Resynchronisation therapy / Pacing 593 PACING

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P3210 | BEDSIDE. Cardiac contractility modulation: first experience in patients with advanced systolic heart failure and permanent atrial fibrillation. S. Roeger1 ...
Resynchronisation therapy / Pacing

P3210 | BEDSIDE Cardiac contractility modulation: first experience in patients with advanced systolic heart failure and permanent atrial fibrillation S. Roeger 1 , R. Pirzer 2 , B. Rudic 1 , V. Liebe 1 , F. Streitner 1 , R. Schimpf 1 , M. Borggrefe 1 , J. Kuschyk 1 . 1 Medical Faculty Mannheim of the University of Heidelberg, 1st Department of Medicine, Mannheim, Germany; 2 Bamberg Hospital, Medical Clinic I, Cardiology, Bamberg, Germany Purpose: Cardiac contractility modulation (CCM) is an electrical device therapy for advanced systolic heart failure (HF). Non-excitatory electrical signals applied during the absolute refractory period enhance the strength of left ventricular contraction without increasing myocardial oxygen consumption. Sinus rhythm (SR) is mandatory for effective CCM treatment because the CCM algorithm requires sequential sensing of atrial and ventricular signals in SR through an atrial electrode and two ventricular septal electrodes. In case of atrial fibrillation (AF) CCM therapy is inhibited, permanent AF is therefore a contraindication for CCM. AF is one of the most frequent comorbidities in advanced HF. The purpose of this study was to demonstrate the feasibility of CCM therapy through circumvention of the CCM sensing algorithm in three patients with permanent AF. Methods: Three of 81 patients who received a CCM system at our hospital between March 2004 and January 2012 developed permanent AF after a mean follow up of 36 months. Via upgrading of the ICD to a CRT-D system with a programmed low atrial sensitivity of 4 mV (provoked atrial undersening) compulsory atrial stimulation of the CRT-D was performed. The CCM system recognised the atrial stimuli as SR which led to consecutive CCM therapy. In case of permanent stimulation biventricular stimulation is superior to exclusive right ventricular stimulation. Therefore CCM stimuli where triggered on the biventricular stimulated QRS-complex. Results: Prior to implantation of CCM the three patients had a mean NYHA class of III, a mean left ventricular ejection fraction (LVEF) of 27% and a mean peak oxygen uptake (VO2 peak) of 13.6 ml/kg/min. After six months of CCM mean NYHA class increased to II, mean LVEF to 33% and VO2 peak to 15.1 ml/kg/min. AF caused inhibition of CCM which was followed by deterioration of clinical condition of all three patients. In all patients system upgrade to CRT-D was performed without complications. Atrial undersensing with consecutive atrial and biventricular stimulation was attained in each patient. CRT stimulation rates of >98% and CCM stimulation rates of 65 to 97% were achieved. Clinical condition of all patients improved significantly. Conclusions: CCM therapy is feasible in patients with AF through additional application of CRT with circumvention of the CCM sensing algorithm and can improve patient’s clinical condition. This experimental approach can be considered in individual cases. A CCM algorithm which is independent of an atrial electrode for sensing and triggering of CCM therapy is desirable and currently in development.

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effective and safe; it may to be explained by smaller percentage of female pts. Higher percentage of complications in both other groups can be explained by longer implant duration, higher percentage of female pts. and toxemia. Conclusions: There is no simple relation between TLE effectiveness/safety and main indication to the procedure.

P3214 | BEDSIDE Right heart large vegetations-clinical aspects and management A. Polewczyk 1 , A. Kutarski 2 , A. Tomaszewski 2 , M. Janion 3 . 1 Swietokrzyskie Cardiology Center II - Cardiology Department, Kielce, Poland; 2 Medical University of Lublin, Department of Cardiology, Lublin, Poland; 3 Swietokrzyskie Cardiology Center II - Cardiology Dept; The Jan Kochanowski University, Dept Sciences, Kielce, Poland Purpose: Right heart vegetations (RVH) are the serious signs of cardiac devicerelated infective endocarditis (CDRIE) and consists class 1 indication for transvenous leads extraction (TLE) procedures, but large size of RVH is often considered to cardiosurgery removal. Methods: Analysis of clinical data, safety and effectiveness of TLE in 41 (mean age 66,2±12,7 years, 17 women) patients with vegetations over 2 cm was performed. This group (12,8%) was separated from 320 CDRIE consecutive patients managed with TLE in single Reference Center in years 2007-2012. Results: The clinical symptoms were nonspecific: 35 (85%) patients complained of recurrent fever, 19 (46,3%) were repeatedly hospitalized from pulmonary infection with documented pulmonary embolism in 3 (7,3%) of them. The mean time from onset of signs was 9,3±17,7 months. The vegetations measurement was performed by transthoracic echocardiography (TTE) in 36 (87,8%) patients, in remaining 5 (12,2%) the pathological structures were visible only in transesophageal echo (TEE). The vegetations were localized in right atrium in 30 cases (73,2%), on tricuspid valve in 6 (14,6%), in the right ventricle - in 3 (7,3%) and in vena cava superior in 2 cases (4,9%). Considering risk of TLE and open heart surgery in all pts TLE was performed and systems were removed as a whole. In 9 of them nitinol basket catheter was used for pulmonary vascular bed protection. The mean time of TLE was 122,2±56,2 min. Complete procedural success was achieved in 37 patients (90,2%), clinical success in 39 (95,1%) patients. Major complications (severe pulmonary embolism) in 2 (4,9%) patients were observed. Control examination after TLE showed the vegetation presence in 19 (46,3%) patients The in-hospital survival was 97,6% - one patient died on the next day after TLE. Conclusions: The diagnostic process of CRIE patients with the large vegetations is difficult because of nonspecific symptoms and problem with visualization despite it major sizes. TLE in patients with vegetations over 2 cm is relatively safe and effective and the TLE procedure and may to be considered as a saver option for patients with risk factors for cardiac surgery. Option of pulmonary bed protection during TLE seems to be interesting and will need dedicated tool.

PACING P3213 | BEDSIDE Have the indications for transvenous lead extraction any influence to procedure related complicatins? A. Kutarski 1 , A. Zabek 2 , K. Boczar 2 , M. Czajkowski 3 , M. Polewczyk 4 . 1 Medical University of Lublin, Department of Cardiology, Lublin, Poland; 2 John Paul II Hospital, Department of Electrocardiology, Krakow, Poland; 3 Medical University of Lublin, Department of Cardiosurgery, Lublin, Poland; 4 Medical University of Warsaw, First Faculty of Medicine, Warsaw, Poland There is considerable controversy regarding different safety of transvenous lad extraction (TLE) in relation to procedure indications and non-infective are sometime recognized as more risky. Objective: Analysis of safety and feasibility of TLE in our material. Methods: We have extracted 2167 ingrown endocardial leads from 1283 patients within the last 7 years. We analyzed complications and technical problems related to percutaneous lead removal procedures referring these problems to three (different indications) groups. Results are shown in Table 1. Table 1 Patients/procedures

Local pocket Lead dependent Non-infective infection endocarditis indications

Number 330 Age of pts 68,7 (13,7) Sex-females % 89 (27,0%) Number of leads extracted (mean (SD)) 1,95 (0,76) Average implant duration – in months (mean (SD)) 72,3 (54,5) Number of procedures before extraction (mean (SD)) 2,19 (1,18) Full radiological success (%) 317 (96,1%) Technical problems during TLE (%) 46 (13,9%) Major complications (%) 1 (0,3%) Minor complications (%) 3 (0,9%) Procedure related death 0 (0,0%)

P

224 65,3 (14,8) 73 (32,6%) 2,21 (0,85)

729 – 62,2 (17,8)