LV dilatation had a less significant role and pacing mode has no apparent effect.
216 Effects of Cardiac Resynchronization Therapy on Left as Well as Right Ventricular Deformation Parameters Antonio Vitarelli1, Pasquale Franciosa1, Ysabel Conde1, Ester Cimino1, Bich Lien Nguyen1, D’Orazio Simona1, Guglielmo De Curtis2, Miguel Cortes Morichetti2, Salvatore Rosanio3; 1Cardiac Dept., La Sapienza University, Rome, Italy; 2Le Kremlin-Bicetre University, Paris, France; 3The University of Texas, Galveston, TX Background. Cardiac resynchronization therapy has been proved to achieve reverse left ventricular (LV) remodeling in patients with advanced heart failure but effects on right ventricular (RV) function are not well established. The aim of this study was to analyse the evolution of LV as well as RV tissue Doppler / strain Doppler imaging (TDI/SRI) parameters after biventricular pacing (BVP). Methods. Thirty-three patients with dilated cardiomyopathy (NYHA class II or greater), left bundle branch block (QRS $ 120ms), and LV ejection fraction #35% were studied with TDI/SRI echocardiography before and after BVP. Intraventricular dyssynchrony was determined as the difference between the longest and shortest electromechanical coupling times in the basal septal, lateral, and posterior LV segments. Interventricular dyssynchrony was determined as the difference between electromechanical coupling times in the basal lateral RV segment and the most delayed LV segment. Velocity and strain traces from right ventricular free wall (basal and mid cavity) were processed in the
217 The Impact of Age, Gender, and Heart Failure Etiology on the Outcome of Cardiac Resynchronization Therapy Omeed Zardkoohi1, Jagmeet Singh1, Theofanie Mela1, Jeremy Ruskin1, Kevin Heist1, Jeffrey Chung1, Kyle Haelewyn1; 1Medicine, Massachusetts General Hospital, Boston, MA Background: Patient responses to cardiac resynchronization therapy (CRT) vary significantly. To better target this therapy to the appropriate population, it is important to know what pre-implant characteristics impact clinical response. The purpose of this study was to determine the effect of age, gender, and heart failure etiology on the long-term outcome of patients receiving CRT. Methods: 117 patients with drug-refractory heart failure, NYHA Class III or IV and a wide QRS complex, who received CRT, were followed for 1 year. Long-term response was measured as a combined endpoint of hospitalization for heart failure and/or all cause mortality. The efficacy of CRT was compared between men and women; between older and younger patients; and between patients with ischemic heart disease and patients with nonischemic heart disease. Time to the primary end-point was estimated by the Kaplan-Meier method, with comparisons made using the Breslow-Wilcoxon test. Results: Baseline clinical characteristics were comparable between the gender, age, and heart failure etiology groups except that younger patients were more likely to have diabetes than older patients, and men were more likely to have ischemic heart disease and less likely to be taking a diuretic than women. There was no significant difference in the combined endpoint between older (age $ 70, n 5 71) and younger (! 70, n 5 46) patients (p 5 0.52). Both genders (men, n 5 91 and women, n 5 26, p 5 0.46) had similar long-term outcome. There was no significant difference between patients with ischemic cardiomyopathy (n 5 79) and patients with.nonischemic cardiomyopathy (n 5 38) (p 5 0.12). However, when stratified by the etiology of the underlying cardiomyopathy, women with underlying ischemic etiology (IF, n510) had a worse outcome compared to the other groups i.e. non-ischemic women (NIW, n516), ischemic men (IM, n569) and non-ischemic men (NIM, n522), p50.04. Conclusions: The beneficial effect of CRT is independent of age, gender, and heart failure etiology. Women with ischemic cardiomyopathy tend to have a worse long-term outcome.
214 Chronic Performance of a New 4 Fr Left Ventricular Unipolar Lead in the Canine Model Vivek K. Sharma1, Christine Palma1, Peter Fong1, Corey Brown1; 1CHF Leads Development, St. Jude Medical CRMD, Sylmar, CA Background: Relatively large diameter of currently marketed transvenous LV leads rules out optimal pacing site selection in many patients. In these cases the first choice target vein is either too small to accept, or too tortuous to track the available CRT leads. A new smaller 4Fr diameter, left ventricular lead has been developed to help physicians select and track to their first choice target vein. The lead design uses the characteristic QuicksiteÒ S-shape fixation mechanism. This lead has been evaluated in a chronic canine study to evaluate the stability, electrical, mechanical and histological performance. Method: A total of 5 canines were implanted with the new lead. These leads were placed in the anterior branch of the coronary venous anatomy using stylets and /or guidewires. Results: During lead implantation the new leads were found to track farther and into more vein branch locations compared to the currently available leads. No lead dislodgements or other lead related complications occurred in these canines. Table 1 shows the electrical performance of the lead over this time period. These values compare favorably with the currently available transvenous LV leads. Conclusions: The new 4Fr LV lead may allow greater ease in successfully positioning the lead into small and tortuous veins without compromising on handling or tracking. In canine studies this lead has exhibited excellent performance with low, stable pacing thresholds, and excellent lead stability. Further testing is in progress.
HFSA
S67
apical 4-chamber view. Diastolic TDI values (Ew, Aw), peak systolic strain and systolic and diastolic strain rate values were determined. Results. At six months followup after BVP, patients functional status improved by one NYHA class or more and LVEF improved overall from 19.9 6 7.5% to 29.3 6 11.4%. A significant reduction in severity of tricuspid regurgitation and pulmonary artery pressure was also observed. Interventricular dyssynchrony by SRI was reduced from 82.4 6 29 ms to 36.5 6 23.4 ms (p!0.005) and intraventricular dyssynchrony from 77 6 31.2 ms to 23.8 6 15.9 ms (p!0.001). The degree of dyssynchrony correlated significantly with the improvement in LVEF and LV end-diastolic diameter. An increase of Ew at basal RV level from 11.8 6 1.9 cm/s to 15.9 6 1.5 cm/s was shown (p!0.005). Peak systolic strain and systolic and early diastolic strain rate at basal RV level increased, respectively, from 20.3 6 6.5% to 30.5 6 7.4%, 2.8 6 1.9 cm/s to 4.7 6 1.5 sec1, and 4.8 6 1.7 cm/s to 7.9 6 1.4 sec1 (p!0.001). RV reverse remodeling was only observed in patients with highest degrees of LV dyssynchrony at baseline. Conclusions. Thus, by improving temporal LV asynchrony, BVP has a positive hemodynamic impact on LV as well as RV function.
Table 1. Chronic Electrical Performance of new 4 Fr unipolar LV lead in a canine model Parameter (Mean 6 Std Dev) Capture Threshold (V @ 0.5 ms) R-Wave amplitude (mV) Pacing Impedance (Ohms)
Implant
One month
Three months
0.30 6 0.11 15.80 6 5.02 678 6 67.2
1.55 6 0.87 18.40 6 1.56 732 6 95.5
1.05 6 0.37 17.33 6 4.35 770 6 115.1
215 Factors Associated with New-Onset Atrial Fibrillation in Patients with Implanted Pacemakers Maria C. Tentori1, Graciela A. Ruiz1, Raul Chirife1, Elena Sztyglic1, Monica Arrascaite1; 1Cardiology, Hospital Fernandez, Buenos Aires, Argentina Background: Since the incidence of AF in patients with implanted pacemakers is higher than the general population, it was the aim of this retrospective study to assess the factors associated with new-onset AF after PM implantation. The clinical and PM variables included in the analysis were: age, sex, indication for PM implant (SSS or AVB), type of cardiophathy, pacing mode (VVI, DDD), left atrial and left ventricular dimensions. Methods: From a database of 869 Pts, 733 Pts with previous to PM implant and no history of AF were included. The mean follow-up period was 90 þ/ 78 months. Multiple linear regressions and multiple discriminant function analysis (MDF) were done between AF and above clinical/PM variables. Results: There 112 cases of new-onset AF detected during PM follow-up. The individual variables revealing a significant association were SSS and LAD, with LVD revealing only a trend. With MDF the combination of SSS and LAD had a predictive accuracy of AF of 72% (P!0.0001). Predominance of atrial pacing over sensing did not affect the incidence of AF. Conclusion: New-onset AF seems to be determined by the presence of SSS and LA dilatation. LV dilatation had a less significant role and pacing mode has no apparent effect.
216 Effects of Cardiac Resynchronization Therapy on Left as Well as Right Ventricular Deformation Parameters Antonio Vitarelli1, Pasquale Franciosa1, Ysabel Conde1, Ester Cimino1, Bich Lien Nguyen1, D’Orazio Simona1, Guglielmo De Curtis2, Miguel Cortes Morichetti2, Salvatore Rosanio3; 1Cardiac Dept., La Sapienza University, Rome, Italy; 2Le Kremlin-Bicetre University, Paris, France; 3The University of Texas, Galveston, TX Background. Cardiac resynchronization therapy has been proved to achieve reverse left ventricular (LV) remodeling in patients with advanced heart failure but effects on right ventricular (RV) function are not well established. The aim of this study was to analyse the evolution of LV as well as RV tissue Doppler / strain Doppler imaging (TDI/SRI) parameters after biventricular pacing (BVP). Methods. Thirty-three patients with dilated cardiomyopathy (NYHA class II or greater), left bundle branch block (QRS $ 120ms), and LV ejection fraction #35% were studied with TDI/SRI echocardiography before and after BVP. Intraventricular dyssynchrony was determined as the difference between the longest and shortest electromechanical coupling times in the basal septal, lateral, and posterior LV segments. Interventricular dyssynchrony was determined as the difference between electromechanical coupling times in the basal lateral RV segment and the most delayed LV segment. Velocity and strain traces from right ventricular free wall (basal and mid cavity) were processed in the
217 The Impact of Age, Gender, and Heart Failure Etiology on the Outcome of Cardiac Resynchronization Therapy Omeed Zardkoohi1, Jagmeet Singh1, Theofanie Mela1, Jeremy Ruskin1, Kevin Heist1, Jeffrey Chung1, Kyle Haelewyn1; 1Medicine, Massachusetts General Hospital, Boston, MA Background: Patient responses to cardiac resynchronization therapy (CRT) vary significantly. To better target this therapy to the appropriate population, it is important to know what pre-implant characteristics impact clinical response. The purpose of this study was to determine the effect of age, gender, and heart failure etiology on the long-term outcome of patients receiving CRT. Methods: 117 patients with drug-refractory heart failure, NYHA Class III or IV and a wide QRS complex, who received CRT, were followed for 1 year. Long-term response was measured as a combined endpoint of hospitalization for heart failure and/or all cause mortality. The efficacy of CRT was compared between men and women; between older and younger patients; and between patients with ischemic heart disease and patients with nonischemic heart disease. Time to the primary end-point was estimated by the Kaplan-Meier method, with comparisons made using the Breslow-Wilcoxon test. Results: Baseline clinical characteristics were comparable between the gender, age, and heart failure etiology groups except that younger patients were more likely to have diabetes than older patients, and men were more likely to have ischemic heart disease and less likely to be taking a diuretic than women. There was no significant difference in the combined endpoint between older (age $ 70, n 5 71) and younger (! 70, n 5 46) patients (p 5 0.52). Both genders (men, n 5 91 and women, n 5 26, p 5 0.46) had similar long-term outcome. There was no significant difference between patients with ischemic cardiomyopathy (n 5 79) and patients with.nonischemic cardiomyopathy (n 5 38) (p 5 0.12). However, when stratified by the etiology of the underlying cardiomyopathy, women with underlying ischemic etiology (IF, n510) had a worse outcome compared to the other groups i.e. non-ischemic women (NIW, n516), ischemic men (IM, n569) and non-ischemic men (NIM, n522), p50.04. Conclusions: The beneficial effect of CRT is independent of age, gender, and heart failure etiology. Women with ischemic cardiomyopathy tend to have a worse long-term outcome.