Search

Even after a successful ventricular tachycardia ablation (VTA), some patients have recurrent ventricular tachycardia (VT) during their follow-up. We assessed the long-term predictors of recurrent VT after having a successful VTA. The patients who underwent a successful VTA (defined as the non-inducibility of any VT at the procedure’s end) in 2014–2021 at our center in Israel were retrospectively analyzed. A total of 111 successful VTAs were evaluated. Out of them, 31 (27.9%) had a recurrent event of VT after the procedure during a median follow-up time of 264 days. The mean left ventricular ejection fraction (LVEF) was significantly lower among patients with recurrent VT events (28.9 ± 12.67 vs. 23.53 ± 12.224, p = 0.048). A high number of induced VTs (>two) during the procedure was found to be a significant predictor of VT recurrence (24.69% vs. 56.67%, 20 vs. 17, p = 0.002). In a multivariate analysis, a lower LVEF (HR, 0.964; p = 0.037) and a high number of induced VTs (HR, 2.15; p = 0.039) were independent predictors of arrhythmia recurrence. The inducibility of more than two VTs during a VTA procedure remains a predictor of VT recurrence even after a successful VT ablation. This group of patients remains at high risk for VT and should be followed up with and treated more vigorously.

Background: Diabetes mellitus (DM) is an independent risk factor for atrial fibrillation (AF). Surgical ablation or "maze procedure" is an option for patients with (AF) undergoing concomitant or isolated cardiac surgery. The aim of this study was to evaluate the impact of DM on early and long-term outcomes of patients following surgical AF ablation. Methods: We performed an observational cohort study in Israel’s largest tertiary care center. All data of patients who underwent surgical AF ablation, between 2006 and 2021 were extracted from our departmental database. Patients were divided into Group I (non-diabetic patients) and Group II (diabetic patients). We compared the two groups with respect to freedom from recurrent atrial arrhythmia, and mortality rate. Results: The study population included 606 patients. Group I (non-DM patients), consisting of 484 patients, and Group II (DM type 2 patients), comprised 122 patients. Patients with DM were older, had more hypertension and incidence of cerebrovascular accident (CVA)/transient ischemic attack (TIA), higher EuroSCORE (p p=0.028). The mean follow-up duration was 39.0 ± 22.7 months. Freedom from atrial fibrillation was similar between the non-DM and DM groups after a 1-year follow-up, 414 (88.2%) vs. 101 (87.1%) (p = 0.511), after a 3-year follow-up, 360 (86.3%) vs. 84 (79.9%) (p = 0.290) and after a 5-year follow-up, 226 (74.1%) vs. 55 (71.5%) (p = 0.622) respectively. Furthermore, 1- and 3-year mortality was similar between non-DM and DM groups, 2.5% vs. 4.9%, (p = 0.226) and 5.6% vs. 10.5% (p = 0.076) respectively. 5-year mortality was higher in Group II (DM patients) compared with Group I (non-DM patients), 11.1% vs. 23.4% (p = 0.009). Conclusion: Surgical ablation had a high success rate, with freedom from recurrent atrial arrhythmia at 1- 3- and 5- years follow-up in both the DM and non-DM groups. Furthermore,1- and 3-year mortality after surgical ablation was also similar in both groups. However, 5-year mortality was higher in the DM group.

Aim To describe clinical characteristics, procedural details, specific challenges, and outcomes in patients with HeartMate3™ (HM3), a left ventricular assist device system with a magnetically levitated pump, undergoing ventricular tachycardia ablation (VTA). Methods and results Data were collected from patients with an HM3 system who underwent VTA in seven tertiary centres. Data included baseline patient characteristics, procedural data, mortality, and arrhythmia-free survival. The study cohort included 19 patients with cardiomyopathy presenting with ventricular tachycardia (VT) (53% with VT storm). Ventricular tachycardias were induced in 89% of patients and a total of 41 VTs were observed. Severe electromagnetic interference was present on the surface electrocardiogram. Hence, VT localization required analysis of intra-cardiac signals or the use of filter in the 40–20 Hz range. The large house pump HM3 design obscured the cannula inflow and therefore multi imaging modalities were necessary to avoid catheter entrapment in the cannula. A total of 32 VTs were mapped and were successfully ablated (31% to the anterior wall, 38% to the septum and only 9% to the inflow cannula region). Non-inducibility of any VT was reached in 11 patients (58%). Over a follow-up of 429 (interquartile range 101–692) days, 5 (26%) patients underwent a redo VT ablation due to recurrent VTA and 2 (11%) patients died. Conclusions Ventricular tachycardia ablation in patients with HM3 is feasible and safe when done in the appropriate setup. Long-term arrhythmia-free survival is acceptable but not well predicted by non-inducibility at the end of the procedure.

Objectives The aim of this study was to assess in patients with mitral valve prolapse (MVP) mitral annular disjunction (MAD) prevalence, phenotypic characteristics, and long-term outcomes (clinical arrhythmic events and excess mortality). Background Clinical knowledge regarding MAD of MVP remains limited and controversial, and its potential link with untoward outcomes is unsubstantiated. Methods A cohort of 595 (278 women, mean age 61 ± 16 years) consecutive patients with isolated MVP, with comprehensive clinical, rhythmic, Doppler echocardiographic, and consistent MAD assessment, were examined. MAD prevalence, associated MVP phenotypes, and outcomes (survival, clinical arrhythmic events) starting at diagnostic echocardiography were analyzed. To balance important baseline differences, propensity scoring matching was conducted among patients with and those without MAD. Results The presence of MAD was common (n = 186 [31%]) in patients with MVP, generally in younger patients, and was not random but was independently associated with severe myxomatous disease involving bileaflet MVP and marked leaflet redundancy (both P ≤ 0.0002). The presence of MAD was also independently associated with a larger left ventricle (P = 0.005). Age-matched cohort survival after MVP diagnosis was not worse with MAD (10-year survival 93% ± 2% for patients without MAD and 97% ± 1% for those with MAD; P = 0.40), even adjusted comprehensively for MVP characteristics (P = 0.80) and accounting for time-dependent mitral surgery (P = 0.60). During follow-up, 170 patients had clinical arrhythmic events (ventricular tachycardia, n = 159; arrhythmia ablation, n = 14; cardioverter-defibrillator implantation, n = 14; sudden cardiac death, n = 3). MAD was independently associated with higher risk for arrhythmic events (adjusted HR: 2.60; 95% CI: 1.87-3.62; P Conclusions This large cohort with MVP comprehensively characterized shows that MAD is frequent at MVP diagnosis and is strongly linked to advanced myxomatous degeneration. The presence of MAD was independently associated with long-term excess incidence of clinical arrhythmic events. However, within the first 10 years post-diagnosis, MAD was not linked to excess mortality, and although reassurance should be provided from the survival point of view, careful monitoring for arrhythmias is in order for MAD.

We present an asymptomatic 26-year-old athlete, with no family history of sudden cardiac death and no structural heart disease, who displayed short-coupled premature ventricular contractions on exercise test and Holter monitoring. The rarity of the case as well as management dilemmas are discussed. (Level of Difficulty: Intermediate.), Graphical abstract

Brugada syndrome (BrS) is a primary electrical disease predisposing to ventricular tachyarrhythmias and sudden cardiac death [...]

INTRODUCTION: Transvenous Lead Extraction (TLE) is usually performed via a superior approach. Predictors and outcomes of TLE requiring femoral vein bailout are poorly defined. We aimed to analyze predictors and consequences of TLE requiring femoral bailout. METHODS: A single tertiary center cohort of 421 consecutive patients who underwent TLE between May 2010 and February 2020 were analyzed. Venography was routinely performed before system upgrade to identify occluded veins. Patients were divided into 2 groups according to their need for femoral bailout extraction. RESULTS: A total of 928 leads were extracted with femoral bailout approach was needed in 71 leads(7.7%) among 49 patients(11.6%). A higher proportion of right ventricular(RV) leads required femoral bailout approach compared with right atrial(RA) leads[51/499(10.2%) vs 18/326(5.5%);p=0.02]. Femoral bailout was more common among younger patients, longer lead dwell time, more pocket entries, higher number of extracted leads, presence of abandoned leads and among patients with vascular occlusion. Following multivariate analysis, presence of abandoned leads, vascular occlusion and younger age remained a significant predictor for femoral bailout. Femoral bailout resulted in higher rates of major complications [5/49(10.2%) vs 12/372(3.2%);p=0.05] without intra-procedural mortality and no additional 30-day mortality[2/49(4.1%) vs 33/377(8.8%);p=0.39]. CONCLUSION: TLE of abandoned leads, occluded veins and younger age were found to be predictors of femoral bailout requirement. Despite higher rates of major complications in femoral TLE bailout, mortality was not increased. Venography prior to TLE should be considered for procedure planning.

(1) Background: Implantable cardioverter defibrillators (ICDs) have become the standard of care in the prevention of sudden cardiac death, yet studies have shown that competing causes of death may limit ICD benefits. The Norton scale is a pressure ulcer risk score shown to have prognostic value in other fields. The purpose of this study was to assess the use of the Norton scale as an aid for ICD patient selection; (2) Methods: The study was comprised of consecutive patients who underwent defibrillator implantation at Sheba Medical Center between 2008 and 2016. A competing risk analysis was performed to assess the likelihood of death prior to device therapy; (3) Results: 695 patients were included. A total of 59 (8.5%) patients had low admission Norton scale score (ANSS) (≤14), 81 (11.7%) had intermediate ANSS (15–17), and the remainder (79.8%) had high (18–20) ANSS. The cumulative probability of all-cause mortality within one year of ICD implantation in patients with low ANSS was 30%, compared with 20% and 7% among the intermediate- and high-ANSS groups, respectively. Moreover, the one-year mortality rate without ICD therapy in low-ANSS patients was over four-fold compared with that of high-ANSS patients (33% versus 7%, p < 0.0001); (4) Conclusions: The Norton scale could be a useful additional tool in predicting the life expectancy of ICD candidates, thereby improving patient selection.

Background Transvenous Lead Extraction (TLE) is usually performed via a superior approach. Predictors and outcomes of TLE via femoral vein bailout are ill defined. Methods A single tertiary center cohort of 426 consecutive patients who underwent TLE between May 2010 and February 2020 were analyzed. Venography was routinely performed before system upgrade to identify occluded veins. Patients were divided into 2 groups on the basis of the need for femoral bailout extraction. Predictors for TLE requiring femoral bailout and outcomes were analysed. Results A total of 928 leads were extracted and femoral bailout approach was needed in 49 patients (11.5%). A higher proportion of RV leads required femoral bailout approach [51/499 (10.2%)]. Femoral bailout was more common among younger patients, longer lead dwell time, more pocket entries, higher number of extracted leads, presence of abandoned leads [14/49 (28.6%)], and among patients with occluded veins [10/22 (45.5%)]. The presence of abandoned leads, vascular occlusion and age remained a significant predictor for femoral bailout in multivariate analysis. Femoral bailout TLE resulted in a relatively higher rate of major complications [5/49 (10.2%) vs 9/377 (2.4%); p=0.02) but had no related intra-procedural mortality (0/3) and no additional 30 day mortality [2/49 (4.1%) vs 33/377 (8.8%); p=0.4]. Conclusion TLE of abandoned leads, occluded veins and younger age were found to be predictors of femoral bailout requirement. Despite higher rates of major complications in femoral TLE bailout this did not result in increased mortality. Venography before TLE should be considered for procedure planning. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) onset in the young (≤45 years) is uncommon and not well studied. Purpose Identifying the determinants of AF in this population in order to help direct timely diagnosis, appropriate follow up and management. Methods We retrospectively evaluated all patients aged ≤45, admitted to the internal and cardiology wards between January 2009 and December 2019 at a large tertiary center. Clinical, electrocardiographic and echocardiographic data were collected and compared among patients with and without AF at baseline. A subgroup of patients with no AF at baseline and a subsequent hospital visit were followed for development of new onset AF (NOAF). Results A total of 16,432 patients (55.5% male, 33 ±8.3 years old) were analyzed. At baseline, patients with AF (n = 366) tended to be older, more often male, and had a higher proportion of comorbidities and ECG conduction disorders, compared with the patients without AF (n = 16,066). Male sex, increased age, obesity, heart failure (HF) and the presence of left or right bundle branch block (LBBB and RBBB, respectively) were all strongly and independently associated with young-onset AF. A total of 10,691 patients were followed for a median of 41.5 (16.6-78.6) months, during which 85 patients developed NOAF (equivalent to 0.5%/year). Increased age, hypertension, HF, RBBB and LBBB were independent predictors of NOAF. CHARGE-AF score outperformed CHA2DS2-VASc score in NOAF prediction [AUC of ROC 0.75 (0.7-0.8) vs. 0.56 (0.48-0.65)]. Conclusions The annual risk of NOAF among young adults admitted to the hospital is noteworthy. NOAF may be predicted by clinical risk factors and the CHARGE-AF score. Characteristic No AF (N = 16066) AF (N = 366) Total (N = 16432) P value Age- yr. 33.06 ± 8.3 36.8 ± 7.3 33.1 ±8.3 200ms 117 (1.3) 15 (9.1) 132 (1.5) 120ms 220 (2.4) 25 (8.4) 245 (2.6)

The aim of this study was to assess in patients with mitral valve prolapse (MVP) mitral annular disjunction (MAD) prevalence, phenotypic characteristics, and long-term outcomes (clinical arrhythmic events and excess mortality).Clinical knowledge regarding MAD of MVP remains limited and controversial, and its potential link with untoward outcomes is unsubstantiated.A cohort of 595 (278 women, mean age 61 ± 16 years) consecutive patients with isolated MVP, with comprehensive clinical, rhythmic, Doppler echocardiographic, and consistent MAD assessment, were examined. MAD prevalence, associated MVP phenotypes, and outcomes (survival, clinical arrhythmic events) starting at diagnostic echocardiography were analyzed. To balance important baseline differences, propensity scoring matching was conducted among patients with and those without MAD.The presence of MAD was common (n = 186 [31%]) in patients with MVP, generally in younger patients, and was not random but was independently associated with severe myxomatous disease involving bileaflet MVP and marked leaflet redundancy (both P ≤ 0.0002). The presence of MAD was also independently associated with a larger left ventricle (P = 0.005). Age-matched cohort survival after MVP diagnosis was not worse with MAD (10-year survival 93% ± 2% for patients without MAD and 97% ± 1% for those with MAD; P = 0.40), even adjusted comprehensively for MVP characteristics (P = 0.80) and accounting for time-dependent mitral surgery (P = 0.60). During follow-up, 170 patients had clinical arrhythmic events (ventricular tachycardia, n = 159; arrhythmia ablation, n = 14; cardioverter-defibrillator implantation, n = 14; sudden cardiac death, n = 3). MAD was independently associated with higher risk for arrhythmic events (adjusted HR: 2.60; 95% CI: 1.87-3.62; P 0.0001). The link between MAD and arrhythmic events persisted with time-dependent mitral surgery (adjusted HR: 2.54; 95% CI: 1.84-3.50; P 0.0001), was strong under medical management (adjusted HR: 3.21; 95% CI: 2.03-5.06; P 0.0001) but was weaker after mitral surgery (adjusted HR: 2.07; 95% CI: 1.24-3.43; P = 0.005).This large cohort with MVP comprehensively characterized shows that MAD is frequent at MVP diagnosis and is strongly linked to advanced myxomatous degeneration. The presence of MAD was independently associated with long-term excess incidence of clinical arrhythmic events. However, within the first 10 years post-diagnosis, MAD was not linked to excess mortality, and although reassurance should be provided from the survival point of view, careful monitoring for arrhythmias is in order for MAD.

Introduction Hypertrophic cardiomyopathy (HCM) is a structural heart disease defined by an increase in left-ventricular (LV) wall thickness, that may be complicated with a clinical syndrome of heart failure, arrhythmia and death. Purpose To characterize the clinically significant factors for female HCM patients and bring forward the awareness to gender-based differences in HCM. Methods We reviewed the patient records of 1297 patients age ≥18 years, diagnosed with HCM, from two tertiary medical centers in Spain and Israel, and analyzed 748 male and female patients matched for age ≥60 years at admission, BMI, hypertension, diabetes and obstructive HCM. Results Female patients were older at original diagnosis [median 54 years (38–66) vs. 50 years (35–60), p=0.007], and had higher rates of family history of both HCM (46% vs. 37%, p=0.01) and sudden cardiac death (23% vs. 15%, p=0.02). Female patients had lower rates of active smoking (11% vs. 25%, p Conclusions Female patients suffering from HCM have a clinical phenotype defined by slightly later presentation (and shorter time until admission to a tertiary-center cardiomyopathy clinic), smaller LV cavity size, higher severity of mitral insufficiency and pulmonary hypertension and worse functional and exercise capacities. Genders did not differ in 5-year mortality, which was relatively low. Functional and exercise capacity Funding Acknowledgement Type of funding source: None

Background Mitral-annulus-disjunction (MAD), often described in mitral-valve-prolapse (MVP) patients, remains incompletely defined and its clinical outcome consequences are unknown. Objectives To assess MAD prevalence, clinical and echocardiographic characteristics, and independent impact on outcome in patients with isolated-MVP. Methods A cohort of 595 (65±16 years, 278 female) consecutive patients with MVP and comprehensive clinical, rhythmic and Doppler-echocardiographic characterization, was identified. Primary-endpoint was overall-survival, or occurrence of ventricular-arrhythmia. To eliminate clinical differences, we matched MAD-patients 1:1 with no-MAD based on propensity score for overall survival analysis using a greedy 5-to-1 digit-matching algorithm. Results MAD was frequent, present in 186 (31%) of MVP-patients and independently associated to bileaflet-MVP, leaflet-redundancy, younger-age, female-sex, enlarged left-ventricle-endsystolic-diameter and higher left-ventricle-ejection-fraction (all P≤0.04). Outcome primary-endpoint of survival after MVP diagnosis in matched-cohort (10-year 95±1%) was not associated with MAD presence (10-year 93±2% for no-MAD and 97±1% for MAD, P=0.4). Mortality was comparable for MAD (univariate-hazard-ratio 0.64 [0.25–1.65], P=0.4 vs. no-MAD), even adjusted-comprehensively including for MVP-characteristics (adjusted-hazard-ratio 1.17 [0.39–3.50], P=0.8). However, 220 (51%) MVP-patients were diagnosed ventricular-arrhythmia (161 with ventricular-tachycardia only) and long-term, MAD was associated with lower arrhythmia- and ventricular-tachycardia- overall freedom (adjusted-hazard-ratio for MAD 2.35 [1.75–3.15], P Conclusion In this unique MVP cohort, with arrhythmia and MAD comprehensively-characterized, MAD presence was frequent and independently associated to bileaflet-MVP and leaflet-redundancy. Long-term, MAD compared to no-MAD is not independently associated with higher-mortality but to reduced arrhythmia-freedom occurrence. Survival overall and by V arrhythmia Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Mayo Foundation

Background Advanced hypertrophic cardiomyopathy (HCM) may be complicated by a dilated hypokinetic transformation. Reduced left ventricular ejection fraction (HFrEF) has been described in terms of specific risks of morbidity and mortality, and specifically in terms of increased risk for fatal arrhythmias. Nevertheless, recent publications have casted doubt regarding the role of arrhythmia in non-ischemic HFrEF and questioned the role of primary prevention strategies in these cases. Methods We've reviewed clinical characteristics of 883 patients age ≥40, diagnosed with HCM who were evaluated in the cardiomyopathy clinic in two tertiary medical centers in Israel and Spain. Results Forty-five patients (5%) suffered from hypokinetic transformation. They were younger at diagnosis (median 32 [IQR 24–55] vs. 49 [35–60], p Conclusions HCM patients suffering from hypokinetic transformation have lower functional and exercise capacities, are more likely to suffer from ventricular tachyarrhythmias and experience appropriate ICD therapy, and undergo heart transplantation. They also have a significantly lower 5-year survival. Five-year survival Funding Acknowledgement Type of funding source: None

Background The majority of patients with of Mitral-valve-prolapse (MVP) have a excellent prognosis. Until recently most cases of mortality were thought to be related to mitral regurgitation and left ventricular dysfunction. The concept of the arrhythmic MVP emerged to describe cases of sudden cardiac death (SCD) in the presence of isolated MVP yet it’s phonotype remains incompletely and inconsistently defined. Purpose To analyze the prevalence, severity and characteristics of ventricular-arrhythmia (VA), to determine it’s phenotypical context and independent impact on outcome in patients with MVP. Methods A cohort of 595 (65 ± 16 years, 278 female) consecutive patients with MVP and comprehensive clinical, arrhythmia (24hour-Holter) and Doppler-echocardiographic characterization, was identified and long-term outcome analyzed. Results VA was frequent, present in 43% of patients with at least ventricular ectopy≥5%, but was most often moderate (ventricular-tachycardia—VT 120-179bpm) in 27% and rarely severe (VT≥180/min) in 8.6%. Presence of VA was associated with older age, male sex, bileaflet-prolapse, marked leaflet redundancy, mitral-annulus-disjunction (MAD), larger left-atrium and left ventricular end-systolic diameter, and T-wave-inversion/ST-depression (all P ≤ 0.001). Severe VA was independently associated with presence of MAD, leaflet-redundancy and T-wave-inversion/ST-depression (all P Conclusions This large cohort of isolated consecutive MVP characterized with 24-hour-Holter monitoring, clinical and Echocardiographic assessment, demonstrates that VA are frequent with MVP but rarely severe. The arrhythmic MVP was independently and strongly associated with specific ECG and morphologic patterns, particularly ST-T changes, MAD presence and marked leaflet redundancy, suggestive of a specific arrhythmic MVP phenotype, independently of MR-severity. Arrhythmia, particularly severe, is associated with long-term excess-mortality, independently of any other characteristics, including MR severity and LVEF. These findings lay the foundation for novel risk-stratification of MVP for the conduct of prospective controlled studies evaluating the management of MVP high-risk patients. Figure – Impact on survival of ventricular arrhythmia Overall survival of MVP stratified by ventricular arrhythmia (Panel A) or ventricular arrhythmia severity (Panel B) throughout follow-up. Abstract Figure.

Aims Diabetes mellitus (DM) aggravates the clinical features of ischaemic and hypertensive heart diseases and worsens the prognosis of heart failure patients. Hypertrophic cardiomyopathy (HCM) and diabetes coexist fairly frequently in elderly patients but the impact of DM on the clinical phenotype of HCM is yet unknown. We sought to describe if predominant features of heart failure in DM patients exist independently in HCM. Methods and results We reviewed clinical characteristics of 937 patients, age ≥40, diagnosed with HCM, from two tertiary medical centres in Spain and Israel. A propensity score matched cohort of 294 patients was also analysed. Our cohort comprised 102 HCM patients with diabetes (8.7%). Patients with DM were older at diagnosis {median 56 [interquartile range (IQR) 47–67] vs. 53 (IQR 43–63), P = 0.02} and had a higher prevalence of comorbidities. Hypertrophic cardiomyopathy patients with DM had a higher prevalence of diastolic dysfunction, pulmonary hypertension, significant mitral regurgitation, and pacemaker implantation. Hypertrophic cardiomyopathy patients with DM had a higher New York Heart Association (NYHA) class (P Conclusion Hypertrophic cardiomyopathy patients with diabetes are older and have a higher cardiovascular risk profile. They have a lower functional capacity and more heart failure symptoms due to diastolic dysfunction.

Background: Takotsubo cardiomyopathy affects between 1.7% and 2.2% of patients hospitalized with suspected acute coronary syndromes. Characterized by chest pain, electrocardiogram changes, and transient left ventricular apical wall motion abnormality, it is under-recognized and often misdiagnosed. Objectives: In order to better differentiate between St-segment myocardial infarction and Takotsubo cardiomyopathy, we developed a scoring system. Methods: Of the 82 patients enrolled with Takotsubo cardiomyopathy, 67 had ST-segment elevation on electrocardiogram and were compared with 79 ST-elevation myocardial infarction patients. A multi-variant logistic regression model was used to find factors independently associated with Takotsubo cardiomyopathy. The Platelets and Thrombosis in Sheba (PLATIS)-Takotsubo cardiomyopathy is based on a 10-point scoring system: stressful events (3), females (2), no history of diabetes mellitus (2), estimated left ventricular ejection fraction ≤ 40% on admission echo (1), positive troponin on admission (1), and no smoking (1). Patients with Takotsubo cardiomyopathy were older (66 ± 11 vs 60 ± 11 years, p Results: In a multivariate logistic regression analysis, the average Platelets and Thrombosis in Sheba-Takotsubo cardiomyopathy scoring was significantly higher in Takotsubo cardiomyopathy compared with ST-elevation myocardial infarction patients (8.35 ± 1.7 vs 3.42 ± 1.6, p Conclusion: The Takotsubo cardiomyopathy scoring system is a simple, reliable tool that can assist in diagnosing and differentiating between patients with Takotsubo cardiomyopathy and those with ST-elevation myocardial infarction.

Introduction There are limited contemporary data regarding the association between improvement in cardiovascular fitness in heart failure patients who participate in a cardiac rehabilitation programme and the risk of subsequent hospitalisations. Methods The study population comprised 421 patients with heart failure who participated in our cardiac rehabilitation programme between the years 2009 and 2016. All were evaluated by a standard exercise stress test before initiation, and underwent a second exercise stress test on completion of 3 ± 1 months of training. Participants were dichotomised by fitness level at baseline, according to the percentage of predicted age and sex norms achieved. Each group was further divided according to its degree of functional improvement, between the baseline and the follow-up exercise stress test. Major improvement was defined as improvement above the median value in each group. The combined primary endpoint was cardiac hospitalisation or all-cause mortality. Results A total of 211 (50%) patients had low baseline fitness (Conclusion In heart failure patients participating in a cardiac rehabilitation programme, improved cardiovascular fitness is associated with reduced mortality or cardiac hospitalisation risk during long-term follow-up, independent of baseline fitness.

After 50 years of a fundamentally unchanged pacemaker schema—a pulse generator with battery and electronics connects to insulated conductors (leads) that sense and stimulate atrial and/or ventricular myocardium—the basic paradigm of how cardiac tissue is stimulated to treat arrhythmias is dramatically changing. The aim of this chapter is to review pertinent contemporary and emerging pacing technologies and to present concepts and the available clinical evidence evaluating their safety and efficacy. These range from algorithms to extend device longevity and minimize ventricular pacing, to leadless pacemakers and His bundle pacing, which eliminate leads or leverage the heart’s own conductive tissues to effectively distribute stimulation, respectively. Basic pacemaker functions, sensing and pacing, are aptly discussed elsewhere and are the not the focus of this chapter. Rather, we will review more recent advances of the components of pacing systems as well as of the algorithms that govern their function. Implantable cardioverters defibrillators and cardiac resynchronization therapy systems are discussed at length in other chapters of this book and will therefore not be included in the scope of this chapter.

Mitral valve prolapse (MVP) is often considered benign but recent suggestion of an arrhythmic MVP (AMVP) form remains incompletely defined and uncertain.This study determined ventricular arrhythmia prevalence, severity, phenotypical context, and independent impact on outcome in patients with MVP.A cohort of 595 (age 65 ± 16 years; 278 women) consecutive patients with MVP and comprehensive clinical, arrhythmia (24-h Holter monitoring) and Doppler-echocardiographic characterization, was identified. Long-term outcomes were analyzed.Ventricular arrhythmia was frequent (43% with at least ventricular ectopy ≥5%), most often moderate (ventricular tachycardia [VT]; 120 to 179 beats/min) in 27%, and rarely severe (VT ≥180 beats/min) in 9%. Presence of ventricular arrhythmia was associated with male sex, bileaflet prolapse, marked leaflet redundancy, mitral annulus disjunction (MAD), a larger left atrium and left ventricular end-systolic diameter, and T-wave inversion/ST-segment depression (all p ≤ 0.001). Severe ventricular arrhythmia was independently associated with presence of MAD, leaflet redundancy, and T-wave inversion/ST-segment depression (all p 0.0001) but not with mitral regurgitation severity or ejection fraction. Overall mortality after arrhythmia diagnosis (8 years; 13 ± 2%) was strongly associated with arrhythmia severity (8 years; 10 ± 2% for no/trivial, 15 ± 3% for mild and/or moderate, and 24 ± 7% for severe arrhythmia; p = 0.02). Excess mortality was substantial for severe arrhythmia (univariate hazard ratio [HR]: 2.70; 95% confidence interval [CI]: 1.27 to 5.77; p = 0.01 vs. no/trivial arrhythmia), even after it was comprehensively adjusted, including for MVP characteristics (adjusted HR: 2.94; 95% CI: 1.36 to 6.36; p = 0.006) and by time-dependent analysis (adjusted HR: 3.25; 95% CI: 1.56 to 6.78; p = 0.002). Severe arrhythmia was also associated with higher rates of mortality, defibrillator implantation, VT ablation (adjusted HR: 4.68; 95% CI: 2.45 to 8.92; p 0.0001), particularly under medical management (adjusted HR: 5.80; 95% CI: 2.75 to 12.23; p 0.0001), and weakly post-mitral surgery (adjusted HR: 3.69; 95% CI: 0.93 to 14.74; p = 0.06).In this large cohort of patients with MVP, ventricular arrhythmia by Holter monitoring was frequent but rarely severe. AMVP was independently associated with phenotype dominated by MAD, marked leaflet redundancy, and repolarization abnormalities. Long-term severe arrhythmia was independently associated with notable excess mortality and reduced event-free survival, particularly under medical management. Therefore, AMVP is a clinical entity strongly associated with outcome and warrants careful risk assessment and well-designed clinical trials.

Introduction To assess in MVP-patients, MAD prevalence, phenotypic characteristics and long-term outcome. Method A cohort of 595 (278 female, age 61 ± 16 years) patients with isolated MVP, clinical, rhythmic, Doppler-echocardiographic and MAD assessment was examined. MAD prevalence, phenotype and outcome (survival, clinical arrhythmic events) starting at diagnostic echocardiogram were analyzed. To balance important baseline differences, we also propensity-score matched patients with and without MAD (no-MAD). Results MAD presence was common (186–31%) in MVP, generally in younger patients and independently associated with severe-myxomatous-MVP and larger-LV (P ≤ 0.005). Age-matched-cohort survival after MVP diagnosis was not worse with MAD (10-year 93 ± 2% for no-MAD and 97 ± 1% for MAD, P = 0.4), even adjusted-comprehensively for MVP-characteristics (P = 0.8) and accounting for time-dependent (TD) mitral-surgery (P = 0.6). During follow-up, 170 patients had clinical-arrhythmic-events [ventricular tachycardia (n = 159), arrhythmia-ablation (n = 14), Cardioverter-defibrillator-implantation (n = 14) and sudden-cardiac-death (n = 3)]. MAD was independently associated with higher risk of arrhythmic-events [adjusted-HR 2.60(1.87–3.62), P Fig. 1 ). Conclusion This large cohort with MVP comprehensively characterized, shows that MAD is frequent at MVP diagnosis and strongly linked to advanced-myxomatous-degeneration. MAD presence is independently associated with long-term excess-incidence arrhythmic-events. However, within the first 10 years post-diagnosis MAD is not linked to excess-mortality and while reassurance should be provided from the survival point of view careful monitoring for arrhythmias is in order with MAD.

Background: Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. Methods: Data from the Acute Coronary Survey in Israel registry 2000–2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. Results: The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p1 (odds ratio=1.32, pConclusions: Among patients with ST-elevation myocardial infarction, the utilization of mobile intensive care units is associated with increased rates of primary reperfusion, a reduction in the time interval to reperfusion, and a reduction in one-year adjusted mortality.

BACKGROUND The past decade has brought major advances in therapy of patients presenting with acute coronary syndromes (ACS). HYPOTHESIS The outcomes of ACS patients with atrial fibrillation (AF) has improved over the years. METHODS We evaluated time-dependent changes in clinical characteristics, management strategies, and outcomes associated with AF observed during ACS hospitalization in patients enrolled in the biannual ACS Israeli Surveys (ACSIS) between 2000 and 2013. We divided the surveys into early (2000-2006) and late (2008-2013) time periods. RESULTS The study population comprised 13 297 ACS patients, of whom 755 (5.7%) either presented with or developed AF during the index hospitalization. The incidence of AF observed during ACS hospitalization was lower during the later period (6.2% vs 4.9%; P < 0.01). Kaplan-Meier survival analysis showed that 1-year mortality rates were significantly lower among ACS patients with and without AF who were enrolled during the later vs early survey period (log-rank P < 0.01 for the overall difference). However, AF observed among ACS patients was still associated with increased risk for in-hospital complications and 30-day and 1-year mortality during both the early and late survey periods (P < 0.05 for all comparisons). CONCLUSIONS In 10 years, rates of AF among ACS patients have declined significantly. Yet, despite improved overall 1-year survival for patients with AF, the development of AF in this population remains an independent predictor of mortality that has not changed appreciably over the years.

To investigate the association between heart rate recovery (HRR) and new-onset atrial fibrillation (AF) in middle-aged adults.Heart rate recovery was calculated using the exercise stress test in 15,729 apparently healthy self-referred men and women who attended periodic health screening examinations between January 2000, and December 2015. All participants completed the maximal exercise stress test according to the Bruce protocol and were followed clinically on a yearly basis for a median of 6.4±4 years. The primary end point was new-onset AF. Participants were grouped according to HRR at 5 minutes, dichotomized at the median value (73 beats/min).Participants with low HRR were older, were more commonly men, had a higher rate of comorbidities, and were less fit. Kaplan-Meier survival analysis revealed that the cumulative probability of AF at 6 years was higher in participants with low HRR (2.1%) than in those with high HRR (0.6%) (log-rank, P.001). Older age, male sex, obesity resting heart rate, and ischemic heart disease were all associated with increased AF risk in a univariate Cox regression model (P.05 for all). Multivariate Cox regression analysis revealed that low HRR was independently associated with increased AF risk (hazard ratio, 1.92; 95% CI, 1.3-2.8; P.001) after adjustment for multiple confounders.Lower HRR is independently associated with the development of new-onset AF during long-term follow-up in middle-aged adults.

Objectives The study sought to analyze the risk of ventricular tachyarrhythmia (VTA) or death in black and white subjects implanted with implantable cardioverter-defibrillators (ICDs) or defibrillator and combined cardiac resynchronization therapy (CRT-D) in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation with Cardiac Resynchronization Therapy) trial. Background There are limited data on ethnic differences in the risk for VTA in mildly symptomatic heart failure patients with left ventricular dysfunction. Methods The risk for first VTA (≥180 beats/min) or death was evaluated in black (n = 139) versus white (n = 1,638) patients enrolled in the MADIT-CRT trial using Kaplan-Meier survival analyses and Cox proportional hazards regression models after adjustment for relevant clinical covariates. Multivariate analysis was used to identify race-specific risk factors for VTA. Results At 4 years of follow-up, the cumulative probability for a first VTA or death was significantly higher among black patients (42%) as compared with whites (34%; log-rank p value for the overall difference during follow-up = 0.01). Multivariate analysis confirmed significantly higher risk of VTA or death (hazard ratio: 1.60; 95% confidence interval: 1.18 to 2.17; p = 0.002), and higher risk of VTA alone (hazard ratio: 1.71; 95% confidence interval: 1.22 to 2.41; p = 0.002) in blacks compared to whites. The findings were similar in both ICD and CRT-D implanted patients, with no significant race-to-treatment-interaction (interaction p values >0.05). Independent risk factors for VTA among blacks included increased systolic blood pressure values and larger cardiac volumes. Conclusions In the MADIT-CRT trial, black patients had a significantly higher rate of ventricular tachyarrhythmias or death compared to whites, with either an implanted ICD or CRT-D. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation with Cardiac Resynchronization Therapy [MADIT-CRT], NCT00180271 ; Multicenter Automatic Defibrillator Implantation with Cardiac Resynchronization Therapy Post Approval Registry [MADIT-CRT PAR], NCT01294449 ; MADIT-CRT LONG-TERM INTERNATIONAL FOLLOW-UP REGISTRY–EUROPE, NCT02060110 ).

Catheter ablation (CA) is a well-established therapeutic option for patients with recurrent symptomatic atrial fibrillation (AF). Data on gender-related differences are limited with regard to baseline characteristics and long-term success rates of catheter ablation for AF.We analyzed a cohort of 251 consecutive patients who underwent a first catheter ablation for AF in our institute during the period 2008 through 2015. All patients were followed by regular annual clinic visits, electrocardiograms, periodic 24-48 hour Holter monitoring, and loop recorders. The primary endpoint was first recurrence of AF during 1 year of follow-up.The cohort comprised 26% women (n=65), who were older (62.1 ± 9.6 vs. 54.4 ± 11.3 years, P0.01) and had a higher proportion of diabetes mellitus (23.1 vs. 5.4%, P0.001) than male patients. No other significant differences were evident. At 1 year follow-up, the cumulative survival free of AF was significantly higher in women compared with men (83% vs. 66%, respectively, log rank P value = 0.021). Subgroup analysis showed an interaction between female and small indexed left atrial diameter (LADi23 mm/m2).Our findings suggest that women experience a significantly lower rate of AF recurrence post-CA compared with men. This gender-related advantage appears to be restricted to women without significant left atrial enlargement. It further implies that left atrial enlargement has a stronger negative impact on post-CA AF recurrence in females than in males. Due to the relatively small sample number of females further research is warranted to validate our conclusions.

Response to cardiac resynchronization therapy (CRT) is well-established in patients with typical left bundle branch block (LBBB) but modest or even negative in those with intraventricular conduction delay (IVCD). However, IVCD pattern is heterogeneous, and it is possible that QRS patterns may also respond to CRT. Consecutive baseline ECGs of 239 patients implanted between 2007 and 2010 with CRT were analyzed. ECGs were classified into the following three groups: (a) typical LBBB (TLBBB) according to accepted guidelines (n = 67); (b) IVCD with LBBB pattern criteria in V1, 1, and aVL but with QS or rS in V5–V6 which we defined as atypical LBBB (ALBBB) (n = 74); and (c) all other IVCD (OIVCD) patterns (n = 98). Endpoints were 2 years mortality and echocardiographic response, defined as a decrease of ≥ 10% in indexed LVESV or an increase of ≥ 5% in left ventricular ejection fraction at 1 year of follow-up. Baseline clinical characteristics were similar among all the three groups. Rates of echocardiographic response were lower among those with OIVCD compared to those with LBBB and ALBBB (50% vs. 75% and 72%, respectively, p = 0.01 for both comparisons). A multivariable model showed a lower likelihood of echocardiographic response in OIVCD [HR = 0.40; (0.16–0.98)] and a similar likelihood in ALBBBB [HR = 0.98; (0.40–2.40)] compared to TLBBB. Cumulative 2-year survival was 88% in ALBBB, 86% in TLBBB, and 76% in OIVCD (p value = 0.011). Patients with ALBBB may have a favorable echocardiographic response to CRT and display similar survival rates to typical LBBB. This subgroup of IVCD should be considered for CRT. Atypical left bundle branch morphology defined as QS or rS in lead V1, broad R waves in lead I, and aVL but with QS or rS in V5–V6 is associated with favorable echocardiographic response to CRT and displays similar survival rates to typical LBBB patients.

The burden of atrial fibrillation (AF) is projected to increase substantially over the next decade in parallel with the aging of the population. The increasing age, level of comorbidity, and polypharmacy will complicate the treatment of older adults with AF. For instance, advanced age and chronic kidney disease have been shown to increase the risk of both thromboembolism and bleeding in patients with AF. Frailty, recurrent falls and polypharmacy, while very common among elderly patients with AF, are often overlooked in the clinical decision making despite their significant interaction with oral anticoagulant (OAC) and profound impact on the patient's clinical outcomes. Such factors should be recognized, evaluated and considered in a comprehensive decision-making process. The introduction of non-vitamin K oral anticoagulants has radically changed the management of AF allowing for a more individualized selection of OAC. An understanding of the available data regarding the performance of each of the available OAC in a variety of at risk patient populations is paramount for the safe and effective management of this patient population. The aim of this review is to appraise the current evidence, point out the gaps in knowledge, and provide recommendations regarding stroke prevention in older adults with AF and comorbid conditions.

About half of all patients with heart failure are diagnosed with heart failure preserved ejection fraction (HFpEF). Until now, studies have failed to show that medical treatment improves the prognosis of patients with HFpEF.To evaluate changes in exercise capacity of patients with HFpEF compared to those with heart failure with reduced ejection fraction (HFrEF) following an exercise training program.Patient data was retrieved from a multi-center registry of patients with heart failure who participated in a cardiac rehabilitation program. Patients underwent exercise testing and an echocardiogram prior to entering the program and were retested6 months later.Of 216 heart failure patients enrolled in the program, 170 were diagnosed with HFrEF and 46 (21%) with HFpEF. Patients with HFpEF had lower baseline exercise capacity compared to those with HFrEF. Participating in a 6 month exercise program resulted in significant and similar improvement in exercise performance of both HFpEF and HFrEF patients: an absolute metabolic equivalent (MET) change (1.45 METs in HFrEF patients vs. 1.1 in the HFpEF group, P = 0.3).An exercise training program resulted in similar improvement of exercise capacity in both HFpEF and HFrEF patients. An individualized, yet similarly structured, cardiac rehabilitation program may serve both heart failure groups, providing safety and efficacy.

Multiform fascicular tachycardia (FT) was recently described as a ventricular tachycardia (VT) that has a reentrant mechanism using multiple fascicular branches and produces alternate fascicular VT forms. Ablating the respective fascicle may cause a change in the reentrant circuit resulting in a change in morphology. Ablation of the septal fascicle is crucial for successful treatment.To describe four cases of FT in which ablation induced a change in QRS morphologies and aggravated clinical course.Four out of 57 consecutive FT cases at three institutions were retrospectively analyzed and found to involve multiform FT. These cases underwent electrophysiological study, fascicular potential mapping, and electroanatomical mapping. All patients initially had FT with right bundle branch block (RBBB) and superior axis morphology.Radiofrequency catheter ablation (RFCA) targeting the distal left posterior fascicle (LPF) resulted in a second VT with an RBBB-inferior axis morphology that sometimes became faster and/or incessant and/or verapamil-refractory in characteristics. RFCA in the upper septum abolished the second VT with no complications and uneventful long-term follow-up.The change in FT morphology during ablation may be associated with a change in clinical course when shifting from one route to another and may aggravate symptoms. Targeting of the proximal conduction system (such as bifurcation, LPF, left anterior fascicle, high septal/auxiliary pathway) may serve to solve this problem.