iv13
MODERATED POSTERS, SESSION 1, HRC 2011
31
High rate of appropriate therapy justiﬁes implantable cardioverter –deﬁbrillator use in elderly patients
W.B. Nicolson1 (Presenting author), A.E. Nicolson2, A.J. Sandilands3, D.T. Chin3, P.J. Stafford3, W.I. Loke3, R.K. Pathmanathan3, J.D. Skehan3, and G.A. Ng3
1
Leicester Cardiovascular Biomedical Research Unit, Leicester UK; 2University of Cardiff, Cardiff UK; and 3University Hospitals of Leicester NHS Trust, Leicester UK
1.00
0.75
0.75
0.50
Survival
0.50
0.25
0.25
Appropriate therapy (n=571)
Mortality (n=810)
Age <65
Age <75
0.00
0.00
Survival Free of Appropriate Therapy
1.00
Introduction: Implantable cardioverter– deﬁbrillators (ICDs) are an expensive, but effective, treatment modality. Mortality rates are known to be higher in older ICD patients. The aim of this abstract
was to investigate the effect of age on appropriate therapy in ICD patients in the context of increased mortality in the elderly.
Methods and results: A retrospective audit of our University Hospital’s ICD service included analysis of mortality in 810 patients and review of notes for 571 of 810 patients with ICD devices
(implanted on 3 January 2006 to 25 June 2010). Patients were grouped by age: , 65 (333 patients), 65 –75 (301 patients), and .75 (176 patients). Elderly patients have a signiﬁcantly higher mortality and appropriate therapy rates (Figure 1) (P ¼ 0.0001 and P ¼ 0.015, log-rank). The mortality rate at 3 years for patients .75 is 17.4% [conﬁdence interval (CI) 11.8 – 25.4%] compared with
an appropriate therapy rate of 57.0% (CI 43.1– 71.8%). The rate of appropriate therapy at 3 years in patients aged ,65 is 32.8% (CI 26.1 – 40.7%).
Conclusion: Elderly patients have an appropriate therapy rate more than three times their mortality rate and almost double that of younger patients. While appropriate therapy is not commensurate
with mortality these data support the use of ICDs in appropriately selected elderly patients.
1
2
3
Follow Up (Years)
4
5
0
1
2
3
Follow Up (Years)
4
5
32
33
First experience of a new remote catheter system for ablation of atrial
ﬁbrillation using three-dimesional mapping systems
Mitral isthmus ablation is feasible, efﬁcacious, and safe using a robotic
remote navigation system
P.D. Brown1 (Presenting author), S. Yusuf2, S. Chalil2, A.J. Sandilands2, P.J. Stafford2, and G.A. Ng1
K. Wong (Presenting author), M Jones, N. Qureshi, Y. Bashir, T.R. Betts, and K. Rajappan
1
John Radcliffe Hospital, Oxford UK
University of Leicester, Leicester UK; and 2University Hospitals of Leicester, Leicester UK
Introduction: The Amigo Remote Catheter System (RCS, Catheter Robotics Inc.) has recently been
introduced into clinical use. The RCS can manipulate a standard bi-directional ablation catheter on
either the Blazer (Boston Scientiﬁc) or EZ-Steer (Biosense Webster, BW) platforms, without the use
of magnets or steerable sheaths. We describe the ﬁrst use of the RCS, in conjunction with an irrigated
catheter and three different mapping systems, in the ablation of paroxysmal atrial ﬁbrillation (PAF).
Methods and results: Eighteen patients with PAF were recruited. All were anticoagulated with warfarin which was discontinued prior to their procedure and bridging therapy with low-molecular-weight
heparin used until the day of the procedure. A single transseptal puncture was performed manually with
a LAMP 90 sheath (St Jude Medical, SJM). Either pulmonary vein (PV) angiography (for 11 patients)
or 3D rotational angiography (for 7 patients) of the left atrium was performed. Three-dimensional geometry was then generated manually using Carto 3 (BW) for 13 patients, Ensite NavX (SJM) for 2
patients, or Ensite Velocity (SJM) for 3 patients. A circular PV catheter and an EZ-Steer Thermocool
FJ curve ablation catheter (BW) were used for geometry creation. The ablation catheter was then connected to the RCS, which was used to manipulate the catheter for the ablation procedure. Heparin was
given once the transseptal puncture had been completed aiming at ACT . 300 s. All patients tolerated
the procedure well. Pulmonary vein isolation was achieved successfully for all PVs in all patients either
by segmental ostial ablation or wide-area circumferential ablation in pairs. Five patients who were in
atrial ﬁbrillation (AF) at the start and one who went into AF during the procedure returned to sinus
rhythm during ablation. Seven patients had additional lesion sets including roof lines, mitral isthmus
lines, and ablation to the septum or ﬂoor of the left atrium because AF was inducible with programmed
electrical stimulation, all performed with the RCS. There were no complications. Patient demographics
and procedural parameters are summarized in the table. Of note, the operator was protected from
50.4% of the radiation exposure for these cases by use of the RCS.
Female
Age (years)
Duration of PAF (months)
AF at start
Duration of procedure (min)
Total ﬂuoroscopy time (min)
Fluoroscopy time during ablation (min)
Ablation ‘burn’ time (s)
55 + 2
57 + 15
5/18 (27.7%)
274 + 15
76.4 + 7.0
37.7 + 5.5
1500 + 141
Conclusions: This ﬁrst experience with the RCS supports its feasibility and safety for use in ablation
for PAF in conjunction with a variety of commonly used mapping systems. Further work is needed to
assess long-term efﬁcacy and its use in more extensive ablation.
Background: There are limited data on the use of robotic remote navigation system (RNS)
for mitral isthmus ablation.
Objective: This study investigates the safety and feasibility of using the robotic RNS for
mitral isthmus ablation.
Methods and results: This single-centre, prospective study included 30 patients who underwent atrial ﬁbrillation ablation using robotic RNS. A matched cohort of 30 patients who
underwent conventional ablation formed the control group. All patients had circumferential
pulmonary vein isolation, and roof and mitral isthmus ablation. Bi-directional block was the
endpoint for linear ablations. Mean ablation and procedure times were compared. There was
no signiﬁcant difference in baseline clinical characteristics between the two groups. There
were also no signiﬁcant differences in the ablation and procedure times. There was a signiﬁcant reduction in ﬂuoroscopy time in the RNS group (38 + 19 min vs. 49 + 20,
P ¼ 0.048). Acute pulmonary vein isolation and roof line block was achieved in all
patients. Mitral isthmus block was achieved in 29 of 30 patients (97%) in the RNS group.
Sixteen of thirty patients (53%) required coronary sinus (CS) ablation to achieve mitral
isthmus block. In 13 of 16 patients (81%), it was possible to drive the ablation catheter into
the distal CS using the robotic RNS. Mean total mitral isthmus ablation and procedure times
were 14 + 7 min (mean CS ablation time: 3 + 4 min) and 26 + 17 min, respectively.
There was a signiﬁcant trend of reduction in mean procedural time (P ¼ 0.02, analysis of
variance) and mean total mitral isthmus ablation (P , 0.05), especially in mean CS ablation time (P ¼ 0.007) over the course of the study period. There were no such trends
observed for pulmonary vein isolation or roof line ablation.
Conclusion: It is feasible and safe to use robotic RNS for mitral isthmus ablation. There is a
short learning curve. In our series, the success rate of achieving acute mitral isthmus block
was 97% and the need for epicardial CS ablation was 53%.
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0
Age 65-75
iv14
34
Persistent atrial ﬁbrillation ablation guided by selective continuous activity mapping: towards more effective targeting of fractionated sites
P.B. Lim (Presenting author), M. Finlay, J. McCready, X. Jie, L. Xu, S. Ahsan, A.B. Gopalamurugan, L. Nunn, A.W. Chow, M.D. Lowe, O.R. Segal, E. Rowland, and P. Lambiase
The Heart Hospital, University College London, UK
Introduction: Ablation targeting complex-fractionated electrograms (CFE) is potential strategy for treatment of persistent atrial ﬁbrillation (AF). Recently, continuous atrial activity (CAA) observed
on bipolar electrograms has been proposed as a marker of sites critical to AF maintenance (Narayan, Heart Rhythm 2011). We hypothesized that mapping and ablation of sites of CAA would
(i) target areas distinct from those seen on standard CFE analysis, and (ii) could improve rates of AF termination acutely.
Methods and results: Twelve patients (seven male, mean age 60 + 11 years, mean AF duration 24 + 12 months) were recruited. The mean ejection fraction was 51 + 7%, left atrial (LA) size
was 4.7 + 0.7 cm. Following isolation of all pulmonary veins, a CFEmean map was created using NavX and data were immediately exported for analysis in custom software running in Matlab.
Every electrogram was analysed for % continuous activity (deﬁned as activation above baseline threshold, with a refractory period of 40 ms). Results were superimposed on the LA geometry as a colourmap (Figure). CFAE scores were also calculated using algorithms analogous to those in Carto (Fractionation Index) and NavX (CFEmean). Areas of highest CAA were ablated for 30 s each, with
the endpoint of termination of AF into either atrial tachycardia or sinus rhythm during ablation. Seven (58%) of twelve patients had acute termination of AF (four via atrial tachycardias, three directly
into sinus rhythm) during CAA ablation. Ablation duration at CAA sites was 15 + 4 min with acute termination, compared with 15 + 9 min without acute termination (P ¼ 0.95). Follow-up data
.3 months were available in nine patients. Of six patients who had acute termination, four were in sinus rhythm, and two in atrial tachycardia (5.9 + 5.3 months). Of the remaining three patients,
one was in atrial tachycardia, one in AF, and one in sinus rhythm. The mean LA appendage cycle length at the start of the procedure was 161 + 16 ms in the group that had acute AF termination,
and 151 + 24 ms in the group without acute termination (P ¼ ns). However, the mean LA appendage cycle length increased to 186 + 40 ms (23%) before cardioversion was performed in the
group without acute termination. Analyses of 1892 individual 8 s electrograms from seven patients by each algorithm were compared. A moderate correlation existed between CAA vs. CFEmean
(r2 ¼ 0.54 + 0.23, P , 0.0001) and CAA vs. Fractionation Index (r 2 ¼ 0.49 + 0.25, P , 0.0001). Only 1.9 + 1.5% of electrograms were in the ‘most fractionated’ decile in all algorithms,
8.5 + 4.0% were common to the 2nd decile in all three algorithms.
Conclusion: Targeting sites of CAA is distinct from targeting CFAEs, though a proportion of sites overlap. Ablation for persistent AF using a strategy of wide-area circumferential ablation of
pulmonary veins followed by ablation of CAA areas results in a modest acute termination rate, which is maintained at 6-month follow-up.
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iv15
35
Complex cardiac device implantation in a large district general hospital:
can it be done well?
36
Cost analysis of early cardiac device infections
B. Saberwal (Presenting author), S.Y. Ahsan, P.D. Lambiase, O.R. Segal, M. Lowe, C. Koo,
A.B. Gopalamurugan, E. Rowland, L. Nunn, and A.W.C. Chow
Royal Cornwall Hospital, Truro, UK
The Heart Hospital, London UK
Introduction: The expansion of cardiac pacing from specialist centres into the District General
Hospital (DGH) setting was instrumental in the rising implant rates in the UK. National Institute of
Health and Clinical Excellence guidance on implantable cardioverter –deﬁbrillators (ICDs) July 2007
and cardiac resynchronization therapy (CRT) for the treatment of heart failure July 2010 means that
these implants are indicated in a larger population and DGHs will need to play a role similar to that
of bigger centres. Royal Cornwall Hospital Trust is one of the ﬁve trusts in the South west Peninsula
Cardiac Network. The Heart Rhythm Devices: UK National Audit 2009 showed that we implant
above the national average number of CRTs and just below the national average of ICDs.
Methods and results: We performed a 5-year retrospective audit looking at our complex device
implants to see how we compared with the UK, Europe, and large Randomized Controlled Trials
(RCTs). We used TOMCAT to collate data from December 2004 to December 2009. We looked at
our patient demographics, screening times, radiation doses, and complication rates. We studied 225
patients; 85 ICD patients (72 males) aged 31 –85 years (mean age 67.4 + 8.9 years), 75 CRTP
patients (59 males) aged 36 –88 years (mean age 70.9 + 10.99 years), and 65 CRTD patients (61
males) aged 35– 84 years (mean age 66.8 + 8.69 years). One hundred and forty-three (63.6%)
patients had ischaemic cardiomyopathy and 57 (25.3%) had non-ischaemic dilated cardiomyopathies.
We have a similar cohort of patients to those in major RCTs and were successful in 97% implants.
Procedure times for 83 ICD new implants ranged 40 –140 min (mean 71.2 + 17.6 min median
70 min). Radiation doses ranged 17 –1757 cGym2 (mean 440.4 + 454.3 cGym2 median
229 cGym2). Fifty-seven CRTP new implant times 50– 185 min (mean 101 + 32.4 min median
90 min). Radiation doses 272–28 860 cGym2 (mean 4220.6 + 4530.8 cGym2 median 3047 cGym2).
Forty-four CRTD new implant times 68 –192 min (mean 110.7 + 29.4 min median 100 min).
Radiation doses 472– 9491 cGym2 (mean 3350.0 + 2504.7 cGym2 median 2400 cGym2). Our times
and doses both showed a yearly reduction and are comparable with European data. Overall complication rates; 0.4% sustained a pneumothorax requiring drainage, 1.3% had early lead displacement
requiring repositioning, 1.3% had cutaneous erosion requiring wound revision, 0.4% suffered haematoma requiring evacuation, 0.4% had a cerebrovascular event, 0.4% a pericardial effusion, and 0.4%
of patients died as a result of device implantation. Our rates are similar to data presented at Heart
Rhythm Congress 2010 for UK hospitals and the European CRT survey presented at ESC congress in
2009.
Conclusion: Complex device implantation can be achieved in the setting of a large DGH. Implant
success was achieved in over 97% and our overall complication rates are comparable with the rest of
the UK and Europe. We continue to show improvement in implant times and radiation doses. Hence,
DGHs have a crucial role to play in the growing demand in complex devices in the UK.
Introduction: Cardiac device infections (CDI) carry a signiﬁcant morbidity and mortality
and have signiﬁcant ﬁnancial implications. Early CDI are classiﬁed as those occurring within
12 months of implant. We analysed the cost incurred as a result of serious CDI requiring
extraction in a single centre.
Device
Average
device cost
(GBP)
Lab and
staff fees
(GBP)
Total procedure
cost (GBP)
Number of
procedure (n)
Total cost
(GBP)
PPM
ICD
BiV/TriV
1682
13 377
15 330
372
415
484
2739
18 385
21 080
8
16
6
21 912
294 160
126 480
Methods and results: All patients undergoing cardiac device implant at our trust between
2004 and 2009 were included. Medical notes and electronic records were cross referred to
identify those patients who developed CDI requiring extraction within a year of their procedure. Cost estimates of CDI were derived from a combination of factors including bed
costs, cost of device extraction, re-implantation, and antibiotics used. A total of 2780 cardiac
device implants were performed between 2004 and 2009. These were comprised of 944 permanent pacemakers (PPM), 1122 implantable cardioverter –deﬁbrillators (ICD), and 444
cardiac resynchronisation therapy (CRT) devices. Thirty patients (1.1%) developed early
infection. Infection rates by device type were 0.95% PPM, 1.43% ICD, and 1.35% CRT. The
mean duration of stay for all patients with CDI was 29.9 (+28.8) days. The cost of an ITU
bed was 854 GBP, and a cardiac ward bed cost 297 GBP per day. The cost based on bed
occupancy alone totalled 392 216 GBP. A standard extraction cost 2537 GBP. Reimplantation costs were variable depending on device type (Table 1). Antibiotic therapy cost
18 930 GBP. For CDI in the period 2004 –2009, a total of 929 808 GBP was spent by the
trust, which averages 30 994 GBP per CDI.
Conclusions: Early CDI impose a signiﬁcant ﬁnancial burden on hospital trusts. Active periprocedural measures to reduce CDI are cost effective and should be undertaken routinely.
37
38
Patient satisfaction with nurse-led follow-up service for atrial ﬁbrillation
facilitated by implantable reveal XT devices
Should persistent atrial ﬁbrillation always be managed in secondary care?
A comparative study of current practice
M. Castro (RN) (Presenting author), P.B. Lim, M. Dhaliwal (RN), S. Ahsan, A.B. Gopalamurugan,
L. Nunn, M. Finlay, R. Simon, M.D. Lowe, P. Lambiase, A.W. Chow, E. Rowland, and O.R. Segal
A.N. Jordan1 (Presenting author), A.C. Slater2, and C.A. Blakemore1
The Heart Hospital, University College London, UK
Introduction: Patient follow-up in physician-led clinics post-atrial ﬁbrillation (AF) ablation has
traditionally been dependent on symptoms and results of single electrocardiograms (ECGs) and shortterm Holter monitoring. As these recordings are intermittent, it can be difﬁcult to obtain ECG documentation of symptoms. The Medtronic Reveal XT device is an implantable loop recorder that is
triggered by episodes of AF. Patients can upload ECG data trans-telephonically into a central network
during episodes of palpitations, or at pre-determined intervals. These data may then be accessed
online by arrhythmia nurse specialists who can contact the patient (and physician) to discuss management. In this study, we hypothesized that nurse-led follow-up after AF ablation using the Reveal XT
was feasible, would improve patient satisfaction, and would help to facilitate clinical follow-up. To
test the hypothesis, telephone interviews were conducted in two groups of patients; those that received
a Reveal device and those who did not.
Methods and results: Nineteen patients underwent Reveal implantation 6 weeks prior to AF ablation.
Patients were taught to activate, upload, and transmit data trans-telephonically via CareLink
(Medtronic), and contact the arrhythmia nurses to discuss their results. After 3 months, patients were
interviewed by telephone to ascertain their satisfaction with the service using a questionnaire (scores
from 1 to 5). A further 19 patients undergoing AF ablation, but who did not receive a Reveal device
were interviewed in a similar manner. A total of 38 patients (mean age 65 + 10 years, 27 male)
were enrolled. All 19 patients with a reveal device stated they were highly satisﬁed with various
aspects of care, including ability to seek urgent medical advice after ablation, thorough documentation of symptoms, and as a consequence, improved consultation with the physician at the 3-month
appointment (Table). One highly symptomatic patient with symptoms correlating with AF on Reveal
download had a repeat ablation within 3 months of the initial procedure. A further six symptomatic
patients with documented AF were listed for a further AF ablation procedure at the 3-month followup visit. Interestingly, one patient continued to have symptoms following AF ablation which did not
correlate with arrhythmia, and a further patient was rendered asymptomatic following ablation despite
the persistence of AF. In contrast, patient satisfaction was signiﬁcantly lower in the non-Reveal
group, and of 11 patients with recurrent symptoms, none were able to obtain a Holter recording in the
ﬁrst 3 months (Table).
Table.
Conclusions: A nurse-led follow-up service following ablation using Reveal devices is feasible,
greatly improves patient satisfaction, and allows for timely and accurate documentation of symptoms.
This is likely to improve management following ablation, including appropriate cessation of antiarrhythmic and anticoagulant drugs, or expediting early cardioversion or repeat ablation.
1
Poole General Hospital, Poole UK; and 2Whitecliff Surgery, Blandford Forum, UK
Introduction: Controversy exists as to whether all patients with atrial ﬁbrillation (AF) should be managed with secondary care input. We performed a retrospective simultaneous comparison of AF management by general practitioners and cardiologists in the same region to determine if patients are managed differently in the two settings.
Methods and results: Fifty patients referred to a district general hospital cardiology service for management of
persistent AF in 2010 were identiﬁed chronologically. Fifty patients presenting to primary care with new persistent
AF between 2009 and 2011 were pooled from two large practices within the referring region. Presenting features,
investigation, and treatment were analysed and compared with current guidelines [National Institute of Health and
Clinical Excellence (NICE) 2006; European Society of Cardiology (ESC) 2010]. Statistical analysis was performed
using the Student’s t-test for continuous variables and x2 test for discrete variables. CHADS2 scores were similar
but CHA2DS2-vasc scores were signiﬁcantly higher in primary care. Despite this, and with the exclusion of patients
with contra-indications and those adopting rhythm control strategies, there was signiﬁcantly greater warfarin prescription in the secondary care setting, with greater adherence to NICE and ESC guidelines.
In total, 68% patients seen in primary care were referred for specialist input. A minority (14%) of patients were
referred speciﬁcally to consider rhythm control strategies. In 79% of those referred, management was changed
following specialist input.
Primary care
Secondary care
P value
Age (mean)
76
72
CHADS2 score (mean)
1.60
1.46
CHA2DS2-vasc score (mean)
3.14
2.42
Warfarin prescription (excluding rhythm
control patients and those with a
contraindication to anticoagulation)
Adherence to NICE for warfarin
Adherence to ESC for warfarin
First line rate/rhythm control in accordance
with NICE guidance
Rhythm control
Documented discussion regarding rate vs.
rhythm
51%
76%
0.053
CI 20.58 to 7.16
0.54
CI 20.01 to 0.29
0.024
CI 20.02 to 1.46
0.019
77%
59%
80%
95%
90%
92%
0.016
0.0010
0.038
22%
4%
44%
38%
0.0022
,0.0001
CI, 95% conﬁdence interval.
Conclusions: With specialists demonstrating markedly more frequent prescription of warfarin and adherence to
guidelines it could be argued that all AF is best managed with secondary care input. However, this may be difﬁcult to implement in the current ﬁnancial climate. Possible solutions could include improving accessibility to
specialist advice using email or telephone advice services or nominated AF lead practitioners within practices.
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L.T.M. Yung (Presenting author), S. Wilson, R.T. Johnston, and A.K.B. Slade