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Novelties in cardiac resynchronisation therapy NOVELTIES IN CARDIAC RESYNCHRONISATION THERAPY
4856 | BEDSIDE Transseptal endocardial left ventricular lead implantation after failed CRT implantation- long term results L.A. Geller, L. Molnar, S.Z. Szilagyi, E. Zima, G. Szeplaki, V.K. Nagy, E.E. Ozcan, A. Apor, Z. Sallo, B. Merkely on behalf of Bolyai Janos Hungarian Academic Research Fund (GL, SzG). Semmelweis University, Heart and Vascular Center, Budapest, Hungary Introduction: CRT implantation is a well estabilished therapy in chronic heart failure patients. Transvenous left ventricular (LV) lead positioning might be challenging or in some cases impossible. Objectives: The aim of this study was to investigate the effectiveness and safety of transseptal endocardial left ventricular lead implantation (TELVLI) in severe heart failure patients, and evaluate the long term follow-ups of the patients. Methods: TELVLI was performed in 35 patients (30 men, 64±6 years, NYHA III-IV stage). Transseptal (TS) puncture was performed via the femoral vein. Intracardiac ulrasound was used to guide the puncture in 25 pts. The site of the puncture was dilated with a 6mm (3 pts), later with an 8 mm balloon (32 pts). After the puncture of the left subclavian vein, an electrophysiological deflectable CS catheter was introduced into the CS sheath. The CS catheter was used to reach the left atrium and the left ventricle through the dilated transseptal puncture hole. At the latest LV activation site 65 cm active fixation bipolar lead was screwed into the LV wall, at the site of the latest activation. Results: The lead was fixed in the left ventricle in all cases with good pacing threshold (0,84±0,4 V;0,4 ms). Puncture complication, pericardial effusion was not observed. Because of intraoperatively started anticoagulation, pocket haematoma was observed in three (9%) and needed evacuation in one case (3%). Follow-up was longer than one month in 34 patients [38 (22–49) months]. Significant improvement of NYHA was observed in all but one case (97%), at the first month control LV EF was 30±9% vs 38±6%. Early lead dislocation was noticed in two cases (6%), reposition was performed using the original puncture site in one, and transvenous implantation was succesfully carried out in the other case. Explantation of the system was necessary because of pocket infection in four cases (11%), in two of these cases TELVLI was carried out succesfully 3 months later, in one patient 22 months later. All patients were maintained on anticoagulation therapy with INR between 2–3. No thromboembolic complication was noticed during the follow up. 13 patients were lost, one of them died five years after the implantation in renal failure, the other patient died in malignant tumor 4 years after the implantation, 11 patients died due to the progression of the heart failure in average 16 months after the implantation. Conclusion: TELVLI approach might be a very promising alternative technique of the surgical epicardial procedure when transvenous implantation could not be applied.
and randomized (19 CRT, 7 Control). Of these patients, 10 (7 CRT, 3 Control) completed the 6-month visit with paired echocardiographic data. The median LVEF at baseline was 45% in CRT and 46% in Control. No significant increases in LVEF over time were observed. The CRT patients, however, showed reductions in median LVESV (28% decrease) and LVESVi (25% decrease). (Figure) In contrast, the Control patients showed no changes in LVESV (4% increase) or LVESVi (8% decrease). Similar data are seen with average values. The change in LVESV over time was significantly different between groups (p=0.05) but the change in LVESVi was not (p=0.11). Conclusions: In a small sample of patients with HF symptoms, LBBB and LVEF between 36 and 50%, CRT-P appeared to reduce LV volumes compared with control. The hypothesis that CRT can benefit selected HF patients with LVEF >35% should be tested.
4858 | BEDSIDE Cardiac resynchronization therapy in the elderly - is there an indication for a defibrillator? M. Doering, J. Lucas, K. Bode, A. Muessigbrodt, T. Heine, H. Knopp, G. Hindricks, S. Richter. Heart Centre, Department of Electrophysiology, Leipzig, Germany Introduction: Cardiac resynchronization therapy (CRT) is an effective treatment option for heart failure in elderly patients, but the additional benefit of an implantable defibrillator (ICD) in these patients is not evidenced. Purpose: To evaluate the impact of an ICD on all-cause mortality in elderly patients undergoing a CRT device implantation. Methods: Patients at the age of ≥75 years who underwent implantation of either a CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) were identified out of hospital records. Only patients with a Class I or IIa indication for CRT and the primary prophylactic implantation of an ICD due to a severe impairment of the left ventricular ejection fraction (LV-EF) were included in the analysis. Patient characteristics, procedural data and all-cause mortality were compared between the two groups. Results: Between January 2008 and August 2014 two-hundred forty-five seniors were implanted with a CRT device in our centre, whereof 80 patients with CRT-P and 97 patients with CRT-D represent the two study groups. Patients in the CRTP group were more often females (44 vs. 25%; p35% and 130 ms, and left bundle branch morphology. Patients were randomized 2:1 to treatment with CRT-P vs. Control (implanted, LV lead turned OFF). In addition to clinical assessments, echocardiograms were obtained at baseline and at 6 months. Results: Twenty-six patients were successfully implanted with a CRT pacemaker
Kaplan-Meier survival probability
Conclusion: An additional ICD has no impact on survival in elderly patients implanted with a CRT device.
4859 | BEDSIDE Relationship between indices of left ventricular lead electrical position in spontaneous rhythm and right ventricular pacing: implications for optimization of cardiac resynchronization therapy D. Wichterle, K. Sedlacek, H. Jansova, L. Kryze, V. Vancura, R. Cihak, J. Kautzner. Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Cardiac volumes
Purpose: Left ventricular (LV) electrical delay measured from the beginning of the QRS complex to the local LV lead electrogram (EGM), normalized by QRS duration (Q-LV ratio), was found to be a strong and independent predictor of shortterm response to cardiac resynchronization therapy (CRT), heart failure events and mortality. We investigated relationship between Q-LV ratio and similar index obtained during right ventricular pacing (RVP-LV ratio).
Novelties in cardiac resynchronisation therapy Methods: We prospectively collected ECGs and EGMs in 133 consecutive patients (aged 66±10 years; 72% males; 56% nonischemic cardiomyopathy; LVEF 26±5%, 81% true-LBBB) with native non-RBBB QRS morphology undergoing CRT implant. Recordings of spontaneous rhythm and RV midseptum paced rhythm were edited, signal-averaged and measured by electronic calipers. Results: The LV lead position was characterized by the Q-LV ratio of 0.73±0.11 and RVP-LV ratio of 0.77±0.11. Native QRS width (180±21 ms) was shortened by 14±28 ms during biventricular pacing. There was significant but weak correlation between Q-LV and RVP-LV ratios (r2 =0.23, p0.70, defining adequate electrical LV lead positioning, 67% of patients with suboptimal Q-LV ratio had optimal RVP-LV ratio and 13% of patients with optimal Q-LV ratio had suboptimal RVP-LV ratio.
Q-LV versus RVP-LV ratios correlation
Conclusions: While observational studies found association between Q-LV ratio and CRT outcome, this measure may not be optimal for LV lead positioning because intrinsic atrioventricular conduction is not maintained during biventricular pacing. Therefore, RVP-LV ratio may better reflect the interlead electrical distance and deserves further evaluation.
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Medical University of Silesia, SCHD, Department of Cardiology, Congenital Heart Disease & Electrotherapy, Zabrze, Poland Purpose: The aim of the study was to assess the prognostic impact of heart rhythm (sinus rhythm – SR/ atrial fibrillation – AF) with and without low biventricular pacing percentage (CRT%) in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT). Methods: A single centre cohort of 304 consecutive patients implanted with CRTD and subsequently monitored via remote monitoring was divided into four groups depending on rhythm type (SR – sinus rhythm vs AF – atrial fibrillation) and the mean CRT%: – Group 1 – SR and CRT%≥95% (n=132; 43.4%) – Group 2 – SR and CRT%A promoter polymorphism. 1164 consecutive patients who were admitted for assessment of coronary artery disease were tested by allele specific
Haemodynamics in hypertension
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multiplex PCR. Individuals carrying the VKORC1(−1639) A variant showed significantly elevated invasively measured systolic, diastolic and mean arterial blood pressures compared with carriers of the G allele. The (3730) SNP showed only a borderline significance for the diastolic blood pressure. No association with vascular calcification could be observed. Conclusions: The VKORC1 (−1639) A allele is associated with elevated systemic arterial blood pressure. This suggests a novel concept of blood pressure regulation through pathways involving vitamin K epoxide reductase and calcium binding proteins.
4867 | BEDSIDE Lack of regression of left ventricular hypertrophy is accompanied by increased incidence of stroke and combined cardiovascular disease in essential hypertensives D. Tsiachris, C. Tsioufis, V. Antonakis, K. Dimitriadis, D. Flessas, F. Lagiou, S. Galanakos, A. Milkas, D. Roussos, D. Tousoulis. First Cardiology Clinic, University of Athens,Hippokration Hospital, Athens, Greece Purpose: Blood pressure (BP) reduction produces regression of left ventricular hypertrophy (LVH) which is considered to be associated with improved prognosis. We sought to investigate the prognostic role of left ventricular hypertrophy (LVH) regression regarding incidence of cardiovascular disease in essential hypertension. Methods: We prospectively followed up for a median period of 3.8 years 1226 essential hypertensives (mean age 57.8 years, baseline office BP = 143.6/ 89.3mmHg). All subjects visited periodically the outpatient hypertensive unit of our institution and office BP at follow up was calculated based on the measurements of the last 3 visits. Echocardiographic evaluation and determination of the metabolic profile and creatinine levels was performed at entry and at follow up. LVH was defined as LV mass index ≥116g/m2 in men and LV mass index ≥96g/m2 in women. Endpoint of interest was the incidence of stroke, coronary artery disease and their composite. Results: At the end of follow up the incidence of the composite end-point was 4.0% (17 patients with stroke, 34 with CAD, 2 with both). According to the presence of LVH at baseline (20.2%) and at the end of follow-up (15.9%) patients were divided in two groups: with normal LV mass index at both examinations or with LVH at baseline and regression of hypertrophy (n=1031, 84.1%, group 1) and with LVH at baseline and at follow-up and with normal LV mass index at baseline and LVH at follow-up (n=195, group 2). Hypertensives of group 2 compared to those of group 1 were older (by 6.3 years, p
