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Guidance of Intra-Operative Ventricular Tachycardia Ablation during LVAD Implantation with Pre-operative Cardiac MRI
The 22nd Annual Scientific Meeting HFSA
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Table 2. Adjusted risk measures of study outcomes.Based on proportional hazards regression controlling for age, sex, race, dual Medicaid enrollment, comorbidity (CHA2DS2-Vasc, HAS-BELD, history of cardiovascular, cerebrovascular, peripheral vascular, renal, liver disease, diabetes, hypertension, implantable device, polypharmacy and concurrent OAC use)
Figure. Survival following ICD implantation among patients with advanced heart failure
164 Periprocedural Risk and Survival after ICD Placement in Patients with Advanced Heart Failure Marat Fudim1, Craig S. Parzynsk, i2, Sean D. Pokorney1, Andrew P. Ambrosy1, Daniel J. Friedman1, Jeptha P. Curtis2, Gregg C. Fonarow3, Frederick A. Masoudi4, Adrian F. Hernandez1, Sana M. Al-Khatib1; 1Duke, Durham, NC; 2Yale, New Haven, CT; 3 UCLA, Los Angeles, CA; 4University of Colorado, Aurora, CO Background: Implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) are not provided to all patients with heart failure (HF) who qualify clinically for these treatments. Little is known about utilization and outcomes of ICD/CRT-D in patients with advanced HF. Methods: A post-hoc analysis was performed of Medicare fee-for-service beneficiaries enrolled in the National Cardiovascular Data Registry’s (NCDRÒ ) ICD RegistryTM with a diagnosis of HF, an EF 35% and evidence of advanced HF defined as NYHA class IV symptoms, inotrope use within the past 60 days, left ventricular assist device (LVAD) in situ, or currently listed for orthotopic heart transplant (OHT). All eligible patients underwent initial ICD/CRT-D placement for primary prevention of sudden cardiac death before January 2015. Cox hazards model was used to test for association with baseline covariates. Results: Among 81,492 Medicare patients with EF 35% that underwent primary prevention ICD/CDRT-D placement, there were 3,343 advanced-HF patients (4.1%). Amongst advanced HF patients 2,506 (75%) had NYHA class IV symptoms, 676 (20.2%) were currently or recently on inotropes, 129 (3.9%) had an LVAD, and 158 (4.7%) were listed for OHT. Patients had a mean age of 74§9 years and 28.3% were female (N=946). The majority received a CRT-D device (N=2,424, 72.6%). The aggregate in-hospital periprocedural complication rate was 3.74% (95% CI 3.124.44) with the majority of adverse events being in-hospital fatalities (1.82%, 95% CI 1.40-2.34) or resuscitated cardiac arrests (1.05%, 95% CI 0.73-1.45). All-cause survival rates are shown in the Figure. Median survival following device implantation was 1,178 days (95% CI 1,013-1,364). After adjusting for potential confounders, females had a lower rate of all-cause death (HR 0.81, 95% CI 0.71-0.93, p<0.01) while patients with NYHA class IV (HR 1.40, 95% CI 1.02-1.93, p=0.04), ischemic heart disease (HR 1.24, 95% CI 1.04-1.48, p=0.02), and diabetes (HR 1.17, 95% CI 1.04-1.33, p=0.01) were associated with a higher risk of death. Conclusion: A small proportion of older patients with advanced HF undergo initial ICD/CRT-D placement for primary prevention. These patients experience clinically important periprocedural complication rates driven by in-hospital deaths and aborted sudden cardiac arrest. Additional prospective research is necessary to clarify the role of primary prevention ICDs in patients with advanced HF.
165 Guidance of Intra-Operative Ventricular Tachycardia Ablation during LVAD Implantation with Pre-operative Cardiac MRI Farah Al-Saffar1, Saif Ibrahim2, Car , oline Dailey1, Robert Scott1, Jama Jahanyar1, Siva Mulpuru1; 1Mayo Clinic, Scottsdale, AZ; 2University of Florida, Jacksonville, FL Introduction: Ventricular tachycardia (VT) is common in ischemic cardiomyopathy (ICM). Ablation maybe required to reduce ICD shocks and improve the quality of life. Preoperative VT mapping is an invasive electrophysiologic study prior to the surgery which heart failure patients may not tolerate. Substrate modification is usually done in an open epicardial approach during LVAD implantation. Non-invasive mapping techniques have not been described before. In this case pre-operative cardiac magnetic resonance (CMR) imaging was used to plan VT scar mapping and guide intra-operative cryoablation that was done while performing LVAD implantation. Case Report: 69-year-old man with ICM (ejection fraction of 23%) and
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biventricular cardioverter-defibrillator (ICD). He has history of VT, four ablations, and on mexiletine and amiodarone. He had VT-related syncope terminated with antitachycardia pacing (ATP). ICD interrogation showed 15 appropriate shocks and >100 ATP therapies since the device implantation 6 months prior. In hospital he had slow monomorphic VT (slow cycle length 650 msec) with left bundle-branch morphology and superior axis positive in AVR. Milrinone was started for cardiogenic shock (cardiac index of 1.81 L/min/m2). He was not a transplant candidate so he was scheduled for destination therapy LVAD. Before the procedure he had sustained monomorphic VTs refractory to ATP requiring ICD shock. Cardiac MRI showed large chronic infarct with marked remodeling and transmural delayed enhancement in the inferoseptal, inferior, and inferolateral segments at the base a mid-ventricular portions of the left ventricle (LV) extending into the inferior aspect of the apical LV. Six myocardial segments equivalent was involved with transmural infarct. We decided to do an intra-operative VT ablation during LVAD implantation. Intraoperatively the LVAD ring was anchored to the apex with sutures. LV incision was made, and cryoablation of the inferoseptal towards inferolateral wall was performed using Cryo3 cryoICE catheter. Corresponding to the scar on MRI ablation lesions were created and the lesions were overlapping (from 3 to 9 o’clock position). The incision site was also cryoablated with a total of ten cryoablations. Conclusion: This is the first case to use cardiac MRI for preoperative VT mapping and did correspond to the lesions seen intraoperatively. This is a novel non-invasive mapping tool for heart failure patients undergoing surgical cryoablation . At 1 month follow up the patient has had 68 episodes of non-sustained VT, and 8 episodes of VT, successfully treated with ATP.
166 Association between Age and Early Mortality Risk after Implantable Cardioverter Defibrillator Implantation within The Veteran Affairs Health System Marat Fudim1, Srikant Devaraj2, Tarek Ajam3, Andrew Ambrosy1, Masoor Kamalesh4; 1Duke University, Durham, NC; 2Ball State University, Muncie, IN; 3 Saint Louis University, Saint Louis, MO; 4Indiana University, Indianapolis, IN Background: Implantable cardioverter-defibrillator (ICD) therapy improves outcomes in patients with heart failure (HF) but current guidelines advise against placement of ICDs in patients with a life expectancy of less than 1 year. We examined the association between age and early mortality rate in patients who underwent primary or secondary prevention ICD in the Veterans Affairs (VA) Health System. Methods: The analysis included US veterans with a diagnosis of heart failure and reduced ejection fraction (HFrEF) and a new implantation of primary or secondary prevention ICD. Patients treated nationwide in the VA-Health System from January 2007 to January 2015 were included. Diagnosis of HFrEF and ICD implantation was established through ICD9-codes. Mortality data were obtained fromthe VA’s death registry. The patient cohort was divided in age quartiles and the 1-year and 8-year all-cause mortality were examined. Results: A total of 17,901 patients with HFrEF and new ICD placement were identified. Distribution of age across quartiles (Q) was as following: Q1 23-61 years, mean 56; Q2 61-67 years, mean 64; Q3 67-76 years, mean 71; Q4 76-99 years, mean 82. The comorbidity burden (i.e. coronary artery disease, atrial fibrillation, chronic kidney disease and diabetes mellitus) was higher in Q3 and Q4 compared to Q1 and Q2. One-year and 8-year mortality are presented in the Figure. In the Q4 group, 32% of patients died within 1 year. Higher age quartiles were associated with significantly worse 1 and 8-year mortality when compared to Q1 (p< 0.001 for all Q), with the highest mortality in the Q4 group. Conclusion: Elderly veterans with HFrEF and a new ICD implantation experience a high early mortality. Knowledge of clinical features associated with early mortality in the elderly population could help in the selection of appropriate ICD candidates in the VA population.
167 Characteristics of Patients with Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation. Manju Bengaluru Jayanna, Ala Mohsen, Christopher Dezorzi, Ghanshyam Palamaner Subash Shantha, Chakradhari Inampudi, Michael Giudici, Alexandros Briasoulis; University of Iowa Hospitals and Clinics, Iowa City, IA Objectives: Previous studies have shown benefit of catheter ablation of atrial fibrillation in patients with heart failure(HF). This study aims to study characteristics of patients with heart failure undergoing catheter ablation of atrial fibrillation (AF). Methods: In this retrospective cohort study, we analyzed 269 consecutive patients with mean age of 61 years who underwent catheter ablation for AF. 64 patients (24%) had known history of Stage C heart failure including both Heart failure with reduced ejection fraction and preserved ejection fraction. We compared baseline characteristics at the time of ablation and procedure outcomes between patients who had known heart failure to those who did not. Results: At the time of the procedure, patients with HF had significantly higher body mass index (34.4vs32.3 p=0.0432), CHADS2Vasc score (2.6 vs 1.8 p<0.0001), heart rate (81 vs 73 p=0.0023), coronary artery disease (28% vs 15% p=0.0186) and left atrial enlargement by echocardiogram (53%vs29% p=0.0008). Other baseline characteristics including age, sex, race, comorbidities including valvular heart disease, hypertension, diabetes mellitus, peripheral vascular disease, sleep apnea were similar. Procedure duration was significantly longer in patients with HF (300 minutes vs 262 minutes p=0.0016) but other procedure characteristics including radiation exposure, fluoroscopy time, periprocedural complications were similar. Amongst patients with available follow up, patients with HF had higher unadjusted rates of recurrence at 3 months, (33%vs 17% p=0.0095 Relative risk(RR) 1.97(1.19-3.2 95%CI) and at 1 year (48% vs 29% p=0.0120 RR=1.13-2.4 95%CI). However, on logistic regression analysis adjusting for left atrial size and CHADS2Vasc score as covariates there was no significant difference. Conclusion: Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year.
168 Conservative Management of Atrial Fibrillation in Heart Failure Patients in a Tertiary Care Medical Center Lawrence J. Saliba, Julie Mease, John Hummel; The Ohio State University Wexner Medical Center, Columbus, OH
Figure. 1 and 8-year Kaplan Meier survival curve for all-cause mortality. Times to events were compared using log-rank tests Quartile (Q) 1 is the reference group.
Introduction: Several recent studies support a salutary effect of atrial fibrillation (AF) ablation in patients with heart failure with reduced ejection fraction (HFrEF), with ablation reducing mortality and heart failure hospitalization compared to strategies of rate control or anti-arrhythmic medication. The current patterns of AF management in the HFrEF population in tertiary care centers are not well understood. Objective: To determine the primary approach to AF treatment in patients with HFrEF in a large tertiary care center with access to all modalities of CHF and AF
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Table 2. Adjusted risk measures of study outcomes.Based on proportional hazards regression controlling for age, sex, race, dual Medicaid enrollment, comorbidity (CHA2DS2-Vasc, HAS-BELD, history of cardiovascular, cerebrovascular, peripheral vascular, renal, liver disease, diabetes, hypertension, implantable device, polypharmacy and concurrent OAC use)
Figure. Survival following ICD implantation among patients with advanced heart failure
164 Periprocedural Risk and Survival after ICD Placement in Patients with Advanced Heart Failure Marat Fudim1, Craig S. Parzynsk, i2, Sean D. Pokorney1, Andrew P. Ambrosy1, Daniel J. Friedman1, Jeptha P. Curtis2, Gregg C. Fonarow3, Frederick A. Masoudi4, Adrian F. Hernandez1, Sana M. Al-Khatib1; 1Duke, Durham, NC; 2Yale, New Haven, CT; 3 UCLA, Los Angeles, CA; 4University of Colorado, Aurora, CO Background: Implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) are not provided to all patients with heart failure (HF) who qualify clinically for these treatments. Little is known about utilization and outcomes of ICD/CRT-D in patients with advanced HF. Methods: A post-hoc analysis was performed of Medicare fee-for-service beneficiaries enrolled in the National Cardiovascular Data Registry’s (NCDRÒ ) ICD RegistryTM with a diagnosis of HF, an EF 35% and evidence of advanced HF defined as NYHA class IV symptoms, inotrope use within the past 60 days, left ventricular assist device (LVAD) in situ, or currently listed for orthotopic heart transplant (OHT). All eligible patients underwent initial ICD/CRT-D placement for primary prevention of sudden cardiac death before January 2015. Cox hazards model was used to test for association with baseline covariates. Results: Among 81,492 Medicare patients with EF 35% that underwent primary prevention ICD/CDRT-D placement, there were 3,343 advanced-HF patients (4.1%). Amongst advanced HF patients 2,506 (75%) had NYHA class IV symptoms, 676 (20.2%) were currently or recently on inotropes, 129 (3.9%) had an LVAD, and 158 (4.7%) were listed for OHT. Patients had a mean age of 74§9 years and 28.3% were female (N=946). The majority received a CRT-D device (N=2,424, 72.6%). The aggregate in-hospital periprocedural complication rate was 3.74% (95% CI 3.124.44) with the majority of adverse events being in-hospital fatalities (1.82%, 95% CI 1.40-2.34) or resuscitated cardiac arrests (1.05%, 95% CI 0.73-1.45). All-cause survival rates are shown in the Figure. Median survival following device implantation was 1,178 days (95% CI 1,013-1,364). After adjusting for potential confounders, females had a lower rate of all-cause death (HR 0.81, 95% CI 0.71-0.93, p<0.01) while patients with NYHA class IV (HR 1.40, 95% CI 1.02-1.93, p=0.04), ischemic heart disease (HR 1.24, 95% CI 1.04-1.48, p=0.02), and diabetes (HR 1.17, 95% CI 1.04-1.33, p=0.01) were associated with a higher risk of death. Conclusion: A small proportion of older patients with advanced HF undergo initial ICD/CRT-D placement for primary prevention. These patients experience clinically important periprocedural complication rates driven by in-hospital deaths and aborted sudden cardiac arrest. Additional prospective research is necessary to clarify the role of primary prevention ICDs in patients with advanced HF.
165 Guidance of Intra-Operative Ventricular Tachycardia Ablation during LVAD Implantation with Pre-operative Cardiac MRI Farah Al-Saffar1, Saif Ibrahim2, Car , oline Dailey1, Robert Scott1, Jama Jahanyar1, Siva Mulpuru1; 1Mayo Clinic, Scottsdale, AZ; 2University of Florida, Jacksonville, FL Introduction: Ventricular tachycardia (VT) is common in ischemic cardiomyopathy (ICM). Ablation maybe required to reduce ICD shocks and improve the quality of life. Preoperative VT mapping is an invasive electrophysiologic study prior to the surgery which heart failure patients may not tolerate. Substrate modification is usually done in an open epicardial approach during LVAD implantation. Non-invasive mapping techniques have not been described before. In this case pre-operative cardiac magnetic resonance (CMR) imaging was used to plan VT scar mapping and guide intra-operative cryoablation that was done while performing LVAD implantation. Case Report: 69-year-old man with ICM (ejection fraction of 23%) and
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biventricular cardioverter-defibrillator (ICD). He has history of VT, four ablations, and on mexiletine and amiodarone. He had VT-related syncope terminated with antitachycardia pacing (ATP). ICD interrogation showed 15 appropriate shocks and >100 ATP therapies since the device implantation 6 months prior. In hospital he had slow monomorphic VT (slow cycle length 650 msec) with left bundle-branch morphology and superior axis positive in AVR. Milrinone was started for cardiogenic shock (cardiac index of 1.81 L/min/m2). He was not a transplant candidate so he was scheduled for destination therapy LVAD. Before the procedure he had sustained monomorphic VTs refractory to ATP requiring ICD shock. Cardiac MRI showed large chronic infarct with marked remodeling and transmural delayed enhancement in the inferoseptal, inferior, and inferolateral segments at the base a mid-ventricular portions of the left ventricle (LV) extending into the inferior aspect of the apical LV. Six myocardial segments equivalent was involved with transmural infarct. We decided to do an intra-operative VT ablation during LVAD implantation. Intraoperatively the LVAD ring was anchored to the apex with sutures. LV incision was made, and cryoablation of the inferoseptal towards inferolateral wall was performed using Cryo3 cryoICE catheter. Corresponding to the scar on MRI ablation lesions were created and the lesions were overlapping (from 3 to 9 o’clock position). The incision site was also cryoablated with a total of ten cryoablations. Conclusion: This is the first case to use cardiac MRI for preoperative VT mapping and did correspond to the lesions seen intraoperatively. This is a novel non-invasive mapping tool for heart failure patients undergoing surgical cryoablation . At 1 month follow up the patient has had 68 episodes of non-sustained VT, and 8 episodes of VT, successfully treated with ATP.
166 Association between Age and Early Mortality Risk after Implantable Cardioverter Defibrillator Implantation within The Veteran Affairs Health System Marat Fudim1, Srikant Devaraj2, Tarek Ajam3, Andrew Ambrosy1, Masoor Kamalesh4; 1Duke University, Durham, NC; 2Ball State University, Muncie, IN; 3 Saint Louis University, Saint Louis, MO; 4Indiana University, Indianapolis, IN Background: Implantable cardioverter-defibrillator (ICD) therapy improves outcomes in patients with heart failure (HF) but current guidelines advise against placement of ICDs in patients with a life expectancy of less than 1 year. We examined the association between age and early mortality rate in patients who underwent primary or secondary prevention ICD in the Veterans Affairs (VA) Health System. Methods: The analysis included US veterans with a diagnosis of heart failure and reduced ejection fraction (HFrEF) and a new implantation of primary or secondary prevention ICD. Patients treated nationwide in the VA-Health System from January 2007 to January 2015 were included. Diagnosis of HFrEF and ICD implantation was established through ICD9-codes. Mortality data were obtained fromthe VA’s death registry. The patient cohort was divided in age quartiles and the 1-year and 8-year all-cause mortality were examined. Results: A total of 17,901 patients with HFrEF and new ICD placement were identified. Distribution of age across quartiles (Q) was as following: Q1 23-61 years, mean 56; Q2 61-67 years, mean 64; Q3 67-76 years, mean 71; Q4 76-99 years, mean 82. The comorbidity burden (i.e. coronary artery disease, atrial fibrillation, chronic kidney disease and diabetes mellitus) was higher in Q3 and Q4 compared to Q1 and Q2. One-year and 8-year mortality are presented in the Figure. In the Q4 group, 32% of patients died within 1 year. Higher age quartiles were associated with significantly worse 1 and 8-year mortality when compared to Q1 (p< 0.001 for all Q), with the highest mortality in the Q4 group. Conclusion: Elderly veterans with HFrEF and a new ICD implantation experience a high early mortality. Knowledge of clinical features associated with early mortality in the elderly population could help in the selection of appropriate ICD candidates in the VA population.
167 Characteristics of Patients with Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation. Manju Bengaluru Jayanna, Ala Mohsen, Christopher Dezorzi, Ghanshyam Palamaner Subash Shantha, Chakradhari Inampudi, Michael Giudici, Alexandros Briasoulis; University of Iowa Hospitals and Clinics, Iowa City, IA Objectives: Previous studies have shown benefit of catheter ablation of atrial fibrillation in patients with heart failure(HF). This study aims to study characteristics of patients with heart failure undergoing catheter ablation of atrial fibrillation (AF). Methods: In this retrospective cohort study, we analyzed 269 consecutive patients with mean age of 61 years who underwent catheter ablation for AF. 64 patients (24%) had known history of Stage C heart failure including both Heart failure with reduced ejection fraction and preserved ejection fraction. We compared baseline characteristics at the time of ablation and procedure outcomes between patients who had known heart failure to those who did not. Results: At the time of the procedure, patients with HF had significantly higher body mass index (34.4vs32.3 p=0.0432), CHADS2Vasc score (2.6 vs 1.8 p<0.0001), heart rate (81 vs 73 p=0.0023), coronary artery disease (28% vs 15% p=0.0186) and left atrial enlargement by echocardiogram (53%vs29% p=0.0008). Other baseline characteristics including age, sex, race, comorbidities including valvular heart disease, hypertension, diabetes mellitus, peripheral vascular disease, sleep apnea were similar. Procedure duration was significantly longer in patients with HF (300 minutes vs 262 minutes p=0.0016) but other procedure characteristics including radiation exposure, fluoroscopy time, periprocedural complications were similar. Amongst patients with available follow up, patients with HF had higher unadjusted rates of recurrence at 3 months, (33%vs 17% p=0.0095 Relative risk(RR) 1.97(1.19-3.2 95%CI) and at 1 year (48% vs 29% p=0.0120 RR=1.13-2.4 95%CI). However, on logistic regression analysis adjusting for left atrial size and CHADS2Vasc score as covariates there was no significant difference. Conclusion: Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year.
168 Conservative Management of Atrial Fibrillation in Heart Failure Patients in a Tertiary Care Medical Center Lawrence J. Saliba, Julie Mease, John Hummel; The Ohio State University Wexner Medical Center, Columbus, OH
Figure. 1 and 8-year Kaplan Meier survival curve for all-cause mortality. Times to events were compared using log-rank tests Quartile (Q) 1 is the reference group.
Introduction: Several recent studies support a salutary effect of atrial fibrillation (AF) ablation in patients with heart failure with reduced ejection fraction (HFrEF), with ablation reducing mortality and heart failure hospitalization compared to strategies of rate control or anti-arrhythmic medication. The current patterns of AF management in the HFrEF population in tertiary care centers are not well understood. Objective: To determine the primary approach to AF treatment in patients with HFrEF in a large tertiary care center with access to all modalities of CHF and AF