scholarly journals Device therapy guided by implantable loop recorders: predictors of bradyarrhythmic events

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Cardoso ◽  
B Faria ◽  
P Von Hafe ◽  
G Dias ◽  
T Pereira ◽  
...  
Keyword(s):  
Diagnostic Yield ◽  
Clinical Predictors ◽  
Device Therapy ◽  
Bundle Branch Block ◽  
Intraventricular Conduction ◽  
Conduction Disturbances ◽  
Device Implantation ◽  
Unexplained Syncope ◽  
Implantable Loop Recorders

Abstract Background Implantable loop recorders (ILR) improved diagnostic yield in unexplained syncope patients (pts). Data on possible predictive factors for bradycardia requiring device implantation in these pts is limited. We aim to identify clinical predictors for device implantation due to a significant bradyarrhythmia in patients who underwent ILR insertion for the study of syncopal/presyncopal (S/pS) events. Methods Single-center retrospective study of patients who implanted an ILR for the study of unexplained S/pS episodes between 2013 and 2018. The primary endpoint was a documented bradyarrhythmia requiring device implantation during the follow-up. Results A total of 251 pts were included. Mean age was 68±15 years and 53% were female. The majority of pts (220; 88%) had normal ejection fraction. Fifty-two (21%) pts had atrial fibrillation (AF). Regarding basal electrocardiographic characteristics, 34 (14%) pts had 1st degree auriculo-ventricular block (AVB), 31 (12%) pts had left bundle branch block (L-BBB), 22 (9%) pts had R-BBB and 13 (5%) pts had bifascicular block. During a median follow-up of 20 (IQR 9–34) months, 74 (29%) pts required device implantation because of a significant bradyarrhythmia (92% pacemaker, 4% CRT, 4% ICD). Median duration from ILR until device implantation was 5 (IQR 1–10) months. The indications were sick-sinus-syndrome in 47 (64%) pts, advanced AV block in 23 (31%) pts and symptomatic slow AF in 4 (5%) pts. Patients who required device implantation were older (73±12 vs 66±15 years, p <0.001), had more hypertension (73% vs 59% p=0.048), a higher prevalence of AF (34% vs 15% p=0.001) and a lower glomerular filtration rate (GFR<60 ml/min: 32% vs 21%, p=0.047). They also had more 1st AVB (22% vs 11%, p=0.026) and intraventricular conduction disturbances (38% vs 25%, p=0.025). There was a trend for a higher device implantation in pts with concomitant 1st AVB and left anterior fascicular block (7% vs 2%, p=0.063) In a logistic regression model, age >75 years (HR: 1.7; 95% CI: 1.1–2.8) and the presence of AF (HR: 1.8; 95% CI: 1.1–3.0) were independent predictors for device implantation. Conclusion An older age and the presence of AF were independent predictors for device therapy in pts who implanted an ILR for the study of S/pS. These factors may identify a higher risk group and should be considered in the initial workup of these pts. Funding Acknowledgement Type of funding source: None

scholarly journals Iatrogenic bradyarrhythmia: previous conduction disturbances predicted need for permanent pacing

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
AF Esteves ◽  
L Parreira ◽  
R Marinheiro ◽  
M Fonseca ◽  
JM Farinha ◽  
...  
Keyword(s):  
Emergency Room ◽  
Cox Regression ◽  
Univariate Analysis ◽  
Drug Discontinuation ◽  
Bundle Branch Block ◽  
Conduction Disturbances ◽  
Device Implantation ◽  
Permanent Pacing ◽  
Antidepressant Use

Abstract Funding Acknowledgements Type of funding sources: None. Background In bradyarrhythmia due to negative chronotropic medication, the need for permanent pacing after drug discontinuation is not always straightforward. Purpose Evaluate prevalence and predictors of the need of permanent pacing in patients with symptomatic bradyarrhythmia under negative chronotropic drugs. Methods We retrospectively studied patients admitted to the emergency room between January 2012 and December 2018 with symptomatic bradyarrhythmia who were under negative chronotropic drugs. We analysed patient demographic factors, previous medical history or electrocardiographic abnormalities and concomitant drugs. We evaluated the laboratory results, electrocardiographic and echocardiographic parameters at admission. During follow-up we analysed mortality, re-hospitalizations and device implantation. We used cox regression to assess the predictors of device implantation. Results 85 patients, were admitted to the emergency room, 47% male, median age 81 (76-87) years. The majority of patients (39, 46%) were admitted with syncope/presyncope and presented with complete AV block (62 patients, 73%). 54% had previous bundle branch block and most (69%) were taking beta blockers. Of note, 17 (20%) presented with ionic disturbances. 17 (20%) patients needed temporary pacing and 60 (71%) patients needed permanent pacing, implanted during index-hospitalization in 78 (92%) patients. Intra-hospital mortality was 5%. During a median follow-up of 66 months, 31 (36%) patients were re-hospitalized and 7 (8%) needed device implantation. Global mortality was 26%. In univariate analysis, previous bundle branch block predicted the need for permanent pacing, while presence of atrial fibrillation, antipsychotic/antidepressant use, acute kidney failure and hypo/hyperkalaemia precluded its requirement. In multivariate analysis, previous bundle branch block was the only independent predictor of the need for permanent pacing. Conclusion In this group of patients with iatrogenic symptomatic bradyarrhythmia, the need for permanent pacing was independently associated with the presence of previous conduction disturbances. Univariate analysisHR (95% CI), p-valueMultivariate analysisHR (95% CI), p-valueAge in years0.987 (0.959-1.016), 0.3330.988 (0.955-1.024), 0.514Previous bundle branch block2.197 (1.137-4.246), 0.0192.081 (1.042-4.156), 0.038Previous atrial fibrillation0.559 (0.321-0.974), 0.0400.903 (0.491-1.662), 0.743Use of antipsychotic/antidepressant drugs0.429 (0.202-0.908), 0.0270.717, (0.276-1860), 0.494Acute kidney failure0.500 (0.281-0.889), 0.0180.950, (0.455-1.984), 0.891Hypo/hyperkalaemia0.359 (0.163-0.792), 0.0110.470, (0.172-1.288), 0.142

scholarly journals Sensing issues related to the clinical use of implantable loop recorders

EP Europace ◽  
2003 ◽  
Vol 5 (2) ◽  
pp. 143-148 ◽  
Author(s):  
S. I. Chrysostomakis ◽  
N. C. Klapsinos ◽  
E. N. Simantirakis ◽  
M. E. Marketou ◽  
D. C. Kambouraki ◽  
...  
Keyword(s):  
Body Position ◽  
Initial Assessment ◽  
Group Differences ◽  
Loop Recorder ◽  
New Device ◽  
Device Implantation ◽  
Insertable Loop Recorder ◽  
Qrs Morphology ◽  
Unexplained Syncope

Abstract Aims The newer insertable loop recorder device (Reveal Plus 9526, Medtronic Inc, Minneapolis MN, U.S.A.) is equipped with auto-activation capabilities. In this study we investigated whether the new device encounters sensitivity problems in the form of oversensing or undersensing. We also tested whether body position changes influence the sensed electrogram's amplitude, therefore affecting the device's autosensing ability. Methods and results We enrolled 32 patients aged 58·1±11·7 years with a loop recorder implanted either in the left parasternal or in the heart's apex area, to investigate undiagnosed syncopal episodes after initial assessment. During the follow-up period (5·7±2·7 months), that began 6 months after the device implantation, we analysed 284 auto-recorded episodes (103 undersensed and 181 correctly sensed). No oversensing episodes were recorded. The recorded QRS amplitude in five different body positions: supine, left and right lateral, sitting and standing was measured. No statistically significant changes were observed in the different postures. Even when patients were divided into subgroups according to implant site or the occurrence of undersensing episodes, no significant inter- or intra-group differences of the sensed electrogram were observed. Conclusion Undoubtedly this device is the current gold standard for the diagnosis of unexplained syncope. In the population we studied though, the device faced undersensing problems. Consequently, the device should be equipped with more advanced software for QRS morphology recognition, to improve the diagnostic accuracy of the recorder.

scholarly journals The presence of symptons and symptom-rhythm correlation in patients with Implantable loop recorders

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
ML Goncalves ◽  
MARIA Goncalves ◽  
INÊS Pires ◽  
JOÃO Santos ◽  
JOANA Correia ◽  
...  
Keyword(s):  
Previous History ◽  
Heart Rhythm ◽  
Coronary Intervention ◽  
Ventricular Rate ◽  
Presenting Symptoms ◽  
Device Implantation ◽  
History Of ◽  
Implantable Loop Recorders ◽  
Diagnostic Outcome

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Implantable loop recorders (ILR) are a powerful diagnostic tool for heart rhythm diseases, and particularly useful when symptoms are infrequent or when long-term data are required. The main indication is for study of syncope/presyncope due to suspected cardioinhibitory etiology. OBJECTIVE To evaluate the diagnostic profitability of ILR in patient (P) with syncope/ presyncope and to evaluate the effect of symptons on follow-up. METHODS Included P undergoing ILR implantation in 6 consecutive years, to study syncope/presyncope. Information was collected on P characteristics, indication, diagnostic outcome and subsequent management and complications. A follow-up (FU) of 1 year and 3 years were done. Diagnostic outcome was based in symptom-rhythm correlation. Symptons and correlation to ECG during the FU and management after the diagnosis were assessed. RESULTS 99 P were selected. Evaluation of syncope in 91.9% (n = 91) and presyncope in 8.1% (n = 8). 54.5% female, median age 59.4 ± 17.4 years. 55.8% (n = 53) completed the 3 years FU and 84.2% (n = 80) completed the 1 year FU. Death occurred in 4% (n = 4) during the FU. ILR results led to device implantation in 35% of the P (22 pacemakers and 1 ICD) in 1 year FU, with a median time to implantation of 11.6 months after ILR, and the majority of ILR motivated by syncope (87%). If we consider only P that finished the 3 years of FU, in 47.2% P were implanted a device. The most common arrhythmic finding were AV block (47.8%), followed by sinus pauses / asystole (43.5%), AF with slow ventricular rate (4.3%) and VT (4.3%). 4.9% of P experienced a complication related to the device (2 infection and 3 non-infectious pain), that resulted in explantation. 60.9% of the P were symptomatic during the FU, with 24.1% achieving symptom-rhythm correlation and 36.8% who did not. Device implantation was associated with the presence of symptons in FU (82.6% vs 17.4%, p = 0.012) and symptom-rhythm correlation (95% vs 5%,p = 0.001). 38.7% (n = 27) of the P finished the 3 years of FU without a diagnostic outcome or detectable event, with 44.4% being assymptomatic and 55.6% presenting symptoms without ECG correlation. Compared to the P that implanted a device, this type of P was frequently of female sex (57.6% vs 30.4%, p = 0.045), younger age (54.8 ± 18.1 vs 65.8 ± 12.8 years, p = 0.014), with less cardiovascular risk factors like dyslipidemia (37.0% vs 78.3%, p = 0.003) and arterial hypertension (48.1% vs 73.9%, p = 0.05), AF (0% vs 19%, p = 0.025), previous history of myocardial infarction and percutaneous coronary intervention (3.2% vs 17.4%, p = 0.05; 3.0% vs 21.7%, p = 0.028) and more frequently with history of depression (51.9% vs 22.7%, p = 0.037). CONCLUSION In this study, ILR monitoring led to a device implantation in 47.2% of the P that finished the 3 years FU. The presence of symptons and symptom-rhythm correlation during FU was associated with device implantation.

P6561Diagnostic yield of implantable loop recorders: a comparison of arrhythmia nurse specialists versus clinicians

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J D Lee ◽  
H Eftekari ◽  
G Paul ◽  
A Zhupaj ◽  
S Panikker ◽  
...  
Keyword(s):  
Diagnostic Yield ◽  
Critical Role ◽  
Cryptogenic Stroke ◽  
Specialist Nurse ◽  
Entire Cohort ◽  
Patient Demographics ◽  
Tertiary Centre ◽  
Implantable Loop Recorders ◽  
Management Changes

Abstract Background Implantable loop recorders (ILR) are recommended in guidelines to determine symptom-rhythm correlation. Arrhythmia Nurse Specialists (ANS) play a critical role in the assessment of such patients. Their effectiveness at risk stratification for ILR implantation is unknown. The ESC 2018 Syncope guidelines recommend more research in this field. Aim To evaluate the diagnostic yield of consecutive ILR implants at a tertiary centre over a 2year period and compare ANS versus Clinicians. Methods A retrospective study of all patients undergoing ILR implant between April 2016 and April 2018. Data collected included baseline patient demographics, referral source and management changes made by ILR findings. Results 305 patients had an ILR; median age was 71yrs (interquartile range 52–81), 55% male. Median follow-up time was 15months. Referrals were from general cardiology (GC) = 98 (32%), electrophysiology (EP) = 105 (34%), and ANS-led syncope clinic = 102 (34%). Indications for ILR implant were syncope = 203 (65.9%), palpitation = 21 (6.9%), pre-syncope = 16 (5.2%), cryptogenic stroke = 35 (11.5%) and others 7 (8.9%) (falls, channelopathies). Of the entire cohort, 102 (34.0%) experienced arrhythmias recorded on the ILR that resulted in a change of management. This included: pacemaker implant = 49 (16.1%), complex-device implant = 7 (2.3%), AF=28 (9.2%), SVT=14 (4.6%), VT=1 (0.3%). Of those with a syncope indication (n=203), findings on ILR altered management in 73patients (36.0%) over a median follow-up of 18months; a pacing indication in this syncope group was present in 44 (21.9%) patients (median time to diagnosis: 2.7 months) with 24 receiving a pacemaker indication within 3 months of ILR insertion. ANS had a higher pacemaker implant rate. Overall, an ILR resulted in a diagnostic yield of 34.1% (n=104). Specialist nurse referral resulted in an overall greater trend towards change of management in 38.2% of patients compared with GC (32.7%) and EP (31.0%) (p=0.593 nurse vs. consultant). Conclusion The overall diagnostic yield of ILR insertion was 34% in our study. ANS had a trend towards a greater diagnostic yield compared with clinicians, and significantly more pacemaker indications. Our data suggests that ANS patient selection for ILR insertion are at least comparable to clinicians.

Intraventricular conduction disturbances

ESC CardioMed ◽  
2018 ◽  
pp. 345-358
Author(s):  
Antoni Bayés de Luna ◽  
Marcelo V. Elizari
Keyword(s):  
Left Bundle Branch Block ◽  
Clinical Implications ◽  
Bundle Branch Block ◽  
Intraventricular Conduction ◽  
Conduction Disturbances ◽  
Key Concepts ◽  
Ecg Criteria ◽  
Electrocardiogram Ecg

This chapter highlights the key concepts related to the electrocardiogram (ECG) diagnosis of intraventricular conduction disturbances, including right and left bundle branch block. In both cases, but especially in left bundle branch block, the chapter discusses the diagnosis when the block is at a proximal level and in the fascicles. This includes the ECG diagnosis of the superoanterior and inferoposterior fascicles of the left bundle (the hemiblocks). The possible diagnosis of the block of middle fibres (septal fascicle) of left bundle is briefly mentioned. Finally, the ECG criteria for the diagnosis of bifascicular and trifascicular block are described. In all cases, the most important clinical implications of each diagnosis are discussed.

604 Long Term Follow-Up of Implantable Loop Recorders: Prolonging Observation Period Increases Diagnostic Yield?

2012 ◽  
Vol 28 (5) ◽  
pp. S323
Author(s):  
V. Exposito ◽  
F. Rodriguez-Entem ◽  
S. González-Enríquez ◽  
P. Lerena ◽  
J.M. Gomez-Delgado ◽  
...  
Keyword(s):  
Diagnostic Yield ◽  
Long Term Follow Up ◽  
Implantable Loop Recorders ◽  
Observation Period

The diagnostic yield of implantable loop recorders in unexplained syncope: A systematic review and meta-analysis

2017 ◽  
Vol 231 ◽  
pp. 170-176 ◽  
Author(s):  
Monica Solbiati ◽  
Giovanni Casazza ◽  
Franca Dipaola ◽  
Franca Barbic ◽  
Maja Caldato ◽  
...  
Keyword(s):  
Systematic Review ◽  
Diagnostic Yield ◽  
Meta Analysis ◽  
Unexplained Syncope ◽  
Implantable Loop Recorders

Feasibility and efficacy of left bundle branch area pacing in patients indicated for cardiac resynchronization therapy

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii54-ii60
Author(s):  
Yuqiu Li ◽  
Lirong Yan ◽  
Yan Dai ◽  
Yu’an Zhou ◽  
Qi Sun ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Bundle Branch Block ◽  
Ventricular Ejection Fraction ◽  
Intraventricular Conduction ◽  
Lead Placement

Abstract Aims The present study was to evaluate the feasibility and clinical outcomes of left bundle branch area pacing (LBBAP) in cardiac resynchronization therapy (CRT)-indicated patients. Methods and results LBBAP was performed via transventricular septal approach in 25 patients as a rescue strategy in 5 patients with failed left ventricular (LV) lead placement and as a primary strategy in the remaining 20 patients. Pacing parameters, procedural characteristics, electrocardiographic, and echocardiographic data were assessed at implantation and follow-up. Of 25 enrolled CRT-indicated patients, 14 had left bundle branch block (LBBB, 56.0%), 3 right bundle branch block (RBBB, 12.0%), 4 intraventricular conduction delay (IVCD, 16.0%), and 4 ventricular pacing dependence (16.0%). The QRS duration (QRSd) was significantly shortened by LBBAP (intrinsic 163.6 ± 29.4 ms vs. LBBAP 123.0 ± 10.8 ms, P < 0.001). During the mean follow-up of 9.1 months, New York Heart Association functional class was improved to 1.4 ± 0.6 from baseline 2.6 ± 0.6 (P < 0.001), left ventricular ejection fraction (LVEF) increased to 46.9 ± 10.2% from baseline 35.2 ± 7.0% (P < 0.001), and LV end-diastolic dimensions (LVEDD) decreased to 56.8 ± 9.7 mm from baseline 64.1 ± 9.9 mm (P < 0.001). There was a significant improvement (34.1 ± 7.4% vs. 50.0 ± 12.2%, P < 0.001) in LVEF in patients with LBBB. Conclusion The present study demonstrates the clinical feasibility of LBBAP in CRT-indicated patients. Left bundle branch area pacing generated narrow QRSd and led to reversal remodelling of LV with improvement in cardiac function. LBBAP may be an alternative to CRT in patients with failure of LV lead placement and a first-line option in selected patients such as those with LBBB and heart failure.

scholarly journals Atrial fibrillation in unexplained syncope: observations from the Reveal LINQ registry

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Del Greco ◽  
A Natale ◽  
K Kusano ◽  
A Verma ◽  
S Beinart ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Private Company ◽  
Detection Rates ◽  
External Reviewer ◽  
Funding Sources ◽  
Kaplan Meier ◽  
History Of ◽  
Unexplained Syncope ◽  
Implantable Loop Recorders

Abstract Background Implantable loop recorders (ILRs) have come to play an important role in the workup of patients with recurrent syncope of uncertain origin. In addition to detecting bradyarrhythmias related to syncope, which is the main diagnostic focus in these patients, ILRs are also capable of uncovering subclinical atrial fibrillation (AF). Purpose We sought to determine the percentage of patients monitored with an ILR for unexplained syncope who have AF detected and to describe clinical actions taken in these patients. Methods Patients enrolled in the Reveal LINQ Registry who received an ILR for unexplained syncope and had at least one follow-up form were included. The device automatically detects AF episodes lasting ≥2 minutes. Patients were considered to have AF based on an AF diagnosis made by the treating physician during follow-up or if device-detected AF was adjudicated as true AF by an external reviewer. AF detection rates were calculated using Kaplan-Meier methods. Results In total, 498 patients (aged 61.8±20.0 years, 49.6% female, CHA2DS2VASc score 2.2±1.7) were included and followed for 22±12 months. A history of AF was present in 97 (20%) patients, while 401 patients had no history. By 18 months, the incidence of AF was 70.9% (95% CI, 60.8%, 80.3%) in patients with a history of AF and 21.4% (95% CI, 17.4%, 26.1%) in patients without (Figure). AF detection in those with (30.4%) and without (30.1%) syncope during follow-up was similar. By the end of follow-up, and among patients with newly detected AF, 29/86 (33.7%) were on oral anticoagulation, 7 (8.1%) underwent AF ablation, 6 (7.0%) underwent other type of ablation, and 2 (2.3%) received cardioversion. Other actions among the whole cohort included implant of an IPG, ICD, or CRT in 98/498 (19.7%). Conclusion Among patients monitored with ILRs to determine the cause of recurrent syncope episodes, approximately 1 in 5 patients had new AF detected. In addition to improving the management of patients with syncope, ILR data served to support AF-related clinical decisions. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic Inc Incidence of AF according to baseline AF

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