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Incessant Ventricular Tachycardia Secondary to Giant-Cell Myocarditis Treated with Stellate Ganglion Blockade
The 23rd Annual Scientific Meeting HFSA increase in RV pacing threshold (mean threshold = .98V pre-VAD vs 4.79V postVAD, P< .001). Among these patients, ventricular sensing was also significantly reduced (13.1mv to 2.9mv, P<.001) and there was a significant rise in ventricular impedance (480V to 689V, P=0.03). Atrial thresholds were available for 5 of these patients (0.82V to 1.02V, P=0.25) and LV threshold data was available for 3 patients (0.7V to 2.6V, P=NT). Five patients had single chamber ICDs, two had dual chamber ICDs and three had biventricular ICDS. Devices were manufactured by three different companies and both HVAD and HM3 were affected. Only two of the VAD implantations included concomitant tricuspid valve repair and two were performed using a less-invasive approach. Conclusion: RV pacing and sensing thresholds significantly increased after implantation of a HVAD or HM3 in more than one-fifth of patients with existing transvenous ICDs. The magnitude and frequency of these changes appear to greater than previously described with earlier-generation axial VADs. The etiology of this change in pacing performance warrants further investigation as it may result in adverse clinical events in this highly susceptible patient population.
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220 Meta-Analysis of n-3 Polyunsaturated Fatty Acid Supplementation for the Prevention of Post-Operative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Surgery Rahul Gupta, Jason Jacobson, Howard A. Cooper, Gregg M. Lanier; Westchester Medical Center, Valhalla, NY Background: Several randomized clinical trials (RCTs) have evaluated whether pre-operative supplementation of omega-3 (n-3) polyunsaturated fatty acids (PUFA) protects against postoperative atrial fibrillation (POAF) after coronary artery bypass surgery (CABG). However, the efficacy of this intervention remains controversial. We performed a meta-analysis to determine if PUFA supplementation prevents POAF. Methods: A systematic literature search was performed (through December 20, 2018) using PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials to identify RCTs evaluating PUFA supplementation for postCABG POAF prevention. The primary outcome was the incidence of POAF. For each study, the incidence of AF in the intervention and placebo groups was extracted to calculate odds ratio and 95% confidence intervals (CIs). Mantel-Haenszel random effects model was used to summarize data across treatment arms. Heterogeneity between the studies was assessed using the chi square test and was considered significant if p values < 0.10 or I2> 50%. Results: We identified 11 RCTs that included a total of 3,127 participants (1,557 in the PUFA group and 1,570 in the placebo group). Pooled analysis demonstrated a significant reduction in POAF in patients treated with PUFA as compared to placebo (OR 0.66; 95% CI, 0.48-0.90; p=0.008). The estimated number-needed-to-treat was 18 (95% CI 11.53-45.67). The test of heterogeneity was significant (I262%, p = 0.003). Conclusions: Preoperative supplementation of omega-3 (n-3) polyunsaturated fatty acids reduces the incidence of POAF in patients undergoing CABG surgery.
219 Phrenic Nerve Stimulation is Safe and Improves Sleep and QOL in Patients with Central Sleep Apnea and Atrial Fibrillation Regardless of Heart Failure Status Ralph Augostini1, Christoph Stellbrink2, Darius Jagielski3, Daniel Beyerbach4, Sanjaya Gupta5, Klaus Gutleben6, John Hayes7, Robin Germany8, Maria Rosa Costanzo9; 1The Ohio State University, Columbus, OH; 2Bielefeld Medical Center, Bielefeld, Germany; 34th Military Hospital, Wroclaw, Poland; 4The Christ Hospital, Cincinnati, OH; 5Saint Luke’s Mid-America Heart Institute, Kansas City, MO; 6Klinikum Herford, North Rhine-Westphalia, Germany; 7Marshfield Clinic, Marshfield, WI; 8 Respicardia Inc., Minnetonka, MN; 9Advocate Heart Institute, Naperville, IL Introduction: Central sleep apnea (CSA) is common in patients with atrial fibrillation (AF) with or without heart failure (HF). CSA is also a known trigger of new onset AF. Phrenic nerve stimulation (PNS) is an approved technology implanted by electrophysiologists shown to treat CSA effectively and safely. Hypothesis: Phrenic nerve stimulation is safe and effective in a cohort of patients with CSA and AF. Methods: Sleep metrics and quality of life (QOL) were analyzed for change from baseline to 6 months in patients with AF from the remede System Pivotal Trial. Related serious adverse events (SAE) through 12 months are also reported. Results: Baseline AF was reported in 42% (64/151) patients (32 Treatment [TX] and 32 Control [CL]). The mean age was 72, 88% were male, 78% had HF and 55% had an implanted cardiac device. Median ejection fraction was 38%. Baseline mean values for TX vs CL included: apnea hypopnea index (AHI) 46 vs 40 events/hr, central apnea index (CAI) 29 vs 21 events/hr, oxygen desaturation (ODI4) 39 vs 36 events/hr, arousal index (Arl) 50 vs 39 events/hr, Epworth Sleepiness Scale (ESS) 8 vs 9 and % of sleep in rapid eye movement (REM) 8 vs 12. Following 6 months of PNS therapy, 56% of patients in the TX group achieved 50% improvement in the AHI compared to 3% in CL (mean difference 53%, p<0.001). Changes in the other variables also favored the Treatment group. The following results are presented as the difference between the change from baseline for the TX group minus the change from baseline for the CL group: AHI (-26 events/hr, p<0.001), CAI (-31 events/hr, p<0.001), ODI4 (-21 events/hr, p<0.001), and Arl (-21 events/hr, p<0.001), ESS (2, p=0.053) and REM sleep (4, p=0.079). Marked or moderate improvement in the Patient Global Assessment (PGA) was reported by 54% in TX vs 11% in CL (difference of 43%, p<.001). Importantly, results were similar to the non-AF cohort. Improvements were observed in AF patients regardless of HF status. For example, AHI improved by a mean of 33 events/hr in the TX group without HF (80% [4/5] had 50% AHI reduction) and 20 events/hr in the TX group with HF (50% [10/20] had 50% AHI reduction). PGA was markedly or moderately improved in 60% and 52% of subjects in the TX group with and without HF, respectively. Related SAEs were reported by 8% of AF patients and 9% of nonAF patients and all events resolved without sequela. Conclusions: Phrenic nerve stimulation is safe and improves sleep and QOL in CSA patients with AF regardless of HF status. These findings underscore the need to evaluate changes in AF burden with PNS in future studies.
221 Incessant Ventricular Tachycardia Secondary to Giant-Cell Myocarditis Treated with Stellate Ganglion Blockade Andres Carmona-Rubio1, Andres F. Sanchez2, Hardik Bhansali1, David Lopez1, Craig Asher1, Pablo Bejarano1, Cedric Sheffield1, Juan Giraldo1, Jose Baez-Escudero1, Elsy V. Navas1; 1Cleveland Clinic, Weston, FL; 2St. Matthew’s University School of Medicine, Orlando, FL Background: Giant cell myocarditis (GCM) is a cardiac inflammatory disease that is characterized by the widespread infiltration of multinucleated giant cells interspersed in the myocardium, cardiomyocyte necrosis and eventually fibrosis. This disorder is rare, rapidly progressive and frequently fatal. Typically, it manifests with fulminant heart failure, atrioventricular blocks and/or ventricular tachyarrhythmias. Current therapies rely on the use of immunosuppression, ventricular assist devices and ultimately cardiac transplantation. Introduction: We describe the successful cessation of ventricular tachyarrhythmias in the setting of GCM with the use of a stellate ganglion blockade. Case: A 47-year-old female with a history of Hashimoto’s thyroiditis presented to an outside hospital with flu-like symptoms and dyspnea. Had a NT-proBNP of 6,080 pg/mL and TroponinT of 1.3 ng/mL. EKG demonstrated ST depressions in the anterolateral leads. Echocardiography showed severe LV dysfunction with global hypokinesis and an LVEF 25%. Telemetry revealed multiple runs of polymorphic sustained ventricular tachycardia (VT). Coronary angiography demonstrated normal coronary arteries. The patient was started on IV amiodarone, IV lidocaine, a continuous magnesium drip and transferred to our facility. A cardiac MRI showed extensive late gadolinium enhancement of the subendocardium at the inferobasal septum, mid wall and the epicardium along the mid septum. She continued to have incessant multifocal VT, despite being on three AAD’s. Thus, we intubated her and placed her under general anesthesia, but she continued to have VT. The decision was made to perform a left stellate ganglion blockade, which was immediately successful at suppressing the electrical storm. A right heart catheterization revealed a cardiac index of 1.4 L/min/m2 and a mean PCWP of 27 mmHg. The patient underwent IABP insertion followed by an endomyocardial biopsy of the RV. Biopsy was consistent with GCM and the patient was started on cyclosporine and high dose steroids while she was evaluated for cardiac transplantation. Two days later she received a heart and has been doing well post-operatively. Conclusion: To our knowledge this is the first case reported where incessant VT in GCM is treated with a stellate ganglion nerve blockade. This technique should be considered in GCM patients presenting with electrical storm refractory to AAD’s.
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220 Meta-Analysis of n-3 Polyunsaturated Fatty Acid Supplementation for the Prevention of Post-Operative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Surgery Rahul Gupta, Jason Jacobson, Howard A. Cooper, Gregg M. Lanier; Westchester Medical Center, Valhalla, NY Background: Several randomized clinical trials (RCTs) have evaluated whether pre-operative supplementation of omega-3 (n-3) polyunsaturated fatty acids (PUFA) protects against postoperative atrial fibrillation (POAF) after coronary artery bypass surgery (CABG). However, the efficacy of this intervention remains controversial. We performed a meta-analysis to determine if PUFA supplementation prevents POAF. Methods: A systematic literature search was performed (through December 20, 2018) using PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials to identify RCTs evaluating PUFA supplementation for postCABG POAF prevention. The primary outcome was the incidence of POAF. For each study, the incidence of AF in the intervention and placebo groups was extracted to calculate odds ratio and 95% confidence intervals (CIs). Mantel-Haenszel random effects model was used to summarize data across treatment arms. Heterogeneity between the studies was assessed using the chi square test and was considered significant if p values < 0.10 or I2> 50%. Results: We identified 11 RCTs that included a total of 3,127 participants (1,557 in the PUFA group and 1,570 in the placebo group). Pooled analysis demonstrated a significant reduction in POAF in patients treated with PUFA as compared to placebo (OR 0.66; 95% CI, 0.48-0.90; p=0.008). The estimated number-needed-to-treat was 18 (95% CI 11.53-45.67). The test of heterogeneity was significant (I262%, p = 0.003). Conclusions: Preoperative supplementation of omega-3 (n-3) polyunsaturated fatty acids reduces the incidence of POAF in patients undergoing CABG surgery.
219 Phrenic Nerve Stimulation is Safe and Improves Sleep and QOL in Patients with Central Sleep Apnea and Atrial Fibrillation Regardless of Heart Failure Status Ralph Augostini1, Christoph Stellbrink2, Darius Jagielski3, Daniel Beyerbach4, Sanjaya Gupta5, Klaus Gutleben6, John Hayes7, Robin Germany8, Maria Rosa Costanzo9; 1The Ohio State University, Columbus, OH; 2Bielefeld Medical Center, Bielefeld, Germany; 34th Military Hospital, Wroclaw, Poland; 4The Christ Hospital, Cincinnati, OH; 5Saint Luke’s Mid-America Heart Institute, Kansas City, MO; 6Klinikum Herford, North Rhine-Westphalia, Germany; 7Marshfield Clinic, Marshfield, WI; 8 Respicardia Inc., Minnetonka, MN; 9Advocate Heart Institute, Naperville, IL Introduction: Central sleep apnea (CSA) is common in patients with atrial fibrillation (AF) with or without heart failure (HF). CSA is also a known trigger of new onset AF. Phrenic nerve stimulation (PNS) is an approved technology implanted by electrophysiologists shown to treat CSA effectively and safely. Hypothesis: Phrenic nerve stimulation is safe and effective in a cohort of patients with CSA and AF. Methods: Sleep metrics and quality of life (QOL) were analyzed for change from baseline to 6 months in patients with AF from the remede System Pivotal Trial. Related serious adverse events (SAE) through 12 months are also reported. Results: Baseline AF was reported in 42% (64/151) patients (32 Treatment [TX] and 32 Control [CL]). The mean age was 72, 88% were male, 78% had HF and 55% had an implanted cardiac device. Median ejection fraction was 38%. Baseline mean values for TX vs CL included: apnea hypopnea index (AHI) 46 vs 40 events/hr, central apnea index (CAI) 29 vs 21 events/hr, oxygen desaturation (ODI4) 39 vs 36 events/hr, arousal index (Arl) 50 vs 39 events/hr, Epworth Sleepiness Scale (ESS) 8 vs 9 and % of sleep in rapid eye movement (REM) 8 vs 12. Following 6 months of PNS therapy, 56% of patients in the TX group achieved 50% improvement in the AHI compared to 3% in CL (mean difference 53%, p<0.001). Changes in the other variables also favored the Treatment group. The following results are presented as the difference between the change from baseline for the TX group minus the change from baseline for the CL group: AHI (-26 events/hr, p<0.001), CAI (-31 events/hr, p<0.001), ODI4 (-21 events/hr, p<0.001), and Arl (-21 events/hr, p<0.001), ESS (2, p=0.053) and REM sleep (4, p=0.079). Marked or moderate improvement in the Patient Global Assessment (PGA) was reported by 54% in TX vs 11% in CL (difference of 43%, p<.001). Importantly, results were similar to the non-AF cohort. Improvements were observed in AF patients regardless of HF status. For example, AHI improved by a mean of 33 events/hr in the TX group without HF (80% [4/5] had 50% AHI reduction) and 20 events/hr in the TX group with HF (50% [10/20] had 50% AHI reduction). PGA was markedly or moderately improved in 60% and 52% of subjects in the TX group with and without HF, respectively. Related SAEs were reported by 8% of AF patients and 9% of nonAF patients and all events resolved without sequela. Conclusions: Phrenic nerve stimulation is safe and improves sleep and QOL in CSA patients with AF regardless of HF status. These findings underscore the need to evaluate changes in AF burden with PNS in future studies.
221 Incessant Ventricular Tachycardia Secondary to Giant-Cell Myocarditis Treated with Stellate Ganglion Blockade Andres Carmona-Rubio1, Andres F. Sanchez2, Hardik Bhansali1, David Lopez1, Craig Asher1, Pablo Bejarano1, Cedric Sheffield1, Juan Giraldo1, Jose Baez-Escudero1, Elsy V. Navas1; 1Cleveland Clinic, Weston, FL; 2St. Matthew’s University School of Medicine, Orlando, FL Background: Giant cell myocarditis (GCM) is a cardiac inflammatory disease that is characterized by the widespread infiltration of multinucleated giant cells interspersed in the myocardium, cardiomyocyte necrosis and eventually fibrosis. This disorder is rare, rapidly progressive and frequently fatal. Typically, it manifests with fulminant heart failure, atrioventricular blocks and/or ventricular tachyarrhythmias. Current therapies rely on the use of immunosuppression, ventricular assist devices and ultimately cardiac transplantation. Introduction: We describe the successful cessation of ventricular tachyarrhythmias in the setting of GCM with the use of a stellate ganglion blockade. Case: A 47-year-old female with a history of Hashimoto’s thyroiditis presented to an outside hospital with flu-like symptoms and dyspnea. Had a NT-proBNP of 6,080 pg/mL and TroponinT of 1.3 ng/mL. EKG demonstrated ST depressions in the anterolateral leads. Echocardiography showed severe LV dysfunction with global hypokinesis and an LVEF 25%. Telemetry revealed multiple runs of polymorphic sustained ventricular tachycardia (VT). Coronary angiography demonstrated normal coronary arteries. The patient was started on IV amiodarone, IV lidocaine, a continuous magnesium drip and transferred to our facility. A cardiac MRI showed extensive late gadolinium enhancement of the subendocardium at the inferobasal septum, mid wall and the epicardium along the mid septum. She continued to have incessant multifocal VT, despite being on three AAD’s. Thus, we intubated her and placed her under general anesthesia, but she continued to have VT. The decision was made to perform a left stellate ganglion blockade, which was immediately successful at suppressing the electrical storm. A right heart catheterization revealed a cardiac index of 1.4 L/min/m2 and a mean PCWP of 27 mmHg. The patient underwent IABP insertion followed by an endomyocardial biopsy of the RV. Biopsy was consistent with GCM and the patient was started on cyclosporine and high dose steroids while she was evaluated for cardiac transplantation. Two days later she received a heart and has been doing well post-operatively. Conclusion: To our knowledge this is the first case reported where incessant VT in GCM is treated with a stellate ganglion nerve blockade. This technique should be considered in GCM patients presenting with electrical storm refractory to AAD’s.