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Optimizing Quadripolar Leads to Reduce Heart Failure Hospitalizations
S104 Journal of Cardiac Failure Vol. 21 No. 8S August 2015
Electrophysiology/Arrhythmias II Heart Rhythm Center, Phoenix, AZ; 10Scripps Health, San Diego, CA; Clinic, Rochester, MN; 12Boston Scientific, St. Paul, MN
240 Optimizing Quadripolar Leads to Reduce Heart Failure Hospitalizations Alvaro ManriqueGarcia, Vidya Thandra, Samer A. De Oliveira, Judith Mackall, Harish Manyam; University Hospitals Case Medical Center, Cleveland, OH Introduction: The position of the left ventricular lead (LV lead) serves as an important step in the implantation of cardiac resynchronization therapy devices. However coronary sinus anatomy in each patient can be variable. Placement of the LV lead in the apical position is known to increase heart failure readmissions. Quadripolar leads offer an increase in the number of vectors to choose alternative pacing configurations. Methods: We assessed 100 patients with St. Jude quadripolar leads to determine the position of left ventricular leads based on postoperative PA/Lateral X-ray (Figure 1). Positions were added from PA and Lateral films with summation scores from 2-6 (Figure 1). Paced activation times (PAT) and sensed activation times (SAT) from the site of pacing were analyzed to determine if recurrence could be predicted based on cathode position. Results: Patients who had heart failure readmissions (n513) had a mean summation score of 4 6 1.0. Patients who had no heart failure readmissions (n587) had a mean summation score of 3.14 6 0.99 (p50.03). Patients without heart failure readmissions had SAT of 103.1 6 33.5 and PAT of 153.3 6 56.0. Patient with heart failure readmissions had SAT of 43.5 6 25.6 and PAT of 185.5 6 29.1. Comparison of SAT in the heart failure group versus those without heart failure was statistically different p50.006. The PAT showed no difference. Conclusion: Optimizing lead position still appears to be beneficial. Patients who had cathode placed where the sensed activation time to the anode was longer had no heart failure hospitalizations. Programming heart failure patients with a cathode to anode sensed time that is the longest should become standard as this would result in a reduction of heart failure hospitalizations.
11
Mayo
Background: The Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT-AF) trial and subsequent Continued Access registry (CAP) compared left atrial appendage (LAA) closure with the Watchman device to continued warfarin anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Although the device was shown to have a high level of procedural safety across the entire trial population, safety of LAA closure in heart failure patients has not been assessed. Purpose: To evaluate the safety of LAA closure in patients with NVAF and reduced left ventricular ejection fraction (LVEF). Methods: Of the 1,669 enrolled patients with NVAF and CHADS2 scores $ 1, 15.0% had LVEF EF 30-45%, including 14.8% of the 1,293 who received the Watchman device (n5191). Baseline characteristics, procedural outcomes and safety information for patients were compared to those with LVEF O45%. Results: Patients with LVEF #45% were more often male (78.1% vs. 65.9%, p50.0008), with higher mean CHADS2 score (2.6. 2.361.3 vs. 2.361.1, p50.0002) and clinical history of heart failure (45.3% vs. 18.9%, p!0.05). LAA sizes and procedural time were similar for both groups. There was no difference in procedure-related safety events, device-related safety, or incidences of cardiac perforation, pericardial effusion, or tamponade between groups within seven days. Conclusion: In both the randomized controlled trial and registry, the safety of LAA closure in patients with reduced LVEF was comparable to that in patients with preserved left ventricular systolic function. Table 1. Frequency of Left Atrial Appendage Closure Safety Events within 7 Days in Relation to LVEF
Relative Risk (95% CI)
Measure
LVEFO45%
LVEF #45%
Pvalue
Procedurerelated safety events Device-related safety events Cardiac perforation Pericardial effusion Pericardial effusion w/tamponade
5.7% (62/1086)
3.2% (6/189)
1.80 [0.79, 4.10]
0.2171
3.3% (36/1086)
2.6% (5/189)
0.8235
0.6% (6/1086)
1.6% (3/189)
1.9% (21/1086)
0.5% (1/189)
1.9% (21/1086)
1.1% (2/189)
1.25 [0.50, 3.15] 0.35 [0.09, 1.38] 3.65 [0.49, 27.01] 1.83 [0.43, 7.73
0.1364 0.2329 0.5605
242 High Prevalence of Sub-clinical Cerebral Infarctions in Patients with Heart Failure with Preserved Ejection Fraction Rebecca J. Cogswell1, Faye L. Norby1, Rebecca F. Gottesman2, Lin Y. Chen1, Scott D. Solomon3, Amil M. Shah3, Alvaro Alonso1; 1University of Minnesota, Minneapolis, MN; 2Johns Hopkins, Baltimore, MD; 3Brigham and Woman’s Hospital, Boston, MA
Figure 1.
241 Safety of Left Atrial Appendage Closure in Patients with Low Ejection Fraction Sameer Gafoor1, Vivek Reddy2, Jonathan Halperin2, Shephal Doshi3, Maurice Buchbinder4, Petr Neuzil5, Kenneth Huber6, Brian Whisenant7, Saibal Kar8, Vijay Swarup9, Mathew J. Price10, David Holmes11, Nicole Gordon12, Horst Sievert1; 1 CardioVascular Center Frankfurt, Frankfurt, Germany; 2Mount Sinai Hospital, New York City, NY; 3Pacific Heart Institute, Santa Monica, CA; 4San Diego Cardiovascular Associates, San Diego, CA; 5Na Homolce Hospital, Prague, Czech Republic; 6St. Luke’s Health System, Kansas City, MO; 7Intermountain Health Care, Salt Lake City, UT; 8Cedars-Sinai Hospital, Los Angeles, CA; 9Arizona
Introduction: Subclinical cerebral infarctions (SCI) are frequently detectable by brain MRI by the time atrial fibrillation (AF) is diagnosed and are associated with cognitive decline. The prevalence of SCIs in patients with heart failure with preserved ejection fraction (HFpEF) without a prior AF diagnosis, which may suggest undiagnosed AF, is unknown. Hypothesis: Cohort subjects with a diagnosis of HFpEF and no prior AF will have a similar prevalence of SCI as those with documented AF (whether with or without CHF), which will be higher than cohort subjects without CHF or AF. Methods: This was a cross-sectional analysis of visit 5 data from the Atherosclerosis Risk in Communities (ARIC) Study. HFpEF at visit 5 was defined as a prior history of HF hospitalization or self-reported diagnosis of HF or HF medication use at visit 5 with a left ventricular ejection fraction $ 50% by visit 5 echocardiogram. The prevalence of SCI detected by brain MRI was compared among the following groups: no congestive heart failure (CHF)/no prior AF (n51273), no CHF/ AF (n553), HFpEF/no AF (n5167), HFpEF/AF (n534). Cognitive scores among these groups were also compared. Results: The study population included 1,527 ARIC subjects. Cohort subjects with HFpEF but no prior diagnosis of AF had a high prevalence of SCI by brain MRI (29.3%), which was similar to the no CHF/ AF (24.5%) and HFpEF/AF (23.5%) groups but higher than the no CHF/no AF subjects (17.3%). The odds of having SCI in subjects with HFpEF/no AF was higher than the no CHF/no AF group even after adjustment for potential confounders of this association (adjusted OR 1.60, 95 % CI 1.08 - 2.36). Individuals with HFpEF and SCI had lower cognitive scores than the reference and HFpEF/no SCI groups.
Electrophysiology/Arrhythmias II Heart Rhythm Center, Phoenix, AZ; 10Scripps Health, San Diego, CA; Clinic, Rochester, MN; 12Boston Scientific, St. Paul, MN
240 Optimizing Quadripolar Leads to Reduce Heart Failure Hospitalizations Alvaro ManriqueGarcia, Vidya Thandra, Samer A. De Oliveira, Judith Mackall, Harish Manyam; University Hospitals Case Medical Center, Cleveland, OH Introduction: The position of the left ventricular lead (LV lead) serves as an important step in the implantation of cardiac resynchronization therapy devices. However coronary sinus anatomy in each patient can be variable. Placement of the LV lead in the apical position is known to increase heart failure readmissions. Quadripolar leads offer an increase in the number of vectors to choose alternative pacing configurations. Methods: We assessed 100 patients with St. Jude quadripolar leads to determine the position of left ventricular leads based on postoperative PA/Lateral X-ray (Figure 1). Positions were added from PA and Lateral films with summation scores from 2-6 (Figure 1). Paced activation times (PAT) and sensed activation times (SAT) from the site of pacing were analyzed to determine if recurrence could be predicted based on cathode position. Results: Patients who had heart failure readmissions (n513) had a mean summation score of 4 6 1.0. Patients who had no heart failure readmissions (n587) had a mean summation score of 3.14 6 0.99 (p50.03). Patients without heart failure readmissions had SAT of 103.1 6 33.5 and PAT of 153.3 6 56.0. Patient with heart failure readmissions had SAT of 43.5 6 25.6 and PAT of 185.5 6 29.1. Comparison of SAT in the heart failure group versus those without heart failure was statistically different p50.006. The PAT showed no difference. Conclusion: Optimizing lead position still appears to be beneficial. Patients who had cathode placed where the sensed activation time to the anode was longer had no heart failure hospitalizations. Programming heart failure patients with a cathode to anode sensed time that is the longest should become standard as this would result in a reduction of heart failure hospitalizations.
11
Mayo
Background: The Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT-AF) trial and subsequent Continued Access registry (CAP) compared left atrial appendage (LAA) closure with the Watchman device to continued warfarin anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). Although the device was shown to have a high level of procedural safety across the entire trial population, safety of LAA closure in heart failure patients has not been assessed. Purpose: To evaluate the safety of LAA closure in patients with NVAF and reduced left ventricular ejection fraction (LVEF). Methods: Of the 1,669 enrolled patients with NVAF and CHADS2 scores $ 1, 15.0% had LVEF EF 30-45%, including 14.8% of the 1,293 who received the Watchman device (n5191). Baseline characteristics, procedural outcomes and safety information for patients were compared to those with LVEF O45%. Results: Patients with LVEF #45% were more often male (78.1% vs. 65.9%, p50.0008), with higher mean CHADS2 score (2.6. 2.361.3 vs. 2.361.1, p50.0002) and clinical history of heart failure (45.3% vs. 18.9%, p!0.05). LAA sizes and procedural time were similar for both groups. There was no difference in procedure-related safety events, device-related safety, or incidences of cardiac perforation, pericardial effusion, or tamponade between groups within seven days. Conclusion: In both the randomized controlled trial and registry, the safety of LAA closure in patients with reduced LVEF was comparable to that in patients with preserved left ventricular systolic function. Table 1. Frequency of Left Atrial Appendage Closure Safety Events within 7 Days in Relation to LVEF
Relative Risk (95% CI)
Measure
LVEFO45%
LVEF #45%
Pvalue
Procedurerelated safety events Device-related safety events Cardiac perforation Pericardial effusion Pericardial effusion w/tamponade
5.7% (62/1086)
3.2% (6/189)
1.80 [0.79, 4.10]
0.2171
3.3% (36/1086)
2.6% (5/189)
0.8235
0.6% (6/1086)
1.6% (3/189)
1.9% (21/1086)
0.5% (1/189)
1.9% (21/1086)
1.1% (2/189)
1.25 [0.50, 3.15] 0.35 [0.09, 1.38] 3.65 [0.49, 27.01] 1.83 [0.43, 7.73
0.1364 0.2329 0.5605
242 High Prevalence of Sub-clinical Cerebral Infarctions in Patients with Heart Failure with Preserved Ejection Fraction Rebecca J. Cogswell1, Faye L. Norby1, Rebecca F. Gottesman2, Lin Y. Chen1, Scott D. Solomon3, Amil M. Shah3, Alvaro Alonso1; 1University of Minnesota, Minneapolis, MN; 2Johns Hopkins, Baltimore, MD; 3Brigham and Woman’s Hospital, Boston, MA
Figure 1.
241 Safety of Left Atrial Appendage Closure in Patients with Low Ejection Fraction Sameer Gafoor1, Vivek Reddy2, Jonathan Halperin2, Shephal Doshi3, Maurice Buchbinder4, Petr Neuzil5, Kenneth Huber6, Brian Whisenant7, Saibal Kar8, Vijay Swarup9, Mathew J. Price10, David Holmes11, Nicole Gordon12, Horst Sievert1; 1 CardioVascular Center Frankfurt, Frankfurt, Germany; 2Mount Sinai Hospital, New York City, NY; 3Pacific Heart Institute, Santa Monica, CA; 4San Diego Cardiovascular Associates, San Diego, CA; 5Na Homolce Hospital, Prague, Czech Republic; 6St. Luke’s Health System, Kansas City, MO; 7Intermountain Health Care, Salt Lake City, UT; 8Cedars-Sinai Hospital, Los Angeles, CA; 9Arizona
Introduction: Subclinical cerebral infarctions (SCI) are frequently detectable by brain MRI by the time atrial fibrillation (AF) is diagnosed and are associated with cognitive decline. The prevalence of SCIs in patients with heart failure with preserved ejection fraction (HFpEF) without a prior AF diagnosis, which may suggest undiagnosed AF, is unknown. Hypothesis: Cohort subjects with a diagnosis of HFpEF and no prior AF will have a similar prevalence of SCI as those with documented AF (whether with or without CHF), which will be higher than cohort subjects without CHF or AF. Methods: This was a cross-sectional analysis of visit 5 data from the Atherosclerosis Risk in Communities (ARIC) Study. HFpEF at visit 5 was defined as a prior history of HF hospitalization or self-reported diagnosis of HF or HF medication use at visit 5 with a left ventricular ejection fraction $ 50% by visit 5 echocardiogram. The prevalence of SCI detected by brain MRI was compared among the following groups: no congestive heart failure (CHF)/no prior AF (n51273), no CHF/ AF (n553), HFpEF/no AF (n5167), HFpEF/AF (n534). Cognitive scores among these groups were also compared. Results: The study population included 1,527 ARIC subjects. Cohort subjects with HFpEF but no prior diagnosis of AF had a high prevalence of SCI by brain MRI (29.3%), which was similar to the no CHF/ AF (24.5%) and HFpEF/AF (23.5%) groups but higher than the no CHF/no AF subjects (17.3%). The odds of having SCI in subjects with HFpEF/no AF was higher than the no CHF/no AF group even after adjustment for potential confounders of this association (adjusted OR 1.60, 95 % CI 1.08 - 2.36). Individuals with HFpEF and SCI had lower cognitive scores than the reference and HFpEF/no SCI groups.