Implantable Cardioverter Defibrillator
ate therapy and to assess the effect of slow-rate appropriate therapy (VT-zone
170-199 bpm) on high-rate appropriate VT/VF therapy (>200bpm).
Results: During a mean follow-up of 1.4±0.6 years, 186 out of 1500 (12.4%)
patients received appropriate therapy. Slow-rate appropriate therapy was the
strongest predictor of subsequent high-rate appropriate therapy, although we only
identified 7 patients who in the same episode had a slow VT that was accelerated
by ATP. Conventional ICD programming (arm A) was identified as an independent
predictor of high-rate appropriate therapy when compared with arm C, but not
when compared to arm B (Table). Other significant predictors of high-rate appropriate therapy are listed in the Table.
Conclusion: Slow-rate appropriate therapy was associated with significantly increased risk of high-rate appropriate therapy.
P1377 | BEDSIDE
Application of a mortality risk score in a general population of
patients with an Implantable Cardioverter Defibrillator (ICD)
B.A. Schaer, D. Blatter, M.S. Kuhne, S. Osswald, C. Sticherling. University
Hospital Basel, Department of Cardiology, Basel, Switzerland
Patient Registry, all hospital admissions due to MI were identified. Adjusted hazard ratios (aHR) with 95% confidence intervals (CI) were estimated using Cox
proportional hazards regression. Healthcare costs were estimated based on the
financial reimbursement received by the hospitals.
Results: The study population consisted of 4,644 consecutive patients; men:
n=3,788 (82%), median age: 63 years (25th -75th percentiles: 54-70); primary
prevention with a prior history of ischemic heart disease (IHD): n=664 (14%);
secondary prevention without prior history of IHD: n=1,108 (24%); secondary
prevention with a prior history of IHD: n=2,872 (62%); prior history of diabetes:
n=567 (12%); ICD: n=3,905 (84%); cardiac resynchronisation therapy device with
defibrillator: n=739 (16%). Median follow up time was 5.0 years (25th -75th percentiles: 3.4-7.3). A total of 349 patients (7.5%) experienced at least one hospital
admission due to MI during follow-up, encompassing a total of 10,283 hospital
admissions lasting 40,073 days (median 15 days per hospital admission). The
median time from ICD implantation to first hospital admission due to MI was 2.8
years (25th -75th percentiles: 1.2-4.9). These 349 patients underwent a total of
1,516 coronary angiograms, 667 percutaneous coronary interventions, and 28
coronary artery bypass grafting operations. The risk of hospital admission due to
MI was higher if the patient was older (above 80 years: aHR 2.0; 95% CI 1.1-3.5),
or had a prior history of diabetes (aHR 1.5; 95% CI 1.1-2.0). The risk was lower
if the indication for implantation was secondary prevention and no prior history
of IHD (aHR 0.3; 95% CI 0.2-0.4). We found no association between the type
of device implanted and the risk of later hospital admission due to MI. The total
healthcare cost related to hospital admission due to MI was US$ 1,672,000 with
a mean cost per hospital admission of US$ 4,600.
Conclusions: We report risk, predictors and healthcare costs of hospital admissions due to MI after ICD implantations in the Danish population.
P1379 | BEDSIDE
Usefulness of cardiovascular magnetic resonance to predict life
threatening ventricular tachyarrhythmias in patients with
idiopathic dilated cardiomyopathy
M. Chimura, K. Okajima, S. Yamada, Y. Taniguchi, Y. Yasaka. Himeji
Cardiovascular Center, Himeji, Japan
Background: Current ESC guideline recommends implantable cardioverterdefibrillator (ICD) insertion for primary prevention of sudden cardiac death (SCD)
in a subgroup of patients with idiopathic dilated cardiomyopathy (DCM) who have
a left ventricular ejection fraction (LVEF) less than or equal to 30% to 35%, and
are NYHA functional class II or III. However, the majority of patients with ICD implantation for primary prevention never receive appropriate delivery for ventricular
tachycardia (VT) or ventricular fibrillation (VF).
Purpose: The purpose of this study was to evaluate the association between
myocardial fibrosis detected by cardiovascular magnetic resonance (CMR) and
life threatening ventricular arrhythmic events in patients DCM.
Methods: One-hundred and thirty-two DCM patients with LVEF ≤35% and NYHA
functional class II or III, (59.4±15 years, 86 males, LVEF 27.9±5.5%) were studied. Myocardial fibrosis was identified with late gadolinium enhancement (LGE) on
CMR. Clinical events were defined as SCD or sustained ventricular tachyarrhythmias and were followed up for 1665±877 days.
Results: Myocardial fibrosis was detected in 99 patients (75%: LGE(+) group).
Age, sex, LVEF were not different between LGE(+) and LGE(-) group. In addition,
the proportion of patients on treatment with beta blockers and ACE inhibitors were
comparable. However, clinical events occurred in no patient of LGE(-) group compared with 17 patients (17%) of LGE(+) group (P<0.01). Seventeen VT events
and 4 VF events in 17 patients including 15 patients with primary ICD implantations occurred in LGE(+) group.
Conclusion: In a general ICD population, the presented risk score shows a significant and clinically relevant correlation between risk score and mortality, both
overall and in the subgroup of ischemic heart disease.
P1378 | BEDSIDE
Myocardial infarction in Danish ICD patients: risk, predictors and
healthcare costs
R. Kirkfeldt 1 , H. Nielsen 2 , S.P. Johnsen 2 , J.C. Gerdes 1 , J.C. Nielsen 1 . 1 Aarhus
University Hospital, Skejby, Department of Cardiology, Aarhus, Denmark;
2 Aarhus University Hospital, Skejby, Department of Clinical Epidemiology,
Aarhus, Denmark
Purpose: To determine the risk of myocardial infarction (MI) in all Danish patients
receiving their first implantable cardioverter defibrillator (ICD). Furthermore, to
identify predictors of MI after ICD implantation, and to estimate healthcare costs
associated with hospital admission due to MI.
Methods: A nationwide cohort study was performed using Danish medical registries. We identified all Danish patients receiving their first ICD from 1997 to 2008
in the Danish Pacemaker and ICD Register. By linkage with the Danish National
Figure 1
Conclusions: Negative LGE on CMR predicts preventing life threatening ventricular arrhythmia in the near future. CMR may be a useful tool to guide the patient
selection for primary ICD implantation in DCM patients.
P1380 | BEDSIDE
Implantable cardioverter-defibrillator shocks in patients with
ventricular assist devices
A. Gkouziouta, A. Katsianis, A. Kostopoulou, P.H. Cokkinos, G. Karavolias,
T.H. Maounis, E. Livanis, G. Theodorakis, P. Sfirakis, S. Adamopoulos. Onassis
Cardiac Surgery Center, Athens, Greece
Purpose: Ventricular assist device (VAD) use is becoming increasingly common
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Background: Efficacy of Implantable Cardioverter Defibrillators (ICD) has been
shown in randomised trials. Death is a competing risk. A risk score was developed from the MADIT-II trial to predict mortality. However, only pts with ischemic
cardiomyopathy in primary prevention were included. We analysed data from our
ICD registry that includes patients with different cardiomyopathies in primary and
secondary prevention.
Methods: All pts from our prospective registry were included. 4 of the 5 risk
factors (age, QRS width, atrial fibrillation, NYHA class) of the original score were
used, BUN, however, was replaced by glomerular filtration rate (MDRD formula).
Patients were censored at death (256 pts), month of last visit if lost to follow-up
(22 pts), time of heart transplantation (8 pts), time the ICD was deactivated (12
pts) or at the time of last registry access in December 2012.
Results: Cohort of 1032 pts, 881 (86%) men, age 61±14 years, follow-up 66±46
months. VVI device in 62%, a DDD in 16%, a CRT in 22% of pts. Secondary
prevention in 48%, ischemic heart disease in 62%, dilated cardiomyopathy in 21%
and others in 17%. NYHA class was I in 24%, II in 43%, III in 30% and IV in 3%
of pts. Prevalence of risk factors were: age >70 yrs 27%; atrial fibrillation 8%;
QRS width ≥120ms 40%; NYHA class ≥3 33%; GFR < 60 ml/min/1.73m2 30%.
Risk categories were: No risk factors (RF) 32%; 1 RF 27%; 2 RF 20%; 3-5 RF
21%. 256 pts died 58±41 months after implant (median 49 mths). Kaplan-Meyer
curves are shown in the figure. A similar curve is present in ischemic cardiopathy
alone (not shown).
259
260
Implantable Cardioverter Defibrillator
P1382 | BEDSIDE
Arrhythmic risk and long-term prognosis in cardiac
resynchronization therapy with a defibrillator and mildly impaired
left ventricular function by cardiac magnetic resonance
O. Fabregat Andres 1 , P. Garcia-Gonzalez 1 , B. Bochard-Villanueva 1 , A. Valle 2 ,
J. Estornell-Erill 3 , R. Paya-Serrano 1 , V. Palanca 1 , A. Quesada 1 , S. Morell 1 ,
F. Ridocci-Soriano 1 . 1 University General Hospital of Valencia, Valencia, Spain;
2 Hospital Marina Salud, Denia, Valencia, Spain; 3 University General Hospital of
Valencia, ERESA, Valencia, Spain
Purpose: Clinical trials showed that cardiac resynchronization therapy with a defibrillator (CRT-D) improves survival in advanced Heart Failure (HF). These trials
have usually excluded patients with mildly impaired Left Ventricular Ejection Fraction (LVEF). We assess the prognostic impact of CRT-D in patients with LVEF
>35% by cardiac magnetic resonance (CMR).
Methods: 241 consecutive patients in New York Heart Association (NYHA) functional class II or III, with QRS ≥120 ms and LVEF by echocardiography ≤35%,
admitted for decompesated HF between 2004 and 2011, were analyzed. We included all patients (n=103) who underwent a CMR previously to CRT-D device
implantation for primary prevention. Ventricular arrhythmia that required device
therapy were considered as arrhythmic event, and mortality and readmission for
HF as clinical outcomes. Patients were divided in two groups according to LVEF
by CMR (CMR-LVEF).
Results: At 6 months follow-up both groups showed comparable improvements
in NYHA functional class and LVEF. At a median follow-up of 60 months, we found
a non-significant trend toward a higher risk of total mortality in CMR-LVEF ≤35%,
with a similar risk of ventricular arrhythmia or hospitalizations for HF. To determine whether Late Gadolinium Enhancement (LGE) on CMR impacts prognosis,
we divided the sample according to CMR-LVEF and presence of LGE. Interestingly, necrosis pattern identified patients with a worse prognosis for ventricular
arrhythmias and mortality in both groups. Secondly, the absence of necrosis and
CMR-LVEF >35% recognized patients with better prognosis (Figure 1).
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for patients with end-stage heart failure (HF). The majority of events seem to
occur in the early post-operative period.We sought to confirm the efficacy of ICDs
in a single center cohort of VAD-supported HF patients.
Methods: All adult subjects who underwent VAD support since 2003 as a
bridge to transplantation (BTT) were reviewed and included in the study.All
subjects in the cohort received one of the following VAD systems: HeartMate
XVE,Novacor LVAS,LVAD INCOR Berlin Heart,HeartWare LVAS and Berlin Heart
(LVAD and BiVAD).All patients had the ICD turned off for VAD implantation, and
only LVAD recipients had the ICD turned on post-operatively (routinely within 12
– 48hours).BIVAD recipients had the ICD set to monitor only. Appropriate ICD
shocks for Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF) were
recorded.The primary outcome was survival to transplantation.
Results: A total of 87 VADs were implanted for the indication of bridge to transplantation.Of these,34 were left ventricular assist devices (LVAD) and 53 were
biventricular assist devices (BIVAD).57 patients had an ICD (23 LVAD, 34 BIVAD).Mean age 40±12 years,78% male,LVEF 18±9%,54% dilated.Mean length
of support was 365 days (range 1–1280). Overall, 48 (56%) patients survived to
transplantation.More patients with an ICD were treated with amiodarone reflecting a higher incidence of arrhythmias.Of the 23 LVAD patients with an ICD,10
received at least one ICD shock.Appropriate shocks were delivered to 7 patients
after LVAD implantation (5 VT, 1 VF, 1VT and VF). The mean time to first shock
after LVAD implant was 129±109 days.In the LVAD cohort, more patients had an
appropriate ICD shock for VT or VF before LVAD implant than afterwards.Of great
interest was the analysis of the arrhythmias detected in the BiVAD group (15 patients out of 53 had at least one event VT or VF and one of them suffered an
electrical storm).In BiVAD patients detection of those arrhythmias were of great
importance because a decrease in cardiac outpout was observed. Arrhythmias
detected in both groups were of prognostic significance,especially in the LVAD
Group (RV failure and aortic regurgitation) In addition, two patients without an
ICD had ventricular arrhythmias requiring placement of an ICD after VAD placement.
Conclusion: ICD shocks are common after implantation of VADs.Shock frequency decreases after VAD implantation, likely due to ventricular unloading, but
appropriate ICD shocks still occur in VAD supported patients.
P1381 | BEDSIDE
The impact of the AIGISRX antimicrobial pouch on Cardiac
Implantable Electronic Device (CIED) infection rates: a comparison
of de novo vs non-de novo procedures
S. Mittal, R.E. Shaw, K. Michel, R. Palekar, A. Arshad, D. Musat, M. Preminger,
T. Sichrovsky, J.S. Steinberg. The Valley Hospital, Ridgewood, United States of
America
Background: Pts undergoing a non-de novo CIED procedure (gen change, upgrade, revision) may be at higher risk of infection. The AIGISRX pouch, which
releases rifampin and minocycline, may reduce infections. We compared the efficacy of the pouch in pts undergoing a de novo vs non-de novo procedure.
Methods: We had 1103 consecutive pts who underwent an ICD or CRT-D procedure. Cohort 1 (n=647) included pts b/w 1/07 – 10/09; no pts received a pouch.
Cohort 2 (n=456) pts underwent a procedure b/w 10/09 – 9/11; we used the pouch
in high-risk pts. We identified all pts who suffered a major infection (removal of all
hardware) within 6-mo of the procedure.
Results: In cohort 1, the 6-mo infection rate was 2.3% (9/388) for de novo and
3.9% (10/259) for non-de novo procedures (p=0.255). In cohort 2, a pouch was
used preferentially in the 184 (40%) pts with variables associated with CIED infection: diabetes, CHF, having an upgrade/revision (all p<0.0001) and EF < 40%
(p=0.0009). Only 0.7% (2/272) of the low-risk cohort 2 pts not treated with a pouch
had an infection. In high-risk cohort 2 pts treated with a pouch, the 6-mo infection
rate was 1.3% (3/232) for de novo and 0.4% (1/224) for non-de novo procedures
(p=0.33). The pouch did not reduce the infection risk in de novo procedures (2.3%
vs 1.3%, p=0.37); however, it significantly reduced the 6-mo infection rate for nonde novo procedures (3.9% vs. 0.4%, p=0.012, Figure).
Figure 1. 6-Month infection rate
Conclusions: An AIGISRX pouch was used in 40% of pts undergoing an ICD
or CRT-D procedure deemed at highest risk for infection. Pts not treated with a
pouch had an infection rate of 0.7%, confirming their low risk. In high-risk pts, the
pouch reduced the infection rate to 0.4% in non-de novo procedures.
Prognosis according to CMR-LVEF and LGE
Conclusions: CRT-D leads to a comparable clinical benefit in patients with either
a CMR-LVEF ≤35% or >35%. The analysis of LGE pattern provides additional
information on arrhythmic risk and long-term prognosis.
P1383 | BEDSIDE
The higher value of high-voltage lead impedance is associated
with a better clinical condition in heart failure patients with an
implanted defibrillating device
M. Bryl 1 , T. Krauze 1 , J. Piskorski 1 , D. Przymuszala 1 , M. Dziarmaga 1 ,
K. Barecka 2 , J. Kaczmarek 2 , K. Klimas 1 , M. Biczysko 1 , P. Guzik 1 . 1 Poznan
University of Medical Sciences, Department of Intensive Cardiac Therapy,
Poznan, Poland; 2 Heliodor Swiecicki University Hospital, Poznan, Poland
Purpose: The electrical impedance measures the total resistance to the current
flow. The lead impedance for implanted devices is a function of various properties
of the electrode and myocardium. On the other hand, myocardium characteristics
determine the patient’s clinical condition. This study evaluated the relation between the high voltage (HV) lead impedance and the thoracic fluid content (TFC)
as well as N-terminal pro B-type natriuretic peptide (NT-proBNP) in patients with
implanted defibrillating devices.
Methods: A group of 350 consecutive patients (62.9±10 years; 67 women) with
an already implanted cardioverter-defibrillator or a cardiac esynchronization therapy device with defibrillating mode were studied. The HV lead impedance was
measured by a telemetry during a routine device check-up. The TFC was measured at supine position after 30-minute rest by cardiac impedance (Niccomo,
Medis, Germany) and plasma NT-pro-BNP was measured in venous blood samples. For the statistical purposes the NT-pro-BNP level was normalized by the
natural logarithm. Patients were divided into tertiles (T1, T2 or T3) of the HV lead
impedance, and the analysis of variance with the Bonferroni post-tests were applied for statistical analysis.
Results: The HV lead impedance was 39.6±9.4 Ohm in T1, 49.9±2.2 Ohm in
T2 and 67.2±8.8 Ohm in T3. The mean TFC was significantly decreasing for
higher tertiles of HV lead impedance from 32.4±6.3 1/kOhm for T1, through