Feb 8, 2018 - multivariable Cox regression models, adjusted for demographic, clinical, and ... Charles Butcher1, Nichola Margerison1, Claudia Josa2, Lucy ...
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136-47 FRAGMENTED QRS AND MORTALITY RISK IN PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION
136-48 UNFAVOURABLE OUTCOME AFTER THE UPGRADE OF AN IMPLANTABLE CARDIOVERTER DEFIBRILLATOR TO CARDIAC RESYNCHRONIZATION THERAPY
Mariem Jabeur1, Malek Akrout1, Salma Charfeddine2, Leila Abid1, Souad Mallek1, Faten Triki1, Maalej Abdelkadr1, Rania Hammemi1, Dorra Abid1, and Samir Kammoun1
Alexandra Kiss, Gabor Sandorfi, Istvan Edes, Zoltan Csanadi, and Marcell Clemens
1
Debrecen, Hungary
Background: Fragmented QRS (fQRS) has been shown to predict cardiac events in select patient populations. Whether fQRS improves patient selection for primary prevention patients eligible for implantable cardioverter-defibrillator (ICD) therapy remains unknown. Methods: It was a prospective study including 142 patients with left ventricular dysfunction (ejection fraction , or ¼35%) representing both ischemic and nonischemic etiology. the presence of fQRS on ECG was assessed using standardized criteria. The association between fQRS and all-cause and arrhythmic mortality was evaluated overall and stratified by ICD status using multivariable Cox regression models, adjusted for demographic, clinical, and treatment variables. Results: Fragmented QRS was present in 46 (32.4%) patients, and there were 32 (22.5%) deaths during a mean follow-up of 10 þ /-7 months. Rates of all-cause mortality did not differ between the fQRSþ (18.4%) and fQRS- (23%) groups; adjusted hazard ratio, 0.88; 95% confidence interval, 0.63-1.22; P ¼ 0.43. Additionally, rates of arrhythmic mortality were similar between the fQRSþ (8.7%) and fQRS- (10.7%) groups: adjusted hazard ratio, 0.77; 95% confidence interval, 0.49-1.31; P ¼ 0.38. Subgroup analyses found no association between fQRS and mortality when the study was further stratified by ICD status, etiology of left ventricular dysfunction, wide (./ ¼ 120 ms) versus narrow (,120 ms) QRS duration, or fQRS myocardial territory. Conclusions: In this prospective study of patients with left ventricular dysfunction, the presence of fQRS on ECG was not associated with a higher risk of either all-cause or arrhythmic mortality. These findings do not provide evidence that fQRS would be effective in risk stratifying primary prevention patients eligible for ICD therapy. Conflict of interest: none
Background: Cardiac resynchronization therapy (CRT) improves survival in selected patients with heart failure (HF). As the potential survival benefit of CRT performed as an upgrade from a previously implanted cardioverter defibrillator (ICD) has not been explored, we evaluated total mortality after CRT upgrade in this context. Methods and results: A total of 31 patients (27 male, mean age:63.7 + 9.6years) with structural heart disease underwent CRT device implantation as an upgrade of a previously implanted single or dual chamber ICD between 2004 and 2015 at our Institute. The indication for ICD implantation was prophylactic based on the MADIT II or SCD-HeFT criteria (in 13 patients) or secondary prevention after a sustained ventricular arrhythmia (in 18 patients). Mean left ventricular ejection fraction (LVEF) was 29.9 + 7.8% and mean NYHA status was 2.4 + 0.8 at the time of ICD implantation. No indication for CRT was present in any of these patients at the time of ICD implantation. CRT upgrade was performed after a mean follow-up of 3.9 + 2.9 years based on the following indications: widening of the QRS complex (from 108 + 20 to 158 + 24 msec.) in 24, decreasing LVEF (from 41.5 + 2.1 to 26.5 + 2.1%) in the presence of LBBB in 2, and an increase in the need for right ventricular stimulation (burden .40%) in 5 patients. A significant reduction in the QRS width after CRT upgrade (from 160.3 + 26 to 130.3 + 23 msec., p , 0.001), an improvement in NYHA class (from 3.1 + 0.8 to 2.5 + 1.0, p ¼ 0.16) and an increase in the mean LVEF (from 27.6 to 33.3%, p ¼ 0.049) was observed including 4 patients (13%) who demonstrated an increase in LVEF above 10 % at the 1-year follow-up. 17/31 patients (55%) died during a mean follow-up of 19.0 + 16.6 months after CRT upgrade. No statistically significant prognostic factor of survival was found among the patients’ baseline data by using the Cox proportional hazard model. Conclusion: Despite a marked reduction in QRS width and a modest improvement in LV EF, mortality remains high after CRT upgrade in this patient cohort. This would argue for an earlier administration of alternative treatment modalities (assist device, heart transplantation) in HF patients who demonstrate QRS widening, a significant decrease in the LV EF or a need for ventricular stimulation.
Sfax, Tunisia; and 2sf, Tunisia
Conflict of interest: none
136-49 A SINGLE CENTER EXPERIENCE WITH CARDIAC RESYNCHRONISATION THERAPY, HOW HELPFUL IS THE ADDITION OF A DEFIBRILLATOR?
136-50 WHO REACH ICD AMONG PATIENTS AFTER IN-HOSPITAL CARDIAC ARREST? THE HIGHER ADOPTION RATE OF ICD FOR PATIENTS AFTER IN-HOSPITAL CARDIAC ARREST IN RECENT YEARS
Charles Butcher1, Nichola Margerison1, Claudia Josa2, Lucy Edmonson1, Tom Wong1, Rebecca Lane1, Jaymin S Shah1, and Mark Mason1 London, United Kingdom; and 2Zaragoza, Spain, Spain
Maki Ono1, Hara Satoshi1, Kuroda Shunsuke2, and Makoto Suzuki2
1
1
Purpose: Cardiac Resynchronisation Therapy (CRT) improves morbidity and mortality in patients with severe heart failure. Routine practice has been to implant a device with defibrillation (CRTD) capability to reduce the risk of sudden cardiac death, however, there is limited data to support this practice. We sought to identify predictors of mortality in patients implanted with a CRT device and investigate if the addition of a defibrillator was associated with a survival advantage compared to those without (CRTP). Methods: We retrospectively analysed consecutive patients implanted with de-novo CRTP or CRTD in our institution between January 2009 and December 2013. Summary: 463 patients (CRTD 320), mean implant age 66.9 (SD 13.6) and mean follow up time of 3.5 (SD 1.6) years. Patients implanted with CRT-P were older (mean difference ¼ 8.5 yrs, 95% CI ¼ 6.2, 10.9, p ,0.001), more symptomatic (NYHA .2, risk ratio ¼ 1.2, 95% CI ¼ 1.1, 1.4, p ¼ 0.003) and less likely to have an ejection fraction of , 35% (risk ratio ¼ 0.7, 95% CI ¼ 0.5, 0.8, p , 0.001) (Table 1). There were no differences in the prevalence of ischaemic aetiology or QRS duration of . 120 ms ( p . 0.05 respectively) in patients implanted. Using a cox regression analysis, univariate predictors of mortality were age at implant (HR ¼ 1.03, 95% CI ¼ 1.00, 1.04, p ¼ 0.004) and ischaemic aetiology (HR ¼ 1.9, 95% CI ¼ 1.3, 2.8, p ¼ 0.002). In a stepwise cox regression analysis the only predictor of mortality was age at implant (HR ¼ 1.04, 95% CI ¼ 1.02, 1.06, p ¼ 0.001) independent of ischaemic aetiology, ejection fraction of ,35%, NYHA class . 2, primary/secondary prevention indication and type of device implanted. Conclusion: The addition of a defibrillator to CRT does not appear to confer a mortality benefit in our cohort despite being younger, having less symptoms, regardless of ischaemic aetiology and regardless of primary/secondary prevention indication for device implantation. This observation deserves further investigation. Table 1:Population demographics n (%)
CRTP (n 143)
CRTD (n 320)
P Value
Male Ischaemic Aetiology EF , 35% NYHA . II QRS . 150 Secondary Prevention
106 (74.1) 68 (47.6) 84 (61.3) 99 (71.2) 73 (53.3) 0 (0)
255 (79.7) 178 (56.0) 246 (82.8) 169 (56.5) 139 (48.6) 70 (22.0)
0.2 0.1 ,0.001 0.003 0.4 ,0.001
Kamogawa Chiba, Japan; and 2Kamogawa, Japan
Introduction: Although the effectiveness of ICD after in-hospital cardiac arrest has shown by Paul S. Chan, the adoption rate of ICD was low (28.6%) and recent usage of ICD and survival after the guideline change to Adult Cardiovascular Life Support 2010 have not been known. Method: We retrospectively reviewed all the in-hospital cardiac arrest between 2011 and 2015 at Kameda Medical Center, a tertiary hospital in Japan, with organized resuscitation teams. Results: Of all 234 cases, the initial rhythm at resuscitation showed PEA/asystole in 182 cases and VT/Vf in 54. Among 76 cases with VT/Vf anytime during the resuscitation, 21 cases (15 patients) survived to discharge, and 55 cases (49 patients) died. By univariate analysis younger age ( 68.9 + 8.4, 73.9 + 11.6, p ¼ 0.008) and initial rhythm of VT/Vf (95% vs 61%p ¼ 0.003) related to the survival to discharge, but the resuscitation team involvement, location of the arrest, or time of day did not show the difference. Of 21 cases (15 patients) discharged, 13 cases (9 patients) were eligible for ICD and 8 cases (6 patients) were not because of treatable conditions (5 patients) and carcinoma (1 patient). Of 9 candidates, 8 cases (7 patients) had ICD during the same hospitalization (77.7%) and 5 cases (2 patients) refused the treatment. Two patients had ventricular arrhythmia after ICD which demonstrated the effectiveness of ICD. Because of limited number of patients Kaplan-Meier about all-cause mortality could not show the significance but the result may change with accumulation of cases. Conclusions: Although the candidate of ICD is small (5.5%) among arrest patients, the adoption rate of ICD for the survivor of in-hospital cardiac arrest has been increasing recently (77.7%). Conflict of interest: none
Conflict of interest: none
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