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Effect of Pocket Location on LV→Can Evoked Response Signal for LV Capture Detection in CRT Devices
The 14th Annual Scientific Meeting SCS compared to responders. When stratified by etiology, ischemic patients had significantly lower RV SCS than non-ischemic (7.7 6 4.4 vs. 11.5 6 4.5; p 5 0.0098). Conclusions: Improvement in LV EF upon CRT may be also associated with better RV contractility and is more likely to occur in patients with non-ischemic etiology of heart failure.
HFSA
S55
University Hospitals Leuven, Leuven, Belgium; 2CircuLite, Inc, Hackensack; Cardiology, University Hospitals Leuven, Leuven, Belgium
3
* - p ! 0.001 vs. corresponding non-responders.
Introduction: Full left ventricular (LV) unloading of at least 40 days induces LV reverse structural remodelling, evidenced by normalization of passive end-diastolic pressure-volume relationships (EDPVRs). Hypothesis: Partial unloading induces reverse remodelling effect to a certain extent. Methods: Passive LV EDPVRs were obtained from explanted hearts of 19 patients with chronic heart failure (CHF) undergoing heart transplantation without LV support, 19 CHF patients with full and 5 with partial support before transplantation, and 5 normal human hearts not suitable for transplantation. LV support was at least 40 days. Pressure-volume relationships were measured immediately after explantation of the heart by progressive inflation of a fluid-filled intraventricular balloon with increments of 10mL, while monitoring the pressure inside the balloon at each increment. LV dilatation was indexed by the volume at which LV pressure reached 30 mmHg. Results: The volume at which LV pressure reached 30 mmHg was the smallest in healthy hearts (95 6 12mL); in patients with partial unloading (196 6 22mL; p 5 0.03, compared to unsupported hearts) it was significantly smaller than that of the chronically failing unsupported hearts (265 6 60mL), but larger than the fully supported hearts (150 6 30mL; p ! 0.001, compared to unsupported hearts). Conclusion: Partial mechanical unloading induces reversal of LV dilatation, but to a lesser extent than full LV support.
175
177
Pneumonia in the First Year after Heart Transplant: Epidemiology, Risk Factors, and Effect on Survival Nir Uriel1, Sang-Whoo Pak2, Yacki Hayashi2, Natalie Gukasayan2, Simon J. Tsiouris1, Brian E. Scully1, Hiroo Takayama2, Yoshifumi Naka2, Paolo C. Colombo1, Donna Mancini1, Ulrich P. Jorde1; 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY
Utility of 3-Dimensional Transthoracic Echocardiography To Differentiate between Recipient and Donor Compartments’ Left Atrial Function in Transplanted Hearts Sabha Bhatti, Yuhning L. Hu, Katie E. Butts, Karen A. Moore, Craig O. Breedlove, Yukitaka Shizukuda; Division of Cardiovascular Diseases, University of Cincinnati, Cincinnati, OH
Background: Infections are one of the main complications that cause morbidity and mortality in heart transplant recipients. The lungs are the most common site of serious infection owing to their large surface area. We describe the prevalence of and risk factors for the development of pneumonia (PNA) in the first year post transplant and to its effect on transplant outcome. Methods: Retrospective data collection of all patients transplanted at our center from 1/2004-12/2009 was performed. Baseline characteristic as well as heart transplant data (medication and rejection) were collected. PNA was defined as the presence of fever and productive cough with the radiological evidence of a new or increased pulmonary infiltrate. Hospital-acquired PNA (HAP) was defined as the development of PNA following hospitalization for transplantation. Results: Charts of 464 adult heart transplant recipients were reviewed. 75.6% were male, age was 51.8 6 13.1 yrs. 96 patients were diagnosed with PNA within the first year post transplant. 52 patients developed HAP while 44 were readmitted for PNA. The median time for developing PNA was 32 days. Patients who developed PNA in the first year were older (54.7 6 13.1 vs 51.1 6 12.4 yrs, p 5 0.008) and more likely to have diabetes mellitus (37.5% vs 26.8%, p 5 0.04), prior LVAD implantation (45.8% vs 33.8%, p 5 0.03) and/or prior heart transplant (9.4% vs 4.1%, p 5 0.04). Causative organisms were identified in 66.6% of cases. While bacterial infection with Klebsiella pneumonia (17pt) and Pseudomonas aeruginosa (15pt) were the most common organisms, 8 patients were diagnosed with Aspergillus PNA. One-year survival for PNA patients was 80.0% compare to 88.8% of patients with no PNA (p 5 0.03). Conclusion: PNA in the first year post transplant is common and associated with reduced survival. Older patients, history of diabetes mellitus and prior LVAD or heart transplantation are major risk factors. The use of prophylactic antibiotic treatment for high-risk patients should be studied prospectively.
It has not been well described how recipient (RP) and donor (DN) compartments of left atrium (LA) of transplanted hearts differentially contribute to overall left atrial function in transplanted hearts. Three dimensional transthoracic echocardiography (3DE) can often identify the suture line in the left atrium in 3D planes and it can be used to calculate the compartment-specific atrial functions. Such information may further enhance our knowledge on flow mechanics contributing to left ventricular filling in patients with heart transplant (TP) and may be linked to their clinical outcomes. 21 consecutive patients who underwent TP at the University of Cincinnati (ages 59 6 3, mean 6 SEM, 5 females) who demonstrated traceable LA anastomosis line in the apical image of full volume 3DE obtained by Vivid 7 ultrasound machine (GE Healthcare) was used to assess the compartment-specific LA volume and LA function. The patients with active myocardial ischemia, non-sinus rhythms, and more than mild mitral regurgitation were excluded from this study. TomTec Research Arena software (TomTec, Inc.) was used to calculate compartment-specific LA volumes and LA ejection fractions. Interobserver variability of maximum LA volumes among total, RP, and DN compartments was 5.6 6 2.4, 5.4 6 2.0, 9.3 6 3.2 ml, n 5 11, respectively. Compartmental LA volume indexed to body surface area was 39 6 4 in total, 22 6 2 in RP, 17 6 3 ml/m2 in DH and LA ejection fraction of those was 34 6 2, in total, 29 6 3 in RP, 40 6 4% in DH indicating that LA EF of DH was significantly higher than that of RP (P 5 0.017 by a paired t-test). When the patients were classified into asymptomatic (NYHA class I, n 5 4) and symptomatic (NYHA class II and III, n 5 17), the asymptomatic patients showed a trend toward larger maximum DH LA volume (33 6 4 vs 20 6 2 ml/m2, P 5 0.02), and smaller maximum RH LA volume (13 6 1 ml/m2 vs 19 6 3 ml/m2, P 5 0.05 by an unpaired t-test) as to the symptomatic patients. However, compartmental LA volumes and functions did not differ significantly between the patients with a presence and absence of hospitalization within a prior year. Conclusion: The compartment-specific LA volumes can be assessed by 3DE with modest interobserver variability in HT. The compartment specific volume changes in LA may be associated with clinical outcomes. Further investigation is warranted to evaluate a clinical significance of compartmental LA volume and function in TP population.
Baseline characteristics pre-CRT and echocardiographic parameters of LV and RV function post-CRT stratified by clinical and echocardiographic response NYHA NYHA responders, non-responders, n 5 28 n 5 22 LV EF pre-CRT, % 21 6 % ischemic pre-CRT 50 % LBBB pre-CRT 64 LV EF, % 32 6 LV ESV, mL 128 6 RV SCS, mm 10.4 6
8
12 73 4.4
22 6 45 59 26 6 158 6 8.6 6
8
13 10 5.0
Echo responders, n 5 30 22 6 37 57 36 6 102 6 11.4 6
8
12* 57* 4.6*
Echo non-responders, n 5 20 21 6 65 70 19 6 206 6 6.6 6
8
5 89 3.4
178 Effect of Pocket Location on LV/Can Evoked Response Signal for LV Capture Detection in CRT Devices Michael C. Giudici1, Gautham Kalahasty2, John H. Lobban3, Rahul N. Doshi4, Michael R. Gold5, Steven Eddy6, Phillip Schrumpf6, Yanting Dong6, Shibaji Shome6, Kenneth A. Ellenbogen2; 1Genesis Heart Institute, Davenport, IA; 2 Virginia Commonwealth University, Richmond, VA; 3Monongalia General Hospital, Morgantown, WV; 4St. Jude Medical Center, Fullerton, CA; 5Medical University of South Carolina, Charleston, SC; 6Boston Scientific CRM, St. Paul, MN
176 Reverse Remodelling in Partial Mechanical Circulatory Support Jef H. Geens1, Steven Jacobs1, Michael Martin2, Wolfgang Kerkhoffs2, Filip R. Rega1, Daniel Burkhoff2, Walter Droogne3, Bart Meyns1; 1Cardiac Surgery,
Introduction: Automatic pacing threshold (AT) testing may simplify device followup and improve device longevity. A left ventricular (LV) AT algorithm, based on evoked response (ER) sensing from LV/Can vector, was recently developed for CRT devices. The objective of this analysis was to evaluate the effect of Can location on ER characteristics. Methods: Patients scheduled for CRT-D/P implant, replacement or upgrade were enrolled. A sterile titanium Can emulator was temporarily placed in the device pocket. The leads and Can were connected to an external pacing system (Boston Scientific) with custom software for performing threshold tests and data acquisition. An LV AT test was run in each of 4 pacing vectorse LVTip/ Can, LVTip/RV, LVRing/Can and LVRing/RV. The LV ER was evaluated offline using signal to artifact ratio (SAR 5 [min ER amplitude]/[max pacing artifact amplitude]) and ER peak timing stability (DT 5 [max ER peak time]/[min ER
S56 Journal of Cardiac Failure Vol. 16 No. 8S August 2010 peak time]). Signal quality acceptable for capture detection was defined as SAR O 2 and DT ! 50ms. Results: Data from 70 patients (54M/16F, 68.9 6 10.4 years, LVEF: 27.0 6 9.2%, CRT-D/P: 65/5) were analyzed. Results are shown in the Table. Acceptability criteria were met for all patients and there was no statistical difference between any ER characteristics at the 2 Can locations.
ER signal characteristics in left pectoral and right pectoral Can implant locations DT (ms)
SAR
Can Location Left pectoral Right pectoral
Number of patients with acceptable ER
Mean 6 SD
(min, max) Mean 6 SD (min, max)
60/60
192.6 6 264.9 x (3.3,1113)
8.5 6 5.9
(0, 47.5)
10/10
147.2 6 215.8 x (7.2, 1039)
7.5 6 4.2
(2.5, 20)
x p O 0.1, Student’s t test
p O 0.1, Welch t test
Conclusions: In this study, the LV /Can vector at both left and right pectoral Can locations had similar and acceptable characteristics. This data suggests that the LV AT algorithm may be used in CRT-P/D patients with either left or right pectoral Can location.
HFSA
S55
University Hospitals Leuven, Leuven, Belgium; 2CircuLite, Inc, Hackensack; Cardiology, University Hospitals Leuven, Leuven, Belgium
3
* - p ! 0.001 vs. corresponding non-responders.
Introduction: Full left ventricular (LV) unloading of at least 40 days induces LV reverse structural remodelling, evidenced by normalization of passive end-diastolic pressure-volume relationships (EDPVRs). Hypothesis: Partial unloading induces reverse remodelling effect to a certain extent. Methods: Passive LV EDPVRs were obtained from explanted hearts of 19 patients with chronic heart failure (CHF) undergoing heart transplantation without LV support, 19 CHF patients with full and 5 with partial support before transplantation, and 5 normal human hearts not suitable for transplantation. LV support was at least 40 days. Pressure-volume relationships were measured immediately after explantation of the heart by progressive inflation of a fluid-filled intraventricular balloon with increments of 10mL, while monitoring the pressure inside the balloon at each increment. LV dilatation was indexed by the volume at which LV pressure reached 30 mmHg. Results: The volume at which LV pressure reached 30 mmHg was the smallest in healthy hearts (95 6 12mL); in patients with partial unloading (196 6 22mL; p 5 0.03, compared to unsupported hearts) it was significantly smaller than that of the chronically failing unsupported hearts (265 6 60mL), but larger than the fully supported hearts (150 6 30mL; p ! 0.001, compared to unsupported hearts). Conclusion: Partial mechanical unloading induces reversal of LV dilatation, but to a lesser extent than full LV support.
175
177
Pneumonia in the First Year after Heart Transplant: Epidemiology, Risk Factors, and Effect on Survival Nir Uriel1, Sang-Whoo Pak2, Yacki Hayashi2, Natalie Gukasayan2, Simon J. Tsiouris1, Brian E. Scully1, Hiroo Takayama2, Yoshifumi Naka2, Paolo C. Colombo1, Donna Mancini1, Ulrich P. Jorde1; 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY
Utility of 3-Dimensional Transthoracic Echocardiography To Differentiate between Recipient and Donor Compartments’ Left Atrial Function in Transplanted Hearts Sabha Bhatti, Yuhning L. Hu, Katie E. Butts, Karen A. Moore, Craig O. Breedlove, Yukitaka Shizukuda; Division of Cardiovascular Diseases, University of Cincinnati, Cincinnati, OH
Background: Infections are one of the main complications that cause morbidity and mortality in heart transplant recipients. The lungs are the most common site of serious infection owing to their large surface area. We describe the prevalence of and risk factors for the development of pneumonia (PNA) in the first year post transplant and to its effect on transplant outcome. Methods: Retrospective data collection of all patients transplanted at our center from 1/2004-12/2009 was performed. Baseline characteristic as well as heart transplant data (medication and rejection) were collected. PNA was defined as the presence of fever and productive cough with the radiological evidence of a new or increased pulmonary infiltrate. Hospital-acquired PNA (HAP) was defined as the development of PNA following hospitalization for transplantation. Results: Charts of 464 adult heart transplant recipients were reviewed. 75.6% were male, age was 51.8 6 13.1 yrs. 96 patients were diagnosed with PNA within the first year post transplant. 52 patients developed HAP while 44 were readmitted for PNA. The median time for developing PNA was 32 days. Patients who developed PNA in the first year were older (54.7 6 13.1 vs 51.1 6 12.4 yrs, p 5 0.008) and more likely to have diabetes mellitus (37.5% vs 26.8%, p 5 0.04), prior LVAD implantation (45.8% vs 33.8%, p 5 0.03) and/or prior heart transplant (9.4% vs 4.1%, p 5 0.04). Causative organisms were identified in 66.6% of cases. While bacterial infection with Klebsiella pneumonia (17pt) and Pseudomonas aeruginosa (15pt) were the most common organisms, 8 patients were diagnosed with Aspergillus PNA. One-year survival for PNA patients was 80.0% compare to 88.8% of patients with no PNA (p 5 0.03). Conclusion: PNA in the first year post transplant is common and associated with reduced survival. Older patients, history of diabetes mellitus and prior LVAD or heart transplantation are major risk factors. The use of prophylactic antibiotic treatment for high-risk patients should be studied prospectively.
It has not been well described how recipient (RP) and donor (DN) compartments of left atrium (LA) of transplanted hearts differentially contribute to overall left atrial function in transplanted hearts. Three dimensional transthoracic echocardiography (3DE) can often identify the suture line in the left atrium in 3D planes and it can be used to calculate the compartment-specific atrial functions. Such information may further enhance our knowledge on flow mechanics contributing to left ventricular filling in patients with heart transplant (TP) and may be linked to their clinical outcomes. 21 consecutive patients who underwent TP at the University of Cincinnati (ages 59 6 3, mean 6 SEM, 5 females) who demonstrated traceable LA anastomosis line in the apical image of full volume 3DE obtained by Vivid 7 ultrasound machine (GE Healthcare) was used to assess the compartment-specific LA volume and LA function. The patients with active myocardial ischemia, non-sinus rhythms, and more than mild mitral regurgitation were excluded from this study. TomTec Research Arena software (TomTec, Inc.) was used to calculate compartment-specific LA volumes and LA ejection fractions. Interobserver variability of maximum LA volumes among total, RP, and DN compartments was 5.6 6 2.4, 5.4 6 2.0, 9.3 6 3.2 ml, n 5 11, respectively. Compartmental LA volume indexed to body surface area was 39 6 4 in total, 22 6 2 in RP, 17 6 3 ml/m2 in DH and LA ejection fraction of those was 34 6 2, in total, 29 6 3 in RP, 40 6 4% in DH indicating that LA EF of DH was significantly higher than that of RP (P 5 0.017 by a paired t-test). When the patients were classified into asymptomatic (NYHA class I, n 5 4) and symptomatic (NYHA class II and III, n 5 17), the asymptomatic patients showed a trend toward larger maximum DH LA volume (33 6 4 vs 20 6 2 ml/m2, P 5 0.02), and smaller maximum RH LA volume (13 6 1 ml/m2 vs 19 6 3 ml/m2, P 5 0.05 by an unpaired t-test) as to the symptomatic patients. However, compartmental LA volumes and functions did not differ significantly between the patients with a presence and absence of hospitalization within a prior year. Conclusion: The compartment-specific LA volumes can be assessed by 3DE with modest interobserver variability in HT. The compartment specific volume changes in LA may be associated with clinical outcomes. Further investigation is warranted to evaluate a clinical significance of compartmental LA volume and function in TP population.
Baseline characteristics pre-CRT and echocardiographic parameters of LV and RV function post-CRT stratified by clinical and echocardiographic response NYHA NYHA responders, non-responders, n 5 28 n 5 22 LV EF pre-CRT, % 21 6 % ischemic pre-CRT 50 % LBBB pre-CRT 64 LV EF, % 32 6 LV ESV, mL 128 6 RV SCS, mm 10.4 6
8
12 73 4.4
22 6 45 59 26 6 158 6 8.6 6
8
13 10 5.0
Echo responders, n 5 30 22 6 37 57 36 6 102 6 11.4 6
8
12* 57* 4.6*
Echo non-responders, n 5 20 21 6 65 70 19 6 206 6 6.6 6
8
5 89 3.4
178 Effect of Pocket Location on LV/Can Evoked Response Signal for LV Capture Detection in CRT Devices Michael C. Giudici1, Gautham Kalahasty2, John H. Lobban3, Rahul N. Doshi4, Michael R. Gold5, Steven Eddy6, Phillip Schrumpf6, Yanting Dong6, Shibaji Shome6, Kenneth A. Ellenbogen2; 1Genesis Heart Institute, Davenport, IA; 2 Virginia Commonwealth University, Richmond, VA; 3Monongalia General Hospital, Morgantown, WV; 4St. Jude Medical Center, Fullerton, CA; 5Medical University of South Carolina, Charleston, SC; 6Boston Scientific CRM, St. Paul, MN
176 Reverse Remodelling in Partial Mechanical Circulatory Support Jef H. Geens1, Steven Jacobs1, Michael Martin2, Wolfgang Kerkhoffs2, Filip R. Rega1, Daniel Burkhoff2, Walter Droogne3, Bart Meyns1; 1Cardiac Surgery,
Introduction: Automatic pacing threshold (AT) testing may simplify device followup and improve device longevity. A left ventricular (LV) AT algorithm, based on evoked response (ER) sensing from LV/Can vector, was recently developed for CRT devices. The objective of this analysis was to evaluate the effect of Can location on ER characteristics. Methods: Patients scheduled for CRT-D/P implant, replacement or upgrade were enrolled. A sterile titanium Can emulator was temporarily placed in the device pocket. The leads and Can were connected to an external pacing system (Boston Scientific) with custom software for performing threshold tests and data acquisition. An LV AT test was run in each of 4 pacing vectorse LVTip/ Can, LVTip/RV, LVRing/Can and LVRing/RV. The LV ER was evaluated offline using signal to artifact ratio (SAR 5 [min ER amplitude]/[max pacing artifact amplitude]) and ER peak timing stability (DT 5 [max ER peak time]/[min ER
S56 Journal of Cardiac Failure Vol. 16 No. 8S August 2010 peak time]). Signal quality acceptable for capture detection was defined as SAR O 2 and DT ! 50ms. Results: Data from 70 patients (54M/16F, 68.9 6 10.4 years, LVEF: 27.0 6 9.2%, CRT-D/P: 65/5) were analyzed. Results are shown in the Table. Acceptability criteria were met for all patients and there was no statistical difference between any ER characteristics at the 2 Can locations.
ER signal characteristics in left pectoral and right pectoral Can implant locations DT (ms)
SAR
Can Location Left pectoral Right pectoral
Number of patients with acceptable ER
Mean 6 SD
(min, max) Mean 6 SD (min, max)
60/60
192.6 6 264.9 x (3.3,1113)
8.5 6 5.9
(0, 47.5)
10/10
147.2 6 215.8 x (7.2, 1039)
7.5 6 4.2
(2.5, 20)
x p O 0.1, Student’s t test
p O 0.1, Welch t test
Conclusions: In this study, the LV /Can vector at both left and right pectoral Can locations had similar and acceptable characteristics. This data suggests that the LV AT algorithm may be used in CRT-P/D patients with either left or right pectoral Can location.