Left Ventricular Mechanical Reverse Remodelling Not Followed by Electrical Reverse Remodelling: A Case Report

Patients with severely depressed left ventricular ejection fractions (LVEFs) receive implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden death. However, in some patients, LVEFs may improve or even normalize over time, and these patients would no longer be qualified for ICD implantation based on the original criteria for which they have initially received an ICD. We report a patient with idiopathic dilated cardiomyopathy whose LVEF recovered to normal values after pharmacological therapy. Meanwhile, the patient had life-threatening ventricular fibrillation, aborted by the ICD. We reflect on the pathological features of left ventricular reverse remodelling and ventricular arrhythmogenesis, where the myocardial substrate appears to play an important role. Also, after LVEF improvement in a patient with a cardiac device, there is still a debate on whether we should perform a battery replacement.

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Arrhythmic risk stratification in non-ischaemic dilated cardiomyopathy beyond ejection fraction

Heart ◽

10.1136/heartjnl-2019-315942 ◽

2020 ◽

Vol 106 (9) ◽

pp. 656-664 ◽

Cited By ~ 4

Author(s):

Antonio Cannatà ◽

Giulia De Angelis ◽

Andrea Boscutti ◽

Camilla Normand ◽

Jessica Artico ◽

...

Keyword(s):

Ejection Fraction ◽

Risk Stratification ◽

Dilated Cardiomyopathy ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Novel Approach ◽

Magnetic Resonance Parameters ◽

Reverse Remodelling ◽

Life Threatening

Sudden cardiac death and arrhythmia-related events in patients with non-ischaemic dilated cardiomyopathy (NICM) have been significantly reduced over the last couple of decades as a result of evidence-based pharmacological and non-pharmacological therapeutic strategies. Nevertheless, the arrhythmic stratification in patients with NICM remains extremely challenging, and the simple indication based on left ventricular ejection fraction appears to be insufficient. Therefore, clinicians need to go beyond the current criteria for implantable cardioverter-defibrillator implantation in the direction of a multiparametric evaluation of arrhythmic risk. Several parameters for arrhythmic risk stratification, ranging from electrocardiographic, echocardiographic, imaging-derived and genetic markers, are crucial for proper arrhythmic risk stratification and a multiparametric evaluation of risk in patients with NICM. In particular, integration of cardiac magnetic resonance parameters (mostly late gadolinium enhancement) and specific genetic information (ie, presence of LMNA, PLN, FLNC mutations) appears fundamental for proper implementation of the current arrhythmic risk stratification. Finally, a novel approach focused on both arrhythmic risk and prediction of left ventricular reverse remodelling during follow-up might be useful for effective multiparametric and dynamic arrhythmic risk stratification in NICM. In the future, a complete and integrated evaluation might be mandatory to implement arrhythmic risk prediction in patients with NICM and to discriminate the competing risk between heart failure-related events and life-threatening arrhythmias.

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Clinical effectiveness of primary prevention implantable cardioverter-defibrillators: results of the EU-CERT-ICD controlled multicentre cohort study

European Heart Journal ◽

10.1093/eurheartj/ehaa226 ◽

2020 ◽

Vol 41 (36) ◽

pp. 3437-3447 ◽

Cited By ~ 10

Author(s):

Markus Zabel ◽

Rik Willems ◽

Andrzej Lubinski ◽

Axel Bauer ◽

Josep Brugada ◽

...

Keyword(s):

Cohort Study ◽

Primary Prevention ◽

Clinical Effectiveness ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Chronic Obstructive ◽

Implantable Cardioverter Defibrillators ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Cardioverter Defibrillators

Abstract Aims The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter-Defibrillators (EU-CERT-ICD), a prospective investigator-initiated, controlled cohort study, was conducted in 44 centres and 15 European countries. It aimed to assess current clinical effectiveness of primary prevention ICD therapy. Methods and results We recruited 2327 patients with ischaemic cardiomyopathy (ICM) or dilated cardiomyopathy (DCM) and guideline indications for prophylactic ICD implantation. Primary endpoint was all-cause mortality. Clinical characteristics, medications, resting, and 12-lead Holter electrocardiograms (ECGs) were documented at enrolment baseline. Baseline and follow-up (FU) data from 2247 patients were analysable, 1516 patients before first ICD implantation (ICD group) and 731 patients without ICD serving as controls. Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. During mean FU of 2.4 ± 1.1 years, 342 deaths occurred (6.3%/years annualized mortality, 5.6%/years in the ICD group vs. 9.2%/years in controls), favouring ICD treatment [unadjusted hazard ratio (HR) 0.682, 95% confidence interval (CI) 0.537–0.865, P = 0.0016]. Multivariable mortality predictors included age, left ventricular ejection fraction (LVEF), New York Heart Association class <III, and chronic obstructive pulmonary disease. Adjusted mortality associated with ICD vs. control was 27% lower (HR 0.731, 95% CI 0.569–0.938, P = 0.0140). Subgroup analyses indicated no ICD benefit in diabetics (adjusted HR = 0.945, P = 0.7797, P for interaction = 0.0887) or those aged ≥75 years (adjusted HR 1.063, P = 0.8206, P for interaction = 0.0902). Conclusion In contemporary ICM/DCM patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with a 27% lower mortality after adjustment. There appear to be patients with less survival advantage, such as older patients or diabetics.

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Out of Hospital Sudden Death in a Rural Population: Low Rates of ICD Underutilization Among Decedents

10.22541/au.160641014.45504893/v1 ◽

2020 ◽

Author(s):

Oghenesuvwe Eboh ◽

Yuxuan Mao ◽

Elisabeth Lee ◽

Victor Okunrintemi ◽

Ouassim Derbal ◽

...

Keyword(s):

Rural Population ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Unexpected Death ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Cardioverter Defibrillator ◽

Patients At Risk ◽

Life Threatening ◽

Lost To Follow Up

Introduction: The implantable cardioverter defibrillator (ICD) reduces mortality in patients at risk for potentially life-threatening arrhythmias. Access and distribution of ICDs in rural or economically disadvantaged populations is suspected to be low. This study examined Out of Hospital Premature Natural Death data (OHPND) and electronic medical record (EMR) data to identify rates of non-implantation of ICDs in a sample of decedents in eastern North Carolina. Methods and Results: Death certificate information on 1,316 decedents were matched with EMR data (N = 967, 73.4%). Chart review identified 70 (7.2%) potential ICD candidates with a left ventricular ejection fraction (LVEF) ≤35%. Of the 70 identified patients, 5 (7.1%) did not meet criteria because LVEF subsequently improved. Of the remaining 65 patients, 32 (49.2%) already received an ICD or a wearable cardioverter-defibrillator (WCD), and 33 patients (50.7%) met ICD implantation criteria but had not received one. The reasons identified for non-implantation of ICDs included: limited life expectancy secondary to comorbidities, principally chronic kidney disease (CKD) (N=11, 17%), lack of physician adherence to guidelines (N=9, 14%), lost to follow-up (N=7, 11%), patient refusal (N=5, 8%), and patients yet to commence guideline-directed medical therapy (N=1, 2%). Among our cohort of 967 individuals who died unexpectedly at home, 9 (0.9%) patients may have avoided unexpected death with an ICD/WCD. Conclusion: This study using decedent data shows low rates of ICD-underutilization in a rural population, but also emphasizes the role that advanced comorbidities such as CKD play in ICD-underutilization.

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5164New risk prediction score for life-threatening ventricular tachyarrhythmias in laminopathies

European Heart Journal ◽

10.1093/eurheartj/ehz746.0049 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Cited By ~ 1

Author(s):

K Wahbi ◽

R Ben Yaou ◽

E Gandjbakhch ◽

F Anselme ◽

T Gossios ◽

...

Keyword(s):

Risk Prediction ◽

Ventricular Tachyarrhythmia ◽

External Validation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Accurate Estimation ◽

Validation Sample ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Life Threatening

Abstract Background An accurate estimation of the risk of life-threatening (LT) ventricular tachyarrhythmia (VTA) in patients with LMNA mutations is crucial to select candidates for implantable cardioverter defibrillator (ICD) implantation. Methods We included 839 adult patients with LMNA mutations, including 660 from a French nationwide registry in the development sample, and 179 from other countries, referred to 5 tertiary centers for cardiomyopathies, in the validation sample. LTVTA was defined as a) sudden cardiac death or b) ICD-treated or hemodynamically unstable VTA. The prognostic model was derived using Fine-Gray's regression model. The net reclassification was compared with current clinical practice guidelines. The results are presented as means (standard deviation) or medians [interquartile range]. Results We included 444 patients 40.6 (14.1) years of age in the derivation sample and 145 patients 38.2 (15.0) years in the validation sample, of whom 86 (19.3%) and 34 (23.4%) suffered LTVTA over 3.6 [1.0–7.2] and 5.1 [2.0–9.3] years of follow-up, respectively. Predictors of LTVTA in the derivation sample were: male sex, non-missense LMNA mutation, 1st degree and higher atrioventricular block, non-sustained ventricular tachycardia, and left ventricular ejection fraction. In the derivation sample, C-index (95% CI) of the model was 0.776 (0.711–0.842). In the external validation sample, the C-index was 0.800 (0.642–0.959) and calibration slope 1.082 (95% CI, 0.643–1.522). A 5-year estimated risk threshold ≥7% predicted 96.2% of LTVTA and net reclassified 28.8% of patients with LTVTA compared with the guidelines-based approach. Conclusions Compared to the current standard of care, this risk prediction model for LTVTA in laminopathies facilitated significantly the choice of ICD candidates. Acknowledgement/Funding AFM Téléthon

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Sudden Arrhythmic Death at the Higher End of the Heart Failure Spectrum

Angiology ◽

10.1177/0003319719896475 ◽

2019 ◽

Vol 71 (5) ◽

pp. 389-396

Author(s):

Apostolos Dimos ◽

Andrew Xanthopoulos ◽

Michail Papamichalis ◽

Angeliki Bourazana ◽

Dimitrios Tavoularis ◽

...

Keyword(s):

Heart Failure ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Implantable Cardioverter Defibrillators ◽

Ventricular Ejection Fraction ◽

Arrhythmic Death ◽

Normal Left Ventricular ◽

Life Threatening ◽

Cardioverter Defibrillators ◽

Normal Lvef

The risk of sudden cardiac death (SCD) is high in heart failure (HF) patients. Sudden arrhythmic death (SAD) is a frequent cause of exit in HF patients at the lower end of the HF spectrum, and implantable cardioverter–defibrillators have been recommended to prevent these life-threatening rhythm disturbances in select patients. However, less is known regarding the cause of SCD in patients at the upper end of the HF spectrum, despite the fact that the majority of out-of-hospital SCD victims have unknown or near-normal/normal left ventricular ejection fraction (LVEF). In this review, we report the epidemiology, summarize the mechanisms, discuss the diagnostic challenges, and propose a stepwise approach for the prevention of SAD in HF with near-normal/normal LVEF.

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P1157Defibrillation threshold with subcutaneous implantable-cardioverter defibrillator implanted using an intermuscular 2-incision approach

EP Europace ◽

10.1093/europace/euaa162.145 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

M Biffi ◽

M Ziacchi ◽

C Martignani ◽

C Lavalle ◽

A Piro ◽

...

Keyword(s):

De Novo ◽

Safety Margin ◽

Real Life ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Implantable Cardioverter Defibrillators ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Shock Impedance ◽

Incision Technique

Abstract Funding Acknowledgements NO FUNDING OnBehalf Rhythm Detect Registry Background Current subcutaneous implantable cardioverter–defibrillators (S-ICD) deliver 80J, and the conversion test is usually conducted by delivering shock energy of 65 J to ensure a safety defibrillation margin of at least 15 J. However, little is known about the real safety margin in real life clinical practice. Purpose To determine the defibrillation threshold (DFT) with S-ICD and to investigate its association with clinical characteristics. Methods De novo S-ICD patients were consecutively enrolled and DFT was evaluated using a pre-specified step-up protocol at implantation. Results 35 patients, BMI 25 ± 4 kg/m2, left ventricular ejection fraction (LVEF) 48 ± 19%, underwent S-ICD implantation. The generator was positioned in an intermuscular pocket and a 2-incision technique was applied in all patients. The mean DFT was 30 ± 10J and the DFT was >30J in 7 (20%) patients. A single patient had a >40J DFT. The time to shock was 11 ± 3 seconds and the shock impedance was 67 ±21 Ohm at the lowest effective energy. The DFT was comparable in patients with LVEF ≤35% (33 ± 15J) versus >35% (29 ± 5J, p = 0.278), and in patients with BMI ≤25 kg/m2 (30 ± 5J) versus >25kg/m2 (31 ± 14J, p = 0.864). Conclusions We observed low DFT and low shock impedance in patients who received S-ICD with an intermuscular 2-incision approach. The S-ICD defibrillation success rate at ≤30J was 80%, while 97% of patients were defibrillated at ≤ 40J. We found no difference in DFT according to the LVEF or the BMI.

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Abstract 2431: Left Ventricular Scar Burden Predicts Life-Threatening Arrhythmia in Recipients of Implantable Cardioverter Defibrillilators

Circulation ◽

10.1161/circ.116.suppl_16.ii_534-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Pavlo I Netrebko ◽

Vitaly Geyfman ◽

Louis A Nassef ◽

Randle H Storm ◽

Jess W Oren ◽

...

Keyword(s):

Enzyme Inhibitor ◽

Univariate Analysis ◽

Ventricular Tachyarrhythmia ◽

Left Ventricular ◽

Myocardial Scar ◽

Implantable Cardioverter Defibrillators ◽

Icd Implantation ◽

Scar Burden ◽

End Point ◽

Life Threatening

Objective. Implantable cardioverter defibrillators (ICD) reduce arrhythmic deaths and are implanted based on LV ejection fraction (LVEF) and symptoms. Myocardial scar is a substrate for ventricular tachyarrhythmia (VT). We aimed to assess if number of LV scar segments [#SS, by cardiac magnetic resonance (CMR)] would predict life-threatening VT in recipient of ICD. Methods. Among 722 recipients of ICD (2002–2006), 54 [age 32– 84 (mean 63±12) years, 89% men, 76% ischemic, LVEF ≤35%] had CMR with delayed gadolinium enhancement prior to ICD. Using a 17-segment LV model, presence of scar was determined. End point was defined as confirmed VT requiring termination by anti-tachycardia pacing or shock. Results. At a mean follow-up of 15 (median 11.5) months, 12 (22%) patients reached end point. Univariate analysis identified LVEF and #SS as predictors whereas age, coronary artery disease, diabetes, hypertension, medications (anti-arrhythmic, beta-blocker, angiotensin-converting enzyme inhibitor, statin), creatinine, LV end-diastolic volume or LV mass were not predictive. #SS was higher in those who reached endpoint (8.5±1.2 vs 5.2±0.7, p=0.03). By receiver operator curve, a cut-off of ≥7 scarred segments identified those at high risk for VT (Graph - open circles are those with <7 scarred segments). By logistic regression, after control for EF, #SS remained significant (P 0.03) with 1.3 times higher incidence of VT per added scarred segment. LVEF and #SS did not correlate (p=0.07). Conclusion. Presence of large scar burden predicts VT in patients with advanced LV dysfunction. Assessment of myocardial scar burden by CMR may improve risk stratification prior to ICD implantation.

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MANAGEMENT OF HEART FAILURE PATIENTS (UPDATE 2019) – PHARMACOLOGICAL THERAPY

In a good rythm ◽

10.5604/01.3001.0014.1505 ◽

2020 ◽

Vol 1 (54) ◽

pp. 30-32

Author(s):

Przemysław Mitkowski ◽

Maciej Grymuza

Keyword(s):

Heart Failure ◽

Biventricular Pacing ◽

Total Mortality ◽

Cardiovascular Death ◽

Left Ventricular ◽

Pharmacological Therapy ◽

Left Ventricular Ejection ◽

Premature Ventricular Contractions ◽

Ventricular Ejection Fraction ◽

Patients With Heart Failure

The up-date of ESC Guidelines on the management of patients with heart failure was published last year. The beneficial effect of a new group of drugs (flozins, sacubitril/valsartan - ARNI) in patients with heart failure was pointed out. These drugs not only prevent the onset of heart failure but also reduce HF hospitalization rate and in patients with reduced left ventricular ejection fraction decrease risk of cardiovascular death and in case of empagliflozin, dapagliflozin or sacubitril/valsartan also total mortality. These latter medicines reduce also the likelihood of sudden cardiac death. ARNI reduce the number of appropriate ICD shocks, the incidence of non-sustained VT, premature ventricular contractions, and increase percentage of biventricular pacing in cardiac resynchronization recipients.

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Abstract 2135: Correlation between Resting Heart Rate and Defibrillation Energy Threshold in Patients Undergoing Implantable Cardioverter Defibrillator Device Implantation

Circulation ◽

10.1161/circ.118.suppl_18.s_673 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Ramtin Anousheh ◽

David E Krummen ◽

Navinder S Sawhney ◽

Wei Chung Chen ◽

Linda Tone ◽

...

Keyword(s):

Heart Rate ◽

Beta Blocker ◽

Standard Of Care ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Resting Heart Rate ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Blocker Therapy ◽

Beta Blocker Therapy

To investigate the association between resting heart rate (HR) and defibrillation threshold (DFT) in patients (pts) undergoing ICD implantation. DFT testing is usually considered standard of care during ICD implantation. However, the risk factors for high DFTs remain ill defined and the extent of testing required at implant has not been well defined. Baseline HR has been associated with higher DFTs in prior studies. We studied 128 pts undergoing ICD implantation. Baseline HR and DFTs were determined. HR was determined using ECGs obtained in the resting position on the day of ICD implantation. DFT testing was done during ICD implantation. We excluded 13 pts who were on amiodarone. The baseline characteristics of pts in the study are shown below in the table below (values in parenthesis represents standard error of the mean): First, a multivariate analysis of the association between baseline HR and DFT was performed, adjusting for left ventricular ejection fraction (LVEF), gender, body surface area (BSA) and beta blocker therapy. For every 10 beat increase in heart rate, DFT increased by 1 joule (p=0.02). Gender and beta blocker therapy did not effect this association. Second, pts were dichotomized based on DFTs to low (<15 joules) and high (≥15 joules). Mean resting HR was significantly higher among pts with high DFT (79 bpm) compared to those with low DFT (70 bpm) after adjusting for LVEF and BSA (p=0.01). Baseline resting HR is a risk factor for high DFT and may help define a higher risk pt population undergoing DFT testing.

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