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Incidence of Pacemaker Induced Cardiomyopathy in a Prospective Cohort
Abstracts
345 Impact of Appropriate and Inappropriate Implantable Cardioverter Defibrillator Activations on Mortality D. Nayyar 1,∗ , W. Chik 1 , S. Zaman 1 , W. Stafford 2 , J. Hayes 2 , R. Denman 3 , G. Young 4 , P. Sanders 4 , P. Kovoor 1 , G. Sivagangabalan 1 1 Westmead
Hospital, Sydney, Australia Andrew’s War Memorial Hospital, Brisbane, Australia 3 Prince Charles Hospital, Brisbane, Australia 4 Royal Adelaide Hospital, Adelaide, Australia 2 St
Introduction: The mortality risk after appropriate and inappropriate implantable cardioverter defibrillator (ICD) activations varies considerably between recent studies. The impact of multiple activations on mortality risk is also unclear. Methods: This study reviewed 586 patients with standard indications for ICD therapy prospectively recruited from 6 centres in Australia (2008-2010). Patients were divided into 3 groups - no activations (group 1), appropriate activations only (group 2) and at least one inappropriate activation (group 3). Risk stratification was performed using cox proportionalhazards regression modelling. The primary outcome was allcause mortality. Results: Mean follow up was 19.6±8.5 months. A total 1787 activations occurred in 154 patients, of which 1650 (92.3%) were appropriate and 137 (7.7%) were inappropriate. There were 432 patients (73.7%) in group 1, 128 patients (21.8%) in group 2 and 26 patients (4.4%) in group 3. There were 48 deaths (8.2%) in the study cohort. There was no significant difference in mortality rates between the groups (7.2% vs 11.7% vs 7.7%, p=0.26). Significant independent predictors of mortality included age (HR 1.036, 95% CI 1.005-1.067; p=0.022), left ventricular ejection fraction (HR 0.958, 95% CI 0.926-0.990; p=0.010), total number of activations (HR 1.016, 95%CI 1.006-1.026; p=0.003) and total number of appropriate activations (HR 1.016, 95%CI 1.006-1.027; p=0.002), but not total number of inappropriate activations (HR 0.758, 95%CI 0.361-1.591; p=0.464). Conclusion: Appropriate activations were associated with a higher mortality risk while inappropriate activations were not, suggesting that the underlying arrhythmia is responsible for adverse outcomes in these patients rather than the activation itself. http://dx.doi.org/10.1016/j.hlc.2016.06.346 346 Inappropriate ICD Shock Due to Twiddlers Syndrome and Atrial Flutter G. Wong ∗ , S. Stolcman, M. Cursaro, R. Roberts-Thomson, A. Nelson, K. Roberts-Thomson, G. Young Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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Twiddlers Syndrome is a complication whereby the pulse generator is manipulated leading to lead traction and dislodgement. Modern ICDs possess discriminating algorithms to detect artefact. Despite this, inappropriate ICD shocks continue to occur with adverse outcomes. A 64 year old lady with salient history of CTI ablation for atrial flutter and dilated cardiomyopathy presented to the emergency department with 2 conscious ICD shocks. This occurred 6 months following CRT-D insertion with Quadra Assura MPTM generator and DurataTM and QuartetTM leads (St. Jude Medical, Minnesota). Blood tests were unremarkable. ECG revealed sinus rhythm. Chest x-ray showed RV lead migration into right atrium. Device interrogation showed atrial sensing and atrial capture on the ICD lead. IEGMs showed paroxysmal atrial flutter being detected as VT. Prior to shock delivery, the SecureScanTM algorithm detected a discrepancy between near and far-field electrical activity (Figure). Unfortunately, the algorithm has a non-programmable 30-second timeout which resulted in an inappropriate ICD shock. This restored sinus rhythm. The patient underwent lead repositioning, counselling and remains well with good device parameters at 6 months. Improved arrhythmia discriminators may aid in preventing inappropriate shocks. However, despite SecureScanTM accurately detecting discrepant rhythms, the enabled timeout period did not prevent shocks in our patient. The facility to disable the timeout period in discriminating algorithms should be considered by the manufacturer as recommended in the latest Heart Rhythm Society guidelines.
http://dx.doi.org/10.1016/j.hlc.2016.06.347 347 Incidence of Pacemaker Induced Cardiomyopathy in a Prospective Cohort S. Ahmed ∗ , J. Ng, A. Ng, D. Harrop, J. Scott, G. Kaye Princess Alexandra Hospital, Brisbane, Australia Introduction: Chronic right ventricular apical (RVA) pacing may contribute to decreased left ventricular ejection fraction (LVEF). We investigated the incidence of PICM in a pacemaker patient cohort. Methods: Transthoracic echocardiogram (TTE) ≤12 months pre-device implant was compared to TTE at followup. PICM was defined as reduction in baseline LVEF from normal (≥55%) to follow-up of ≤45%, or an absolute reduction in LVEF ≥10% without another identified cause for a reduction in LVEF. Results: Of 130 patients, 12 with other causes of LVEF deterioration were identified. In the remaining 118, 67 males (mean age 77.8±10.5 years), 51 females (mean age 76.8±11.2 years), the incidence of PICM was 39% (n=46). The presenting rhythms for pacemaker implantation were atrioventricular block (in 64.4%), sinus node disease (18.6%) and tachy/brady syndrome (17%). Mean interval between
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TTEs was 3.5±1.4 years (range 1.5-6.4 years). Mean baseline LVEF was 57.4±10.2% (non-PICM group) and 69.8±7.9% (PICM group) (p<0.001) and follow-up LVEF was 58.8±8.2% and 51.7±10.2% respectively (p=0.005). PICM was significantly associated with increasing ventricular pacing burden (53.9±42.3% [non-PICM] and 70.7±36.6% [PICM group] p<0.05). Patients with PICM were more likely to be smokers (p<0.05) and have a higher BMI (p=0.05). There were no significant differences between pacing lead position, RVA (n=66) and non-RVA (n=52) (p=0.21) or the incidence of diabetes, hyperlipidemia or systemic hypertension. Conclusion: PICM occurred in 39% and was not associated with right ventricular pacing lead position. Patients with chronic RV pacing should undergo periodic assessment of left ventricular function to detect early onset of PICM. http://dx.doi.org/10.1016/j.hlc.2016.06.348 348 Infection Rates with Single Versus Multiple Antibiotic Doses for Cardiac Device Implantation. Are Day Case Implants Safe? I. Matthews ∗ , D. D’Souza, E. Kotschet Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia Introduction: Globally, the number of cardiac device implantations is rising [1–3], and the percentage of device related infections also seems to be rising [1,2]. Device related infections are one of the most severe complications of device implantation [4]. Evidence on reducing device related infections is limited and most guidelines are based on empirical data [1]. Antibiotic use including dose, route and length of antibiotic course widely varies and is generally based on local protocols [1]. Objective: Our objective was to compare patients who received single dose IV antibiotic at the time of cardiac device implantation to those who received multiple doses to see if there was a difference in device related infection. Methods: We surveryed 400 patients who underwent cardiac device implantation at Monash Medical Centre, Clayton, who were subsequently followed up in our pacemaker clinic for their one month check-up. At this time their wounds were assessed and they completed a questionnaire relating to their wound and infection. Results: Preliminary results after analysing 188 out of 400 patients showed a non-significant trend towards increased pocket infections and endocarditis in patients who only received single dose antibiotic therapy (p=0.058). There was no difference in rates of superficial infections (p=0.850) or total infections (p=0.219), although the numbers were small. Conclusions: Preliminary data from this study is concerning that single dose IV antibiotic without oral has a trend towards increased rates of deep device infection (pocket infection and endocarditis), further data is needed to look into this further.
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Reference [1] Korantzopoulos P, et al. Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues. Europace 2015 Oct 29, pii: euv260. [2] Atreya AR, et al. Complications arising from cardiac implantable electrophysiological devices: review of epidemiology, pathogenesis and prevention for the clinician. Arrhythm Electrophysiol Rev 2015 May;4(1):53–7. [3] Rahman R, et al. Infection and readmission rate of cardiac implantable electronic device insertions: An observational single center study. Europace 2015 Oct 29, pii: euv260. [4] Kennergren C. Management of Cardiovascular Implantable Electronic Devices Infections in High Risk Patients. Am J Infect Control 2015 Dec 15.
http://dx.doi.org/10.1016/j.hlc.2016.06.349 349 Initial Australian Experience with Sub-Cutaneous Implantable Cardiac Defibrillators (S-ICD) V. Mutha 1,2 , K. Rangasamy 1,∗ , S. Healy 1,2 , E. Kotschet 1,2 , D. Adam 1,2 , L. Bittinger 1,2 , J. Krafchek 1,2 , J. Alison 1,2 1 Monash
Heart, Monash Health, Clayton, Australia 2 University of Melbourne, Melbourne, Australia Aim: To report on initial Australian Experience with Subcutaneous ICDs (S-ICD) Background: Several trials have demonstrated mortality benefit for implantable cardiac defibrillators (ICDs). However; there is a significant incidence of trans venous lead related complications. Subcutaneous-ICD(S-ICD) have been now approved for use in Australia; these device consist of a tri-polar parasternal lead (12-French) connected to a pulse generator; thus potentially avoiding deleterious effects of trans-venous lead implantation. Methods: Data was prospectively collected for all S-ICDs implanted by Monash Heart doctors. Patients needing ICD without pacing indication were selected at the discretion of operators. All patients had post implant exercise stress tests (30 day) to evaluate ventricular sensing. Results & Discussion: 11 S-ICDs were implanted by Monash Heart doctors during December 2014 – March 2016 with average age of patients being 46 years. Indication was primary prevention (5/11) & secondary prevention (6/11). Primary vector was the most common sensing vector for majority of patients. One patient experienced inappropriate shock with primary vector (sensing related) and his sensing vector was changed to secondary vector. One device failure was seen; with the device not responding to interrogation at one month follow up. This patient got a replacement device and initial reports from manufacturer suggest piezoelectric crystal malfunction. Conclusion: S-ICD is a feasible option for patients requiring implantable cardiac defibrillators without indication for trans-venous pacing. http://dx.doi.org/10.1016/j.hlc.2016.06.350
345 Impact of Appropriate and Inappropriate Implantable Cardioverter Defibrillator Activations on Mortality D. Nayyar 1,∗ , W. Chik 1 , S. Zaman 1 , W. Stafford 2 , J. Hayes 2 , R. Denman 3 , G. Young 4 , P. Sanders 4 , P. Kovoor 1 , G. Sivagangabalan 1 1 Westmead
Hospital, Sydney, Australia Andrew’s War Memorial Hospital, Brisbane, Australia 3 Prince Charles Hospital, Brisbane, Australia 4 Royal Adelaide Hospital, Adelaide, Australia 2 St
Introduction: The mortality risk after appropriate and inappropriate implantable cardioverter defibrillator (ICD) activations varies considerably between recent studies. The impact of multiple activations on mortality risk is also unclear. Methods: This study reviewed 586 patients with standard indications for ICD therapy prospectively recruited from 6 centres in Australia (2008-2010). Patients were divided into 3 groups - no activations (group 1), appropriate activations only (group 2) and at least one inappropriate activation (group 3). Risk stratification was performed using cox proportionalhazards regression modelling. The primary outcome was allcause mortality. Results: Mean follow up was 19.6±8.5 months. A total 1787 activations occurred in 154 patients, of which 1650 (92.3%) were appropriate and 137 (7.7%) were inappropriate. There were 432 patients (73.7%) in group 1, 128 patients (21.8%) in group 2 and 26 patients (4.4%) in group 3. There were 48 deaths (8.2%) in the study cohort. There was no significant difference in mortality rates between the groups (7.2% vs 11.7% vs 7.7%, p=0.26). Significant independent predictors of mortality included age (HR 1.036, 95% CI 1.005-1.067; p=0.022), left ventricular ejection fraction (HR 0.958, 95% CI 0.926-0.990; p=0.010), total number of activations (HR 1.016, 95%CI 1.006-1.026; p=0.003) and total number of appropriate activations (HR 1.016, 95%CI 1.006-1.027; p=0.002), but not total number of inappropriate activations (HR 0.758, 95%CI 0.361-1.591; p=0.464). Conclusion: Appropriate activations were associated with a higher mortality risk while inappropriate activations were not, suggesting that the underlying arrhythmia is responsible for adverse outcomes in these patients rather than the activation itself. http://dx.doi.org/10.1016/j.hlc.2016.06.346 346 Inappropriate ICD Shock Due to Twiddlers Syndrome and Atrial Flutter G. Wong ∗ , S. Stolcman, M. Cursaro, R. Roberts-Thomson, A. Nelson, K. Roberts-Thomson, G. Young Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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Twiddlers Syndrome is a complication whereby the pulse generator is manipulated leading to lead traction and dislodgement. Modern ICDs possess discriminating algorithms to detect artefact. Despite this, inappropriate ICD shocks continue to occur with adverse outcomes. A 64 year old lady with salient history of CTI ablation for atrial flutter and dilated cardiomyopathy presented to the emergency department with 2 conscious ICD shocks. This occurred 6 months following CRT-D insertion with Quadra Assura MPTM generator and DurataTM and QuartetTM leads (St. Jude Medical, Minnesota). Blood tests were unremarkable. ECG revealed sinus rhythm. Chest x-ray showed RV lead migration into right atrium. Device interrogation showed atrial sensing and atrial capture on the ICD lead. IEGMs showed paroxysmal atrial flutter being detected as VT. Prior to shock delivery, the SecureScanTM algorithm detected a discrepancy between near and far-field electrical activity (Figure). Unfortunately, the algorithm has a non-programmable 30-second timeout which resulted in an inappropriate ICD shock. This restored sinus rhythm. The patient underwent lead repositioning, counselling and remains well with good device parameters at 6 months. Improved arrhythmia discriminators may aid in preventing inappropriate shocks. However, despite SecureScanTM accurately detecting discrepant rhythms, the enabled timeout period did not prevent shocks in our patient. The facility to disable the timeout period in discriminating algorithms should be considered by the manufacturer as recommended in the latest Heart Rhythm Society guidelines.
http://dx.doi.org/10.1016/j.hlc.2016.06.347 347 Incidence of Pacemaker Induced Cardiomyopathy in a Prospective Cohort S. Ahmed ∗ , J. Ng, A. Ng, D. Harrop, J. Scott, G. Kaye Princess Alexandra Hospital, Brisbane, Australia Introduction: Chronic right ventricular apical (RVA) pacing may contribute to decreased left ventricular ejection fraction (LVEF). We investigated the incidence of PICM in a pacemaker patient cohort. Methods: Transthoracic echocardiogram (TTE) ≤12 months pre-device implant was compared to TTE at followup. PICM was defined as reduction in baseline LVEF from normal (≥55%) to follow-up of ≤45%, or an absolute reduction in LVEF ≥10% without another identified cause for a reduction in LVEF. Results: Of 130 patients, 12 with other causes of LVEF deterioration were identified. In the remaining 118, 67 males (mean age 77.8±10.5 years), 51 females (mean age 76.8±11.2 years), the incidence of PICM was 39% (n=46). The presenting rhythms for pacemaker implantation were atrioventricular block (in 64.4%), sinus node disease (18.6%) and tachy/brady syndrome (17%). Mean interval between
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TTEs was 3.5±1.4 years (range 1.5-6.4 years). Mean baseline LVEF was 57.4±10.2% (non-PICM group) and 69.8±7.9% (PICM group) (p<0.001) and follow-up LVEF was 58.8±8.2% and 51.7±10.2% respectively (p=0.005). PICM was significantly associated with increasing ventricular pacing burden (53.9±42.3% [non-PICM] and 70.7±36.6% [PICM group] p<0.05). Patients with PICM were more likely to be smokers (p<0.05) and have a higher BMI (p=0.05). There were no significant differences between pacing lead position, RVA (n=66) and non-RVA (n=52) (p=0.21) or the incidence of diabetes, hyperlipidemia or systemic hypertension. Conclusion: PICM occurred in 39% and was not associated with right ventricular pacing lead position. Patients with chronic RV pacing should undergo periodic assessment of left ventricular function to detect early onset of PICM. http://dx.doi.org/10.1016/j.hlc.2016.06.348 348 Infection Rates with Single Versus Multiple Antibiotic Doses for Cardiac Device Implantation. Are Day Case Implants Safe? I. Matthews ∗ , D. D’Souza, E. Kotschet Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, Clayton, Australia Introduction: Globally, the number of cardiac device implantations is rising [1–3], and the percentage of device related infections also seems to be rising [1,2]. Device related infections are one of the most severe complications of device implantation [4]. Evidence on reducing device related infections is limited and most guidelines are based on empirical data [1]. Antibiotic use including dose, route and length of antibiotic course widely varies and is generally based on local protocols [1]. Objective: Our objective was to compare patients who received single dose IV antibiotic at the time of cardiac device implantation to those who received multiple doses to see if there was a difference in device related infection. Methods: We surveryed 400 patients who underwent cardiac device implantation at Monash Medical Centre, Clayton, who were subsequently followed up in our pacemaker clinic for their one month check-up. At this time their wounds were assessed and they completed a questionnaire relating to their wound and infection. Results: Preliminary results after analysing 188 out of 400 patients showed a non-significant trend towards increased pocket infections and endocarditis in patients who only received single dose antibiotic therapy (p=0.058). There was no difference in rates of superficial infections (p=0.850) or total infections (p=0.219), although the numbers were small. Conclusions: Preliminary data from this study is concerning that single dose IV antibiotic without oral has a trend towards increased rates of deep device infection (pocket infection and endocarditis), further data is needed to look into this further.
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Reference [1] Korantzopoulos P, et al. Infection control in implantation of cardiac implantable electronic devices: current evidence, controversial points, and unresolved issues. Europace 2015 Oct 29, pii: euv260. [2] Atreya AR, et al. Complications arising from cardiac implantable electrophysiological devices: review of epidemiology, pathogenesis and prevention for the clinician. Arrhythm Electrophysiol Rev 2015 May;4(1):53–7. [3] Rahman R, et al. Infection and readmission rate of cardiac implantable electronic device insertions: An observational single center study. Europace 2015 Oct 29, pii: euv260. [4] Kennergren C. Management of Cardiovascular Implantable Electronic Devices Infections in High Risk Patients. Am J Infect Control 2015 Dec 15.
http://dx.doi.org/10.1016/j.hlc.2016.06.349 349 Initial Australian Experience with Sub-Cutaneous Implantable Cardiac Defibrillators (S-ICD) V. Mutha 1,2 , K. Rangasamy 1,∗ , S. Healy 1,2 , E. Kotschet 1,2 , D. Adam 1,2 , L. Bittinger 1,2 , J. Krafchek 1,2 , J. Alison 1,2 1 Monash
Heart, Monash Health, Clayton, Australia 2 University of Melbourne, Melbourne, Australia Aim: To report on initial Australian Experience with Subcutaneous ICDs (S-ICD) Background: Several trials have demonstrated mortality benefit for implantable cardiac defibrillators (ICDs). However; there is a significant incidence of trans venous lead related complications. Subcutaneous-ICD(S-ICD) have been now approved for use in Australia; these device consist of a tri-polar parasternal lead (12-French) connected to a pulse generator; thus potentially avoiding deleterious effects of trans-venous lead implantation. Methods: Data was prospectively collected for all S-ICDs implanted by Monash Heart doctors. Patients needing ICD without pacing indication were selected at the discretion of operators. All patients had post implant exercise stress tests (30 day) to evaluate ventricular sensing. Results & Discussion: 11 S-ICDs were implanted by Monash Heart doctors during December 2014 – March 2016 with average age of patients being 46 years. Indication was primary prevention (5/11) & secondary prevention (6/11). Primary vector was the most common sensing vector for majority of patients. One patient experienced inappropriate shock with primary vector (sensing related) and his sensing vector was changed to secondary vector. One device failure was seen; with the device not responding to interrogation at one month follow up. This patient got a replacement device and initial reports from manufacturer suggest piezoelectric crystal malfunction. Conclusion: S-ICD is a feasible option for patients requiring implantable cardiac defibrillators without indication for trans-venous pacing. http://dx.doi.org/10.1016/j.hlc.2016.06.350