Special program and Abstract Issue of the 6th Congress of the European Cardiac Arrhythmia Society Academic research paper on "Clinical medicine"

J Interv Card Electrophysiol (2010) 27:147-266 DOI 10.1007/s10840-010-9483-7

ECAS 2010

6th Annual Congress of the European Cardiac Arrhythmia

Society April 16-18, 2010

Munich, Germany Hotel Bayerischer Hof

ADVANCE PROGRAM

April 16-18, 2010

Munich - Germany

Congress Chairmen Gerhard Steinbeck, MD Samuel Lévy, MD

BAYERISCHER HOF Promenadeplatz 2-6 D-80333 München

Invitation

Dear Colleagues,

This is an invitation to join us at the Sixth Annual Scientific Congress of the European Cardiac Arrhythmia Society "ECAS" to be held in Munich, Germany, 16th—18th April 2010 at the prestigious Hotel Bayerischer Hof. All those who attended previous editions of ECAS Congress know that it is a highly scientific and educational event in a cheerful atmosphere which facilitates the interaction between the renowned Faculty and younger colleagues in the field. This edition promises to be particularly successful, and we will be delighted to welcome you in Munich

Riccardo Cappato, MD Gerhard Steinbeck, MD Samuel Levy, MD

President of ECAS Congress co-Chairman Congress co-Chairman

EXECUTIVE COMMITTEE OF THE EUROPEAN CARDIAC ARRHYTHMIA SOCIETY

Riccardo Cappato (Milan, IT) Wyn Davies (London, UK) Richard Hauer (Utrecht, NL) Massimo Santini (Rome, IT) Samuel Levy (Marseille, FR) Antonio Raviele (Venice, IT) Paul Touboul (Lyon, FR) Eli Ovsyshcher (Beersheba, IL) Leo Van Wersch (Paris, FR)

Organizing Committee ECAS 2010

Riccardo Cappato, Stefan Kaab, Samuel Levy, Michael Nabauer, Gerhard Steinbeck

President Past President

Vice-President (Education & Research) Vice-President (National Societies) Vice-President (International Societies & EU) Secretary Treasurers

Secretary General

Program Committee

Andrey Ardashev; Serge Barold; Riccardo Cappato; Hu Dayi; Roberto De Ponti; Jeronimo Farre; John Fisher; Andreas Götte; Robert Hatala; Richard Hauer; Charles Jazra; Stefan Kaab; Jean-Yves Le Heuzey; Samuel Levy; Thorsten Lewalter; Shaowen Liu; Michael Nabauer; Yuji Nakazato; Andrea Natale; Eli Ovsyshcher; Douglas L Packer; Luigi Padeletti; Nicholas S. Peters; Dubravko Petrac; Antonio Raviele; Amiran Revishvilli; Sanjeev Saksena; Gerhard Steinbeck; Massimo Santini; Neil Sulke; Hein Wellens; Bruce Wilkoff

ScientificAdvisory Board

Masood Akhtar (Milwaukee, USA) Etienne Aliot (Nancy, FR) Maurits A. Allessie (Maastricht, NL) Eckhard Alt (Munich, DE) Charles Antzelevitch (Utica, USA) Andrey Ardashev (Moscow, RU) Serge S. Barold (Boca Raton, USA) David Benditt (Minneapolis, USA) Poul Erik Bloch-Thomsen (Hellerup, DK)

Johannes Brachmann (Coburg, DE) A John Camm (London, GB) Riccardo Cappato (Milan, IT) David S. Cannom (Los Angeles, USA) Stuart J. Connolly (Hamilton, CA) Antonio Curnis (Brescia, IT) D. Wyn Davies (London, GB) Hu Dayi (Beijing, CN) Luc De Roy (Yvoir, BE) Pierre Djiane (Marseille, FR) Sergio Dubner (Buenos Aires, AR) Nils G. Edvardsson (Goteborg, SE) Michaël Eldar (Tel Aviv, IL) Nabil El-Sherif (New York, USA) Jeronimo Farre (Madrid, ES) John Fisher (New-York, USA) Guy Fontaine (Paris, FR) Robert Frank (Paris, FR) Seymour Furman (New York, USA) Bulent Gorenek (Eskisehir, TR)

Mohamed Guediche (Tunis, TN) Stephen C. Hammill (Rochester, MN, USA)

Richard Hauer(Utrecht, NL) Habib Haouala (Tunis, TN) Stefan Hohnloser(Frankfurt, DE) Yoshito Iesaka (Tokyo, JP) Charles Jazra (Beirut, LB) Werner Jung (Villingen, DE) Joergen Kanters (Copenhagen, DK) Gilbert Kirkorian (Lyon, FR) Bondo Kobulia (Tbilisi, GE) Karl-Heinz Kuck (Hamburg, DE) Antoine Leenhardt (Paris, FR) Jean-Yves Le Heuzey (Paris, FR) Samuel Levy (Marseille, FR) Berndt Luderitz (Bonn, DE) Damian Gascon Lopez (Sevilla, ES) Marek Malik (London, GB) Sherif Mokhtar (Cairo, EG) Harry G. Mond (Melbourne, AU) Alessandro A Montenero (Rome, IT) Conception Moro Serrano (Madrid, ES) Arthur J. Moss (Rochester, NY, USA) Gerald V. Nacarelli (Hershey, USA) Franco Nacarella (Bologna, IT) Yuji Nakazato (Tokyo, JP) Andrea Natale (Cleveland, USA) Promound I. W.Obel (Johannesburg, ZA) Bertil S. Olsson (Lund, SE)

Oscar Oseroff (Buenos Aires, AR) Ali Oto (Ankara, TR) Eli Ovsyshcher (Beersheba, IL) Douglas L. Packer (Rochester, USA) Luigi Padeletti (Florence, IT) Nicholas S Peters, (London, GB) Dubravko Petrac (Zagreb, HR) Eric N. Prystowsky (Indianapolis, USA) Antonio Raviele(Venice, IT) Amiran Revishvili (Moskow, RU) Dwight Reynolds (Oklahoma, USA) Edward Rowland (London, GB) Sanjeev Saksena (New Brunswick,, USA)

Massimo Santini (Rome, IT) Maurizio Santomauro (Naples, IT) Dipen Shah (Geneva, CH) Martin Jan Shalij (Leiden, NL) Richard Schilling (London, GB) Georg Schmidt (Munich, DE) Peter M. Spooner (Baltimore, USA) Borys Strasberg (Petah-Tikva, IL) Neil Sulke (Eastbourne, GB) Paul Touboul (Lyon, FR) Isabelle Van Gelder (Groningen, NL) Albert Waldo (Cleveland, USA) Hein JJ Wellens (Maastricht, NL) Arthur Wilde (Amsterdam, NL) Bruce Wilkoff (Cleveland, USA) George D. Wyse (Calgary, CA)

AbstractSelection

We would like to thank the abstract reviewers for their valuable help in abstract selection.

Ghorge Andrei Dan, Andrey Ardashev, Serge Barold, Cristina Basso, Martin Borggrefe, Béatrice Brembilla-Perrot, Ricardo Cappato, Ma Chang Shen, Jacques Clémenty, Christopher Clyne, Wyn Davies, Roberto de Ponti, Luc de Roy, Pascal Defaye, Nabil El-Sherif, Jeronimo Farre, John Fisher, Robert Frank, Bulent Gorenek, Michel Haissaguerre, Habib Haouala, Richard Hauer, Robert Hauser, Ellen Hoffmann, Charles Jazra, Stefan Kaab, Jorgen Kanters, Maria-Teresa La Rovere, Jean-Yves Le Heuzey, Thorsten Lewalter, Bruce Lindsay, Peter Loh, Marek Malik, Francis Marchlinski, Frank Marcus, Annibale Sandro Montenero, Michael Nabauer, Franco Naccarella, Gerald Naccarelli, Yugi Nakazato, Promound Obel, Brian Olshansky, Ali Oto, Eli Ovsyshcher, Douglas Packer, Nicholas Peters, Maria-Vittoria Pitzalis, Amiran Revishvili, Sanjeev Saksena, Walid Saliba, Massimo Santini, David Scher, Richard Schilling, Georg Schmidt, Dipen Shah, Gerhard Steinbeck, Neil Sulke, Tamas Szili-Torok, Carl Timmermans, Claudio Tondo, Ernst Vester, Sami Viskin, Albert Waldo, David Wilber, Bruce Wilkoff.

Congress Chairmen

Gerhard Steinbeck, MD Klinikum der Universitat Munchen, Grosshadern, Munchen, DE

Tel.: +49 8970952371

Fax: +49 897095 8870

gerhard.steinbeck@med.uni-muenchen.de

Samuel Lévy, MD

University of Méditerranée, Marseille, FR

Tel.: +33 674009846 Fax: +33 491375269 samuel@samuel-levy.com

SUNDAY APRIL 18, 2010 Room Furstensalon

12:00pm-12:30 Presentation of the Best Posters and Awards

PUBLICATION

Sanjeev Saksena JICE Editor-in-Chief

JICE (Journal of Interventional Cardiac Electrophysiology) Society

Chaired Poster Sessions

Stefan Kääb Poster Sessions Chair

for Best Oral and Poster Presentations

Thorsten Lewalter ECAS JICE co-Editor

is the official Journal of the European Cardiac Arrhythmia

Michael Näbauer Poster Sessions Chair

THURSDAY APRIL 15, 2010 2:00 pm-6:00 pm

Badges and Congress bags will be available at Hotel Bayerischer Hof, Munich for pre-registered participants and Faculty at the ECAS welcome desk

General Information

Congress venue

BAYERISCHER HOF Hotel Promenadeplatz 2-6 D-80333 München www.bayerischerhof.de

Accommodation

A block of rooms at a special group rate in Hotel Bayerischer Hof where the Congress is taking place and other hotels has been booked for the participants of the ECAS Congress. Reservations will be made on a first-come first-served basis using the hotel reservation form connected to the ECAS web site www.ecas-congress.org or precisely that you are coming to ECAS 2010 in order to get the reduced rates. We kindly advise our participants to make reservations as soon as possible as Munich is a busy and highly appreciated destination. If needed, the secretariat of the congress will provide you with more information and help.

ECAS Congress Secretariat

Josette Razafimbelo

Tel./Fax: +334 83503472

Cell: +336 26075574

E-mail: josetteraz@numericable.fr

Elisabeth Maltot

Tel.: +339 53677241 (Fix)

Cell: +336 10270740

E-mail: elisabeth.maltot@free.fr

Congress Web site

All information, Scientific Program and Registration to the congress, Abstract submission and Membership

subscription with secured payment can be done through our web site

http://www.ecas-congress.org

PROGRAMME AT A GLANCE ECAS 2010

FRIDAY APRIL 16, 2010

8:00am 5:00pm Registration

Concurrent Workshops

8:30am 10:00am Room Konigssaal WS-01 Evolution of Catheter Ablation of Atrial Fibrillation Douglas L. Packer Room Furstensalon WS-02 Cardiac Resynchronization therapy Bruce Wilkoff Neil Sulke Room Gelbersalon Workshop WS-08 Interpretation of ECG and Intracardiac recordings Hein Wellens Jeronimo Farre Room Palaishalle Chaired poster Session A

10:00am-10:30am : Coffee break and visit to the posters

10:30am 12:00pm Concurrent Abstract Sessions

Room Konigssaal Oral Abstract session 01 Room Furstensalon Oral Abstract session 02 Room Gelbersalon Oral Abstract session 03 Room Montgelassaal Oral Abstract Session 04 Room Palaishalle Chaired poster Session A (Cont.)

12:15pm-1:45pm Luncheon Panel Anticoagulation for Atrial Fibrillation: The start of a new era Supported by an educational grant from Bayer Healthcare 12:15pm-1:45pm Luncheon Panel WS-07 Catheter cryoablation of arrhythmias

2:00pm 3:30pm Room Konigssaal Session DT-01 Focus on Devices Progress in device technology Room Furstensalon Session MT-01 Mechanisms of Supraventricular and ventricular tachyarrhythmias Room Gelbersalon Second ECAS-RUSSIA SPECIAL Session Amiran Revishvili Room Montgelassaal Symposium S-02 Cell transplantation and arrhythmias Room Palaishalle Chaired poster Session B

Coffee Break

4.00pm 5:30pm Room Konigssaal Session DT-02 Focus on Devices Evolving ICD indications Room Furstensalon session MT-02 Cellular mechanisms of arrhythmogene sis Room Gelbersalon Symposium S-01 Prevention of sudden death Montgelassaal Symposium S-09 Arrhythmias and sports practice Room Palaishalle Chaired poster Session B (continued)

5:30pm 6:00pm Room Konigssaal Special lecture: A tribute to Philippe Coumel By Michiel Janse (Amsterdam, NL) Mechanisms of Ventricular Arrhythmias Three Decades of Research And Progress

6:00pm 7:00pm Room Konigssaal Opening ceremony All participants are kindly invited to the Opening Ceremony followed by the Cocktail reception

SATURDAY APRIL 17, 2010

Room Konigssaal Room Room Room Room

8:30am Session DT-03 Furstensalon Gelbersalon Montgelassaal Palaishalle

10:00am Focus on Devices session MT-02 S-01 4th WS-10 ECG Chaired poster

Difficulties and From China/ECAS pacemaker and Session C

Complications Mechanism to Symposium CRT dysfunction

related to ICD therapy Special session Serge Barold,

Therapy Genetics and Franco Carsten W.

chanellopathies Naccarella Israel

10:00am-10:30am: Coffee break and Poster presentat ion

Time Simultaneous Oral Abstract sessions

10:30am 12:00pm Room Konigssaal Oral abstract 5 Room Furstensalon Oral abstract 6 Room Gelbersalon Oral abstract 7 Room Montgelassaal abstract 8 Room Palaishalle Chaired poster Session C

12:15pm-13:45pm Luncheon Panel Anticoagulation for Atrial Fibrillation: Which alternatives to warfarin? Supported by an educational grant from BOEHRINGER-INGELHEIM 12:15pm-13:45pm Luncheon Panel Antiarrythmic Therapy for Atrial Fibrillation: Changing Endpoints Sponsored by an educational grant from SANOFI-AVENTIS

Room Konigssaal Room Furstensalon Room Room Room

2:00pm Main session session MT-04 Gelbersalon Montgelassaal Palaishalle

3:30pm DT -04 Mechanisms of AF Workshop Congenital Chaired

CRT in Heart Prevention WS- 0-6 electrical poster

failure patients Focus o n disorders and Session D

Recent Techni- ICD

cal Advances

Coffee break 3:30pm-4:00pm and Posters

Time Simultaneous Oral Abstract sessions

4:00pm 5:30pm Room Konigssaal Oral abstract 9 Furstensalon Oral abstract 10 Gelbersalon Oral abstract 11 Room Montgelassaal Oral abstract 12 Palaishalle Chaired poster Session D

SUNDAY APRIL 18, 2010

Room Furstensalon Room Gelbersalon Room Montgelassaal

8:30am Symposium

10:00am DT-05 S-05 3rd Japan HRS-ECAS Symposium S-11

Sudden cardiac arrest Special session Risk stratification after acute MI:

Yugi Nakazato (Tokyo, JP) How useful it is?

Coffee break and presentation of the best posters

10:30am 12:00pm Room Furstensalon S-04 ICD versus antiarrhythmic therapy in specific clinical settings Room Gelbersalon S-08 Management of syncope Antonio Raviele Brian Olshansky Room Montgelassaal Workshop WS-09 Techniques and tools for AF ablation Neil Sulke, Roberto de Ponti

12:00pm 12:30 pm Room Furstensalon Presentation of the Best Posters and Awards to the Awardees of the Best Abstracts

ECAS 2010 Program

Advance Program

Thursday APRIL 15, 2010 2:00 PM-6:00 PM Registration

Badges and Congress bags will be available at Hotel Bayerischer Hof, Munich, Germany for Pre-registered participants and Faculty at the ECAS welcome desk (hotel lobby).

FRIDAY APRIL 16, 2010 8:30 AM-10:00 AM

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) WORKSHOP-WS-01 :

Evolution of catheter ablation of AF: what is new? What is not?

Chairpersons: Douglas L. Packer (Rochester, USA)

1. Single shot ablation: cryo, HiFu, laser, and RF balloon ablation

Petr Neuzil (Prague, CZ)

2. Complex ablation and advanced disease: Using AF and normal sinus rhythm electrograms

David Wilber (Chicago, USA)

3. 4-5 D image guided catheter based and extended beam ablation

Douglas Packer (Rochester, USA)

4. Lasso vs NavX / Carto 3 guided ablation: what does mapping do for AF success?

Isabel Deisenhofer (Munich, DE)

FRIDAY APRIL 16, 2010 8:30 AM-10:00 AM

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) Workshop WS-2

Cardiac resynchronization therapy

Chairpersons: Bruce Wilkoff (Cleveland, USA), Neil Sulke (Eastbourne, GB)

1. The right patient

Neil Sulke (Eastbourne, GB)

2. The right technology Werner Jung (Villingen, DE)

3. The right implantation technique and goals Tamas Szili-Torok (Rotterdam, NL)

4. The right programmed parameters Walid Saliba (Cleveland, Ohio, USA)

5. The right follow-up Wilfried Mullens (Genk, BE)

FRIDAY APRIL 16, 2010 8:30 AM-10:00 AM

ROOM GELBERSALON (Palais Montgelas, 1st Floor) WORKSHOP WS-08

Interpretation of intracardiac recordings: Case studies Chairpersons: Hein Wellens (Maastricht, NL), Jeronimo Farre (Madrid, ES)

Presentation and interpretation of tracings and interaction with the audience

FRIDAY APRIL 16, 2010 8:30 AM-12:00 AM

ROOM PALAISHALLE (Palais Montgelas, Ground Floor)

Chaired Poster Session A

FRIDAY APRIL 16, 2010 10:30am-12:00pm

Concurrent Abstract sessions 1-4

Luncheon Panels

12:15 pm-1:45 pm Room

Luncheon Panel Anticoagulation for Atrial Fibrillation: The start of a new era

Supported by an educational grant from BayerHealthcare

12:15 pm-1:45 pm Room Luncheon Panel Remote Monitoring of Cardiac Arrhythmias

FRIDAY APRIL 16, 2010 2:00 PM-3:30 PM

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor)

SESSION: DT-01 Progress in device technology

Chairpersons: Sanjeev Saksena (New Brunswick, USA), Michael D Gammage (Birmingham, GB)

1. Leadless pacing

Michael Gammage (Birmingham, GB)

2. Subcutaneous ICD Riccardo Cappato (Milano, IT)

3. New algorithms to minimize ventricular pacing Serge Barold (Tampa, USA)

4. Biological pacemaker: a possible alternative? Kevin Donahue (Cleveland, USA)

FRIDAY APRIL 16, 2010 2:00 PM-3:30 PM

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) Session: MT-01

Chairpersons: Nicholas S Peters (London, GB), Douglas L. Packer (Rochester, USA)

1. Atrial tachycardias

Andrea Natale (Austin, USA)

2. Accessory pathways

Ellen Hoffmann (Munich, DE)

3. Ventricular tachycardias Wyn Davies (London, UK)

4. Atrial fibrillation Shi-Ann Chen (Taipei, TW)

FRIDAY APRIL 16, 2010 2:00 PM-3:30 PM

ROOM GELBERSALON (Palais Montgelas, 1st Floor)

SECOND SYMPOSIUM of ECAS-RUSSIAN Society of Arrhythmology

Catheter ablation of VT without structural heart disease

Amiran S. Revishvili (Moscow, RU), Paolo Della Bella (Milano, IT)

1. VT ablation in children—indications and long-term results

Sergey Termosesov (Moscow, RU) Amiran Revishvili (Moscow, RU)

2. ParaHis and periannular VT ablation. Andrey Ardashev (Moscow, RU)

3. Surgical and interventional VT treatment in difficult cases

Paolo Della Bella (Milano, IT)

Prevention of ventricular electrical storm by VT/VF ablation

Edward Rowland (London, GB)

Mechanisms of supraventricular and ventricular tachyarrhythmias:

What did we learn from catheter ablation?

FRIDAY APRIL 16, 2010 2:00 pm-3:30 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor) Symposium S-02

Cell Transplantation and Arrhythmias

Chairpersons: Wolgang Franz (Munich, DE); Guy Fontaine (Paris, FR)

1. SA and AV nodal reconstruction Mark Boyett (Manchester, GB)

2. Is cell transplantation arrhythmogenic? Thorsten Lewalter (Bonn, DE)

3. Intramyocardial bone marrow stem cells implantation Alexander Kaminski (Rostock, DE)

4. Clinical trials of cell transplantation for myocardial regeneration

Wolgang Franz (Munich, DE)

FRIDAY APRIL 16, 2010 3:30 pm-4:00 pm

ROOM PALAISHALLE (Palais Montgelas, Ground Floor)

Chaired Poster Session B

FRIDAY APRIL 16, 2010 4:00 pm-5:30 pm

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) Session: DT-02 Evolving ICD indications

Chairpersons: Richard Page (Madison, USA); Riccardo Cappato (Milan, IT)

1. Early intervention with cardiac resynchronization therapy in heart failure: an evidence-based analysis

Sanjeev Saksena (New Brunswick, USA)

2. Prevention of sudden cardiac death with ICD's: are we doing too much or not enough?

Robert Hauser (Minneapolis, USA)

3. Are ICD guidelines implemented in Europe? Annibale Sandro Montenero (Milan, IT)

4. ICD trials: where to go from here? Robert Myerburg (Miami, USA)

FRIDAY APRIL 16, 2010 4:00 pm-5:30 pm

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor)

Session MT-02

Cardiac arrhythmogenesis—mechanisms

Chairpersons: Michiel J Janse (Amsterdam, NL); Michael Nâbauer (Munich, DE)

1. Cell-cell coupling as a determinant of myocardial conduction

Nicholas Peters (London, GB)

2. Cell and tissue electrophysiology underlying clinical arrhythmias

Richard Hauer (Utrecht, NL)

3. Dynamic nature of ventricular tachycardia initiation Gheorge Andrei Dan (Bucharest, RO)

4. Novel strategies of arrhythmic substrate modification Albert Waldo (Cleveland, USA)

FRIDAY APRIL 16, 2010 4:00 pm-5:30 pm

ROOM GELBERSALON (Palais Montgelas, 1st Floor) Symposium S-01

Prevention of sudden cardiac death: improving outcomes

Chairpersons: Promound Obel (Johannesburg, ZA), Pascal Defaye (Grenoble, FR)

1. Are all sudden deaths caused by ventricular tachyarrhythmias?

Robert Schweikert (Akron, USA)

2. Outcome of prophylactic ICD early after myocardi-al infarction

Gerhard Steinbeck (Munich, DE)

3. The role of life vests (wearable ICDs) Brian Olshansky (Iowa, USA)

4. Cost effectiveness of automatic external defibrillators (AEDs)

Alessandro Capucci (Ancona, IT)

FRIDAY APRIL 16, 2010 4:00 pm-5:30 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor) Symposium

Arrhythmias and sports practice

Chairpersons: Mark Estes III (Boston, USA), TBA

1. Ventricular arrhythmias in athletes: diagnosis and management

Magdi Sami (Montreal, CA)

2. Atrial fibrillation in competitive athletes

Francesco Furlanello (Milan, IT)

3. Sudden death in athletes Martin Halle (Munich, DE)

4. Sports practice in athletes with implanted devices

Ernst Vester (Dusseldorf, DE)

FRIDAY APRIL 16, 2010 4:00 pm-5:30 pm

ROOM PALAISHALLE (Palais Montgelas, Ground Floor)

Chaired poster session B (Cont.)

FRIDAY APRIL 16, 2010

6:00 PM to 7PM Opening ceremony

Room Konigssaal

During the Opening Ceremony

Outstanding Achievement Awards

Will be presented by Riccardo Cappato (Milan, IT) President of ECAS Gerhard Steinbeck (Munich, DE) and Samuel Levy (Marseille, FR), Congress Chairmen

Followed by a Cocktail Reception

SATURDAY APRIL 17, 2010 08:30 am-10:00 am

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) Session: DT-03

Difficulties and complications related to ICD implantation

Chairpersons: Eli Ovsyshcher (Beer Sheba, IL), Bruce Lindsay (Cleveland USA)

1. Difficulties in lead placement

Promound I. Obel (Johannesburg, ZA)

2. High defibrillation threshold Brian Olshansky (Iowa City, USA)

3. Prevention and management of device-related infection David Scher (Harrisburg, USA)

4. Difficulties in lead extraction Michael D Gammage (Birmingham, GB)

SATURDAY APRIL 17, 2010 08:30 am-10:00 am

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) Session MT-03

Genetics and chanellopathies: knowledge pertinent to the clinician

Chairpersons: Gunter Breithardt (Munster, DE), Jorgen Kanters (Copenhagen, DK)

1. Potassium channel

Michael Näbauer (Munich, DE)

2. Sodium channel

Joachim Ehrlich (Frankfurt, DE)

3. Connexin polymorphisms Peter Loh (Utrecht, NL)

4. What the clinician should know Stefan Kaab (Munich, DE)

SATURDAY APRIL 17, 2010 08:30 am-10:00 am

ROOM GELBERSALON (Palais Montgelas, 1st Floor) S-01 3rd CHINA-ECAS—SPECIAL SYMPOSIUM

Chairpersons: Zhang Shu (Beijing, Riccardo Cappato (Milan, IT)

New and old tools in cardiology

1. The role of electrocardiography Fang Pi Hua (Beijing, CN)

2. Electrocardiography and noninvasive ECG techniques in risk stratification of sudden death

Luigi di Ambroggi (Milano, IT)

3. Role of modern technologies in the Chinese Health Care Reform

Franco Naccarella (Bologna, IT)

4. Role of myocardial regeneration using myoblasts

Peter K. Law (Toronto, CA)

SATURDAY APRIL 17, 2010 08:30 am-10:00 am

ROOM MONTGELASSAAL

W0RKSH0P-WS-06

Pacemaker ECG, ICD and CRT interpretation: case studies

Chairpersons: Serge Barold (Tampa, USA), Eli Ovsyshcher (Beer Sheva, IL)

1. Serge Barold (Tampa, USA) 3. Carsten W. Israel (DE)

SATURDAY APRIL 17, 2010 9:00 am-12:00 pm

ROOM PALAISHALLE (Palais Montgelas, Ground Floor)

Chaired Poster session C

SATURDAY APRIL 17, 2010 10:30 am-12:00 pm

Concurrent Oral Abstract sessions

12:15 pm-1:45 pm LUNCHEON PANEL

(Supported by an educational grant from SANOFI-AVENTIS)

Antiarrhythmic Therapy for Atrial Fibrillation: Changing Endpoints

Chairpersons: John Camm (London, GB), Nicholas Peters (London, GB)

1. New advances in the mechanisms of atrial fibrillation

Maurits Allessie (Maastricht, DE)

2. New and safer antiarrhythmic drug therapy? Samuel Levy (Marseille, FR)

3. Role of catheter ablation of atrial fibrillation in the next decade

John Camm (London, GB)

4. The ATHENA trial: should an antiarrhythmic agent only control the rhythm?

Luncheon Panel: Anticoagulation for atrial fibrillation: the alternative to warfarin (TBA)

Supported by an educational grant from Boehringer-Ingelheim

SATURDAY APRIL 17, 2010 2:00 pm-3:30 pm

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) Session: DT-04

Cardiac resynchronisation therapy (CRT) for heart failure patients

Chair: Tamas Szili-Torok (Rotterdam, NL), Claude Barnay (Aix en Provence, FR)

1. Criteria for patient selection

Mariavittoria Pitzalis (Greenville, USA)

2. Role of imaging techniques Werner Jung (Villingen, DE)

3. Difficulties and complications in CRT John Fisher (New York, USA)

4. CRT in patients with implanted pacemakers ("upgrading")

Massimo Santini (Rome, IT)

SATURDAY APRIL 17, 2010 2:00 pm-3:30 pm

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) Session: MT-04

Recent concepts on mechanisms for atrial fibrillation prevention

Chairpersons: Gheorge Andrei Dan (Bucharest, RO), Brian Olshansky (Iowa, USA),

1. Atrial specific agents: recent developments and perspectives

Nils Edvardsson (Goteborg, SE)

2. ACE Inhibitors and ARBs: what is new?

Jean-Yves Le Heuzey (Paris, FR)

3. Statins

Dubravko Petrac (Zagreb, HR)

4. Omega 3

Robert Hatala (Bratislava, SK)

SATURDAY APRIL 17, 2010 2:00 pm-3:30 pm

ROOM GELBERSALON (Palais Montgelas, 1st Floor)

Focus on Hot Technical Advances TBA

SATURDAY APRIL 17, 2010 2:00 pm-3:30 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor) Symposium S-10

Congenital electrical disorders and ICD indications

Chair: Bruce Wilkoff (Chicago, USA); Luc De Roy (Brussels, BE)

1. Short QT syndrome

Rainer Schimpf (Mannheim, DE)

2. Long QT syndrome

Herve Le Marec (Nantes, FR)

3. Brugada syndrome TBA

4. Early repolarisation syndrome

Stefan Kaab (Munich, DE)

SATURDAY APRIL 17, 2010 2:00 pm-5:00 pm

ROOM PALAISHALLE (Palais Montgelas, Ground Floor) Chaired Poster session D SATURDAY APRIL 17, 2010 Chaired Poster session D

3:30 pm-4:00 pm Coffee break and Posters

SATURDAY APRIL 17, 2010 4:00 pm-5:30 pm

Concurrent Abstract sessions

SUNDAY APRIL 18, 2010 08:30 am-10:00 am

ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) Session DT-05

Sudden cardiac arrest: how to improve survival?

Chair: Paul Schweitzer (New-York, USA), Alessandro Capucci (Ancona, IT)

1. Changing epidemiology of sudden cardiac death

Dietrich Andresen (Berlin, DE)

2. External triggers of sudden cardiac death Maria Teresa La Rovere (Pavia, IT)

3. Automatic external defibrillators (AEDs): time for evaluation?

Richard Page (USA)

4. Recent techniques used in advance life support Mark Estes III ( Boston, USA)

SUNDAY APRIL 18, 2010 08:30 am-10:00 am

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) 2nd JAPAN HRS/ ECAS SYMPOSIUM

Management of ventricular tachycardia in non-ischemic cardiomyopathy

Chairpersons: Yugi Nakazato (Tokyo, JP), Richard Hauer (Utrecht, NL)

1. The role of pharmacological therapy Ichiro Watanabe (Tokyo, JP)

2. Impact of biventricular pacing Andrey Ardashev (Moscow, RU)

3. Efficacy of catheter ablation Kazutaka Aonuma (Tsukuba, JP)

4. Strategy for electrical storm Bulent Gorenek (Eskisheir, TR)

SUNDAY APRIL 18, 2010 08:30 am-10:00 am

ROOM GELBERSALON (Palais Montgelas, 1st Floor) Symposium S-11

Risk stratification after acute myocardial infarction: how useful it is?

Chair: Marek Malik (London, GB); Eckhard Alt (Munich, DE)

1. Predicting lethal and non-lethal events

Poul-Eric Bloch-Thomsen (Copenhagen, DK)

2. Deceleration capacity Georg Schmitt, (Munich, DE)

3. Value of available tests and tools used for risk stratification

Marek Malik (London, GB)

4. Which patient subsets should get a prophylactic ICD?

Bruce Lindsay (Cleveland, USA) Coffee Break

SUNDAY APRIL 18, 2010

10:30 am-12:00 am CONCURRENT SESSIONS

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor)

Symposium S-04

Implantable defibrillators versus antiarrhythmic drug therapy in specific clinical settings

Chairpersons: John Camm (London, GB), Berndt Luderitz (Bonn, DE)

1. Infarct-related ventricular tachycardia

Nabil El-Sherif (New-York, USA)

2. Channelopathies

Eugene Crystal (Toronto, CA)

3. Hypertrophic cardiomyopathy Martin Borggrefe (Mannheim, DE)

4. Heart failure

Christian Torp-Petersen (Hellerup, DK)

SUNDAY APRIL 18, 2010 10:30 am-12:00 am

ROOM GELBERSALON (Palais Montgelas, 1st Floor) Workshop or Symposium S-08 Management of syncope

Chair: Antonio Raviele (Venice, IT) Brian Olshansky (Iowa, USA)

1. Monitoring the patient with syncope

Charles Jazra (Beirut, LB)

2. Role of endogenous adenosine in unexplained syncope

Alain Saadjian (Marseille, FR)

3. Prevention of syncope Ernst Vester (Dusseldorf, DE)

4. Role of cardiac pacing

Eli Ovsyshcher (Beer Sheba, IL)

SUNDAY APRIL 18, 2010 10:30 am-12:00 am

MONTGELASSAAL (Palais Montgelas, 2nd Floor)

WORKSHOP WS-09

Techniques and tools for AF ablation

Chairpersons: Neil Sulke (London, GB); Roberto De Ponti (Varese, IT)

1. A Minimalist approach to AF ablation: can you do it anywhere?

Steve Furniss (Eastbourne, GB)

2. AF ablation with no (or almost no) X-rays, is it best practice?

3. AF ablation with new hot and cold technologies in 2010: which is best?

Edward Rowland (London UK)

4. 3D mapping with imaging integration for AF ablation: necessary or luxury?

Roberto De Ponti (Varese, IT)

Abstract session 1: Catheter ablation of atrial fibrillation I

Friday, April 16, 2010, 10:30 am-12:00 pm ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) 1-1 Abstract 01-02

Ganglionated plexi stimulation produces vagally mediated local changes in atrial fibrillation cycle length

Louisa Malcolme-Lawes1, Phang Boon Lim1, Pipin Kojodjojo2, Zachary Whinnett2, D Wyn Davies2, Nicholas S Peters1, Prapa Kanagaratnam2

1Cardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland; Cardiac Electrophysiology, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Background: The autonomic nervous system is implicated in the pathogenesis of AF, and high-frequency stimulation (HFS) of putative ganglionated plexi (GP) sites can be used to study these mechanisms. GP sites are identified by demonstrating bradycardia with HFS, but resultant changes could be either vagally or sympathetically mediated. We hypothesized that the changes in AF cycle length (AFCL) produced by HFS are vagally driven. Methods: HFS (12 V, 10 ms, 20 Hz, Grass S88 Stimulator) was performed at GP sites adjacent to the pulmonary veins on patients undergoing AF ablation. GP sites were defined as producing an increase in RR interval >50% from baseline and marked on a CARTO map. AFCL was recorded at three sites (HRA, CS, and local PV) and averaged over ten cycles before and after HFS. Atropine (1.6 n/kg) was given and HFS repeated at each GP site. Results: A total of 70 positive vagal sites were identified in seven patients. The mean AFCL in the local PV reduced from 170 to 151 ms following HFS (p < 0.001), at HRA from 174 to 163 ms (p<0.001), and at CS from 169 to 161 ms (p=0.01). These changes were abolished by atropine; the PV CL was 164 and 159 ms (p=0.44), at HRA 176 and 177 ms (p=0.82), and at CS 171 and 170 ms (p=0.59), all pre- and post-HFS, respectively. Conclusions: Atropine abolishes the AFCL shortening due to HFS at GP sites, implying that HFS produces predominantly vagally mediated effects. By promoting AFCL shortening, the parasympathetic nervous system may play a role in the maintenance of AF and could be an effective adjunctive target in AF ablation procedures.

1-2 Abstract 18-18

Isolation of the left atrial appendage (LAA): techniques and safety

Luigi Di Biase1, J. David Burkhardt1, Prasant Mohanty1, Javier E. Sanchez1, Rodney Horton1, Beheiry Salwa2, Amin Al-Ahmad3, Antonio Raviele4, Andrea Natale1 1Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, United States of America; Electrophysiology, California Pacific Medical Center, San Francisco, United States of America; Electrophysiology, Stanford University, Palo Alto, United States of America; 4Electrophysiology, Ospedale Dell 'Angelo, Mestre/Venice, Italy

Introduction: The left atrial appendage (LAA) is an underestimated site of initiation of atrial fibrillation. We report the best strategy for LAA isolation. Methods: Two hundred twenty-three patients undergoing redo catheter ablation for atrial fibrillation and showing firing from the LAA at the time of the procedure have been enrolled in this study. Ablation of the LAA was performed either with focal lesion or to achieve LAA isolation guided by placement of the circular catheter at the ostium of the LAA. Results: Out of the 223 patients, 56 (25%) underwent focal ablation, while 167 (75%) underwent LAA isolation. In the latter group, isolation was achieved with segmental lesion in 117 patients (70%) and with circumferential ablation in 50 patients (30%). The mean RF time for focal ablation was 15 ±5 min and for LAA isolation was 31 ±6 min (p < 0.001). At 12±3 months of follow-up, 38 (68%) of patients undergoing focal ablation and 25 (15%) of patients undergoing LAA isolation experienced AF recurrences (p<0.001). During LAA isolation, four (1.8%) pericardial effusion requiring pericardiocentesis occurred. None of the patients required surgery. All patients were discharged after

a median hospitalization of 1 day. No phrenic nerve damage was observed. Conclusions: Ablation of the LAA may be necessary during catheter ablation of atrial fibrillation. LAA isolation appeared to be the best strategy to achieve cure of atrial fibrillation. Similar to the pulmonary veins, the LAA can be isolated with segmental ablation.

1-3 Abstract 29-03

Epicardial ablation as a valuable alternative treatment for persistent atrial fibrillation: medium- and long-term results

Anca Arhire1, Luc De Roy1, Olivier Xhaet1, Olivier Deceuninck , Edith Collard , Benoit Collet , Fabien Dormal1, Dominique Blommaert1, Mark La Meir1 ICliniques Universitaires UCL Mont-Godinne, Yvoir, Belgium

Background: Catheter ablation for persistent atrial fibrillation (AF) has a lower success rate than for paroxysmal AF. Epicardial ablation might be an alternative treatment for persistent AF patients (pts). Aim: The aim of this study was to asses the medium- and long-term efficacy of right monolateral thoracoscopic epicardial left atrial posterior wall isolation for pts with persistent AF or long-lasting paroxysmal AF. Methods and results: We performed in 88 pts a thoracoscopic procedure with an epicardial microwave (MW) antenna Flex 10 (Boston Corporation) in 64 pts and a radiofrequency (RF) Cobra Adhere (Estech) probe in 24 pts. For the whole group (87.5% male, mean age 58±9.4 years) who underwent an epicardial approach, TIA or stroke was present in 13.6%, heart disease in 22.7%, and a history of AF since 8.8±7 years. Continuous AF was settled for 18.4±22 months for the pts with persistent AF. Left atrial volume was 70.6±20 ml and right atrial volume 60.1 ±21 ml. Eighteen pts (48%) had restoration of sinus rhythm (SR) during the procedure by electrical cardioversion and 26 pts (29.5%) spontaneously. Complications included pleural/pericardial effusion, pulmonary infection, and pneumothorax. Almost half of the pts had associated endocardial catheter ablation performed before, after, or simultaneously. At a medium follow-up (FU) of 15 months 51% of pts in the MW group were in stable SR compared to 63% for the RF group. At a longer FU (50 months) for the MW-treated pts, 50% remained free of AF. In terms of quality of life (QOL) for the whole group of pts in SR, the improvement was statistically significant, with a score from 4.6±2/10 before the procedure to 8.2± 1.6/10 at the last FU (p=0.0001). Conclusion: Right monolateral thoracoscopic PV ablation is a valuable option for these symptomatic refractory persistent AF pts, with an acceptable long-term success rate and significant improvement in QOL. A combined endo/epicardial catheter ablation appears, however, necessary in half of the pts.

1-4 Abstract 01-07

Mitral isthmus plays an important role in maintaining chronic atrial fibrillation

Man Ning1, Sang Cai-Hua1, Tang Ri-Bo1, Chen Gang1, Dong Jian-Zeng1, Ma Chang-Sheng1 1Beijing Anzhen Hospital, Beijing, China

Introduction: Mechanisms of chronic atrial fibrillation (AF) is still unclear. The purpose of the study was to evaluate the effects of mitral isthmus (MI) conduction on the inducibility of AF after pulmonary vein isolation (PVI) and linear block at the left atrial (LA) roof and cavotricuspid isthmus (CTI) were achieved. Methods: Twenty-three consecutive patients (mean age, 58 ± 9 years) with chronic AF underwent catheter ablation. Circumferential pulmonary vein (PV) antrum ablation, linear ablation at the LA roof, and CTI were performed sequentially; cardioversion was performed if sinus rhythm was not restored. PVI and linear block at the LA roof and CTÏ were validated during sinus rhythm. Then, either atria burst pacing or isoprenaline infusion was used to induce atrial arrhythmias. Subsequently, linear ablation at the MI was performed. The procedure endpoint was that all the PVs were isolated and all the ablated lines achieved block. Results: All the targeted PVs were isolated and linear block was achieved in all ablated lines except two at the MI. After initial ablation, AF terminated in three patients during ablation, and sinus rhythm was restored by cardioversion in 18 patients (18/20). After PVI and linear block at the LA roof and CTI were confirmed, atrial tachycardias (ATs) were induced in 14 (14/ 21) patients (AF in eight and organized AT in six). Finally, after linear block at the MI was achieved, ATs were induced in four (4/23, n < 0.05) patients (AF in two patients and organized AT in two patients). Conclusion: MI plays an important role in maintaining AF or organized AT after PVI and linear block at the LA roof and CTI were achieved.

1-5 Abstract 18-04

Long-term efficacy of catheter ablation for AF: impact of additional targeting of fractionated electrograms

Ross Hunter1, Thomas Berriman1, Ihab Diab1, Victoria Baker1, Dominic Abrams1, Mehul Dhinoja1, Mark Earley1, Simon Sporton , Richard Schilling

Cardiology, Barts and The London NHS Trust and QMUL, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We sought to investigate long-term efficacy of catheter ablation for AF and the impact of ablating CFE in addition to PVI in persistent AF (PeAF). Methods:

Consecutive cases from 2002 to 2007 were analysed. All patients underwent wide area circumferential ablation with confirmation of electrical isolation. For PeAF, linear lesions were added at the roof and mitral isthmus, with additional targeting of CFE from 2005. Data were collected in a prospective database. Attempts were made to contact all patients for follow-up in September 2009. Failure was defined as documented recurrence of AF or other atrial tachyarrhythmia (AT) lasting >30 s. Late recurrence was analysed following the first cluster of procedures, defined as when the patient first emerged from their 3-month blanking period free of AF/AT. Results: Two hundred eighty-five patients underwent 530 procedures. Mean age was 57 ±11 years, 75% male, 20% had structural heart disease and 53% paroxysmal AF. Mean number of procedures was 1.9 per patient (1.7 for PAF and 2.0 for PeAF). Procedural complications included stroke or TIA in 0.6% and pericardial effusions in 1.7%. There were no peri-procedural deaths. Of285 patients, 270 were contacted for follow-up. During 3.3 (2.4-7.5)years from the first procedure, there were seven deaths (unrelated to their ablation or AF) and three strokes or TIA (0.3% per year). Freedom from AF/AT at 2.7 (0.2-7.4)years after the last procedure was 86% for PAF and 68% for PeAF. Most recurrence occurred in the first year, with late recurrence >3 years occurring in 3/100 years of follow-up. Kaplan-Meier analysis showed that CFE ablation improved the outcome for PeAF after the first cluster of procedures (p=0.04), with a trend towards improved final outcome (p=0.13). Conclusion: Long-term freedom from AF is achievable in the majority of patients with low rates of late recurrence. Targeting CFE in addition to PVI and linear lesions improves the outcome for PeAF.

1-6 Abstract 15-18

A randomised controlled trial of catheter ablation of atrial fibrillation comparing manual and robotic navigation—experience with the Hansen robotic system

Edward Duncan1, Reginald Liew1, Farai Goromonzi1, Laura Richmond , Victoria Baker , Mehul Dhinoja , Mark Earley , Simon Sporton , Richard Schilling

1Cardiology, St Bartholomew's Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Robotic catheter ablation with the Hansen Sensei system aims to improve outcome through improved tissue contact and catheter stability. We present data from the first randomised controlled trial comprising patients with both paroxysmal (PAF) and persistent (PERS) AF. Methods: Patients undergoing first time AF ablation were randomised to robotic or manual catheter ablation. Using a 3D mapping system, all patients underwent wide area circumferential ablation (WACA). For persistent AF, further lesions were delivered (roof line, CS lines, CFAEs). Results: One hundred patients with AF were randomised. Total procedure times were not prolonged with the robotic approach (PAF: robot 247 ± 64 and manual 218 ± 66 min, p=0.2; PERS AF: robot 328 ± 66 and manual 315 ± 80 min, p=0.4). Total fluoroscopy time was lower with robotic ablation in persistent AF cases, but not PAF (PAF: robot 49 ± 26 and manual 49 ± 26 min, p=0.75; PERS AF: robot 53 ± 22 and manual 81 ± 30 min, p<0.01). Comparable rates of pulmonary vein isolation were achieved (96% and 98%, p=NS). Major complication rates were 8.8% (one death, two tamponades, one retroperitoneal bleed) for robotic ablation and 4.2% (one tamponade, one CVA) for manual (p=NS). At 3 months of follow-up, no significant difference was seen between groups in the following parameters: (1) symptom improvement (PAF: robot 84% and manual 86%, p=NS; PERS AF: robot 71% and manual 74%, p =NS); (2) antiarrhythmic drug use (PAF: robot 20% and manual 26%, p =NS; PERS AF: robot 35% and manual 35%,p =NS); (3) 90-day procedural success as defined by sinus rhythm at follow-up, with no documented atrial arrhythmias and no symptoms suggestive of continuing arrhythmia (PAF: robot 80% and manual 71%, p =NS; PERS AF: robot 48% and manual 65%, p=NS). Conclusions: Acute procedural success and 3-month outcome following AF ablation using robotic catheter navigation are equivalent to those achieved with manual. Fluoroscopy times are reduced in persistent AF cases.

Abstract session 2: Implantable cardioverter defibrillators (ICD). Techniques and results

Friday, April 16, 2010, 10:30 am-12:00 pm

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor)

2-1 Abstract 25-03

Value of routine defibrillation testing during cardioverter-defibrillators implantation

Alexandra Toste1, Mario Oliveira1, Manuel Nogueira da Silva1, Pedro Cunha1, Joana Feliciano1, Ana Lousinha1, Ninel Santos1, Sofia Santos1, Rui Ferreira1 IHospital de Santa Maria, Lisboa Portugal

Defibrillation testing (DFT) is used during cardioverter-defibrillators (ICD) implantation in order to evaluate effectiveness of ventricular fibrillation (VF) detection and interruption. However, DFT has risks and its clinical benefit has not been established. Aim: The aim of this study was to evaluate DFT clinical impact. Methods: We analyzed retrospectively the DFT in 321 consecutive patients (P) who underwent a first ICD implantation. Group 1 (Gr1) included 297 P (80%male, 61 years, 53% ischemic, 29% dilated cardiomyopathy, 65% primary prevention) in whom the DFT was successful on the first attempt. Group 2 (Gr2) had ten patients (100% male, 51 years, 20% ischemic and 50% dilated cardiomyopathy, 80% primary prevention) who needed two or more shocks to VF interruption. In these cases, DFT implied polarity reversal or changing shock configuration (40%), increasing energy or changing shock wave (30%), proximal coil repositioning (10%) or adjusting the sensitivity for detection (20%). Fourteen patients (who were not subjected to DFT) were excluded due to comorbidities or inability to induce VF. We evaluated the number of appropriate therapies (effective and ineffective) and overall and cardiovascular mortality. Results: In all DFT performed, there was one serious complication (electromechanical dissociation after shock, with prolonged resuscitation). During an average follow-up of 18 months, 20 P from Gr1 died (6.7%, seven from cardiovascular causes, one from sudden death and the remainder from non-cardiac causes). In Gr2, there were no deaths. In Gr1, ICD detected ventricular tachyarrhythmias in 41% of cases, and an appropriate therapy occurred in 19.8%. In Gr2, ventricular tachyarrhythmias were detected in one patient (10%), submitted to appropriate and effective therapy. Conclusions: DFT during ICD implantation is associated with a very low risk of complications (<1%) and has implications for the treatment planning parameters in a small percentage of P (3.3%). In this study, the potential impact of DFT in long-term follow-up was limited to <1% of the population.

2-2 Abstract 17-05

Ventricular refractoriness: relative, effective and functional. Possible implications for antitachycardia pacing

John Fisher1, Soo Park1, Marta Martinez1, Omid Kohani1

ICardiology, Montefiore/Albert Einstein College of Medicine, Bronx, NY, United States of America

Introduction: Studies on ventricular refractoriness emphasize the effective refractory period, (ERP) as defined below. We postulated that the stimulation intervals delivered at the RVA may differ from those recorded at a remote site such as the RV inflow (RVI) or LV due to delay in the intervening myocardium. This could affect antitachycardia pacing (ATP) efficacy. Methods: In 41 patients, following drive pacing (S1S1 = 600 ms), one, two, then three RVA extrastimuli (S2, S3, and S4) were sequentially initiated late (S1S2 = 360 ms) then decremented to the closest interval with three captures (effective RP=ERP). The "arrival" of these stimulated wave fronts was timed at the RVI. A shorter stimulation interval that prolonged conduction time from RVA to RVI > 25 ms was termed relative RP (RRP). The shortest times at the RVI of wave fronts generated by S1S2, S2S3, and S3S4 were termed functional RP (FRP). Results: RRPs were identified in most patients: 78% of 14 patients with no structural heart disease (SHD), and 85% of 27 patients with SHD. For all patients, there was a trend towards longer mean coupling intervals in patients with SHD compared to patients with no SHD. In both groups, the FRPs were longer than ERPs at S2 and S3, but shortened by S4 to be comparable to ERPs (accommodation). Conclusions: Intervals recorded at stimulation site (RVA) and remote site (RVI) differ significantly in timing and "pattern". This may affect design or efficacy of ATP algorithms. Table: Relative, effective and functional ventricular refractory periods.

Mean RRPs (S2, S3, S4) Mean ERPs (S2, S3, S4) Mean FRPs (S2, S3, S4) P value (ERP vs. FRP)

No SHD 278±87 246±41 275±48 0.0307

234±35 189±25 220±46 0.0098

231±73 195±35 184±48 0.3762

SHD 300±70 269±40 315±67 0.0001

273±51 239±43 259±45 0.0034

270±53 225 ±43 234±42 0.2258

P value 0.3197 0.0173 0.0014 NA

(No SHD 0.0002 0.0001 0.0013

vs. SHD) 0.0679 0.0020 0.0001

2-3 Abstract 19-12

Efficacy of antitachycardia pacing modes in patients with CAD and ARVD

Andrey Ardashev1, Eugeny Zhelyakov1, Andrey Shavarov2, Maxim Rybachenko1, Yuri Belenkov3 I83 City Clinical Hospital of FMBA, Moscow, Russian Federation; 2Burdenko Head Clinical Hospital, Moscow, Russian Federation; 3Lomonosov Moscow State University, Moscow, Russian Federation

Purpose: The purpose of this study was to assess efficacy of antitachycardia pacing (ATP) modes for ventricular tachycardias (VTs) in patients (pts) with coronary artery disease (CAD) and arrhythmogenic right ventricular dysplasia (ARVD). Methods: The studied population comprised 46 pts (five women, mean age 58.4± 11.3 years) who received treatment with implantable cardioverter-defibrillators (ICD) for primary and secondary prevention of sudden cardiac death. Successful ATP was defined as VTs terminating during the stimuli delivery or within four beats after ATP. The VT acceleration was defined as VT cycle decreasing more than 10% immediately after ATP therapy. Results: Follow-up period was 27.3±8.6 months. Four hundred four VTs episodes (epis) occurred in ARVD pts and 372 VTs epis were detected in CAD pts. Burst ATP terminated 134 (61%) VTs epis in CAD pts and 55 (33%) VTs epis in ARVD pts (p<0.001). Ramp/Ramp + ATP overwhelmed 116 (76%) VTs epis in CAD pts and 47 (20%) VTs epis in ARVD pts (p<0.001). VT acceleration caused by ATP occurred in 21 (6%) cases in CAD pts versus 96 (24%) cases in ARVD pts (p<0.001). Conclusion: The ability of ATP to terminate the VTs epis was significantly higher and risk of VT acceleration was significantly lower in CAD pts to compare with ARVD pts.

2-4 Abstract 25-01

Appropriate therapies in primary prevention recipients of ICD according to number of risk factors previously defined in MADIT II

Ignasi Anguera1, Ainhoa Torrens1, Jose Gonzalez-Costello1, Xavier Sabate1, Enric Esplugas1 Cardiology, Hospital de Bellvitge, Barcelona, Spain

Objective: The objective of this study was to determine the incidence of appropriate therapies (AT) in a series of patients with a primary prevention ICD indication and to correlate the incidence of AT with a subset of risk factors (RF). Introduction: Previous trials for primary prevention (MADIT II and SCD-Heft) have demonstrated a significant

benefit in high-risk patients. However, the benefit of the ICD in the low ejection fraction population may be heterogeneous, and the subgroups that may benefit more have not been well defined. Methods: All patients with a primary prevention ICD implantation were considered candidates for study entry (from March 2003 to November 2008). We analyzed the incidence of AT (antitachycardia pacing and/or high energy discharges) delivered for ventricular arrhythmias with cycle length<300 ms. The presence of previous risk factors identified in MADIT II as those associated with major ICD efficacy and clinical benefit (age >70 years, permanent atrial fibrillation (PAF), QRS > 120 ms, NYHA functional class >II, and mild or moderate renal dysfunction (RD)) were correlated with the incidence of AT. Results: A total of 67 patients were included (mean age 51 years). Ischemic heart disease was present in 48% of patients; mean ejection fraction was 28%. Biventricular ICDs were implanted in 35% of patients. Prevalence of RF were: age>70 years in one patient, PAF in 13 patients, QRS >120 ms in 33 patients, NYHA FC>II in 37 patients, and RD in 13 patients. After a follow-up of 25 months, there were three deaths, three patients had arrhythmic storms, and five patients underwent cardiac transplantation. A total of 13 patients (19%) had AT. Patients with no RF (n = 20) had an incident of AT of 5%, and those with one to four RF (n=47) experienced an incident of AT of 25% (p=0.08). Conclusion: Our study confirms that sub-stratification of patients with LV dysfunction is useful to increase the rate of appropriate therapies in patients with primary implantation of an ICD and, therefore, increases the clinical benefit of the ICD.

2-5 Abstract 05-08

Changes in T wave morphology prior to onset of ventricular arrhythmias in ICDs

Philippe Maury1, Frank Raczka2, Jean-Luc Pasquie2, Lionel Beck , Jerome Taieb , Alexandre Duparc , Benoit Hallier , Fujian Qu5, Rhiddi Shah5

1University Hospital Rangueil, Toulouse, France; 2Cardi-ology, University Hospital Arnaud de Villeneuve, Montpellier, France; 3Cardiology, University Hospital Carremeau, Nimes, France; 4Cardiology, General Hospital, Aix en Provence, France; 5St Jude Medical, Sunnyvale, United States of America

Introduction: T wave morphological changes before onset of ventricular arrhythmia are poorly known. ICD-stored intracardiac electrograms (IEGM) present a unique opportunity for detecting temporal changes in repolarisation before initiation of VT/VF. Methods: Fifty-six implanted patients with St Jude medical ICDs (44 men, 63 ±12 years

old, mean EF 34±15%) were prospectively enrolled. Eleven different T wave parameters were extracted from IEGM (T amplitude, T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes and T wave area). Averaged values of each parameter in recordings prior to VT/VF were compared to control recordings sharing comparable QRS and T wave morphology and similar heart rate in the same patients. Results: Twenty-two VT/VF episodes (24±13 beats) and 13 baseline (25±9 beats, ns) were analyzed in 12 patients (1.8 episode/ patient). Mean heart rate was 71 ±17 bpm for episodes and 66± 16 bpm for baseline recordings (ns). Significant differences were found in T wave amplitude and slopes. Durations and timings of the different parts of the T wave did not significantly vary. Conclusions: Detection of T wave changes prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. T wave amplitude is higher and T wave slopes are steeper before ventricular arrhythmia compared to baseline, without significant shortening of different repolarisation times.

Baseline Episodes P

T amplitude (mV) 1.6 ±0.9 2.2 ± 0.7 0.04

R peak to T peak (ms) 314 ± 54 296 ± 54 0.06

T max ascending slope (mV/ms) 0.016 ± 0.023 ± 0.05

0.013 0.023

R peak to T max ascending 260 ± 63 236 ± 44 0.08

slope (ms)

T max descending slope (mV/ms) 0.02 ± 0.007 0.03 ± 0.019 0.01

R peak to T max descending 326 ± 15 321 ± 58 0.7

slope (ms)

T wave area (mV x ms) 6.5 ± 5.1 8.3 ± 7.8 0.2

T duration (between points of 88 ± 49 102 ± 59 0.2

max slopes) (ms)

T duration (between crossing 185 ± 88 184 ± 88 0.9

isoelectric line, ms)

R peak to T end (ms) 428 ± 86 409 ± 102 0.3

T peak to T end (ms) 310 ± 104 295 ± 82 0.2

2-6 Abstract 25-02

Feasibility of defibrillation and arrhythmia detection using an exclusively subcutaneous defibrillator system in canines

Pier Paolo Lupo1, Paul Erlinger1, Rick Sanghera1, Donald Scheck1, Gust Bardy2, Riccardo Cappato1 Arrhythmias and Electrophysiology Center, IRCCS Poli-clinico San Donato, San Donato Milanese, Italy; 2Seattle Institute for Cardiac Research, Seattle, WA, United States of America

There are no systematic data on the automatic detection and defibrillation requirements for a subcutaneous ICD system entirely located in the thorax. Two canine studies were conducted to test defibrillation and detection feasibility of a fully subcutaneous ICD system located in the left chest. In the first study, two pockets were created in 15 animals for placement of an anterior electrode adjacent to the left edge of the sternum and a lateral electrode at the site along the lateral axillary line between the fourth and sixth intercostals space. Stainless steel flat electrodes with active surface areas of 5, 10, 20, and 25 cm2 were subsequently positioned and the defibrillation threshold (DFT) was measured for multiple dual-electrode combinations. In the second study, the ability of detecting ventricular fibrillation (VF) and providing automatic defibrillation by a custom-built subcutaneous ICD with electrode-to-can electrode configuration implanted in the left lateral thorax were tested in five canines. Ninety-seven DFT tests with seven different dual-electrode combinations were performed. All combinations successfully terminated VF with a DFT of 35±16 J (range, 9-79 J). Nineteen induced VF episodes were correctly recognized, leading to automatic ICD charge and shock delivery in all cases. Subcutaneous defibrillation using different dual electrode combinations in the left thorax successfully terminated all induced VFs within 79 J DFT. A custom-built subcutaneous ICD proved effective to detect and shock activate in response to all induced VF episodes, providing the groundwork for human testing.

Abstract session 3: Atrial fibrillation (AF) mechanisms and management

Friday, April 16, 2010, 10:30 am-12:00 pm ROOM GELBERSALON (Palais Montgelas, 1st Floor) 3-1 Abstract 15-09

Left atrial volume and function assessment by magnetic resonance imaging

Irene Hof1, Birgitta Velthuis1, Vincent van Driel1, Fred Wittkampf1, Richard Hauer1, Peter Loh1

1University Medical Center Utrecht, Utrecht, the Netherlands

Introduction: In patients with atrial fibrillation (AF) undergoing catheter ablation, left atrial (LA) volume and function before and after ablation can be determined by magnetic resonance imaging (MRI). The most accurate method to determine LA volume is the multiple slice method (MSM) which involves manual tracing of LA area on each slice.

However, this is time-consuming. The area length method (ALM) offers a simplified alternative but is not validated for LA volume assessment by MRI. The aim of this study was to compare LA volume and function assessment by ALM with MSM. Methods: MRI was performed before and after catheter ablation in 40 patients with AF (30 men, mean age 57 years). All patients had normal sinus rhythm during imaging. In total, 72 MRI scans were available. LA end diastolic and end systolic volumes (EDV and ESV, respectively) were measured by both methods. LA function was determined by calculating LA ejection fraction (EF=(EDV -ESV)/EDV). Results: Measured by ALM, mean LA EDV and ESV were significantly lower than using MSM (102 and 49 ml versus 111 and 65 ml, respectively, p<0.001) with a larger difference in mean ESV than EDV (16 versus 9 ml). This resulted in an overestimation of LA EF by ALM with a mean of 11% (54% by ALM and 42% by MSM, p<0.001). Intra-observer variability for LA EDV and ESV did not differ between both methods (6% versus 5%, p=0.44). A good correlation of both methods was found (Figure). Conclusion: ALM significantly underestimates LA volumes and overestimates LA function. ALM correlates well with the more accurate MSM.

3-2 Abstract 15-30

Plasma B-type natriuretic peptide: an independent predictor of atrial fibrillation recurrence after pulmonary vein isolation

Ayman Hussein1, David Martin1, Mazyar Shadman1, Bryan Baranowski , Thomas Dresing , Mohamed Kanj , Walid Saliba , Andrea Natale , Oussama Wazni ICleveland Clinic Foundation, Cleveland, United States of America

Introduction: Plasma B-type natriuretic peptide (BNP) is associated with atrial fibrillation (AF). It is not known whether BNP levels are associated with recurrence of AF after pulmonary vein isolation (PVI). We aimed to determine the value of BNP for the prediction of PVI

outcomes. Methods: All 1,871 patients who underwent PVI between January 2003 and December 2005 were included. All had their plasma BNP levels measured on the day of ablation. Recurrence was identified by symptoms with documentation, event monitoring, Holter recordings, and ECGs. Logistic regression models were used to assess the value of BNP and covariates for the prediction of AF recurrence. Results: Over a median follow-up of 21 months (range, 12-38), 509 patients (27.2%) had AF recurrence. Pre-PVI plasma BNP were higher in patients who developed recurrence (133.6±45.4 vs. 69.5±44.2 pg/ml, p< 0.0001). The odds ratio of recurrent atrial fibrillation according to increasing BNP quartiles compared with patients in the lowest quartile were 1.84, 3.71, and 8.90 (p trend<0.001). In multivariate analysis using a logistic regression model adjusting for age, gender, diabetes, coronary disease, body mass index (BMI), left ventricular

ejection fraction (EF), left atrial size (LAS), type, and duration of ablated AF, pre-PVI BNP level>50th percentile was found to be a strong predictor of AF recurrence (OR 5.50; 95% CI 3.87-7.89, p<0.0001). Other independent predictors for recurrent arrhythmia were age (OR 1.02, p= 0.003), BMI (OR 1.04, p=0.002), non-paroxysmal AF (OR 1.96, p<0.0001), EF (OR 1.03, p<0.0001), and LAS (OR 1.08, p<0.0001). Conclusions: BNP is an independent predictor of AF recurrence after PVI regardless of age, BMI, type of AF, EF, and LAS. Importantly, elevated BNP was a stronger predictor than traditional predictors of AF. High BNP levels may reflect increased cardiac chamber wall stress and/or intrinsic atrial disease, thus resulting in arrhythmia recurrence.

3-3 Abstract 15-33

Dynamics of pro-MMPl and MMP9 levels after maze procedure

Roman Batalov1, Sergey Popov1, Igor Antonchenko1, Tatiana Suslova1, Irina Kologrivova1

Scientific Institute of Cardiology, Tomsk, Russian Federation

Atrial fibrillation (AF) is the most common clinical arrhythmia. It results in considerable morbidity, mortality, and medical expenses. Although pathophysiologic mechanisms are multifactorial, organic heart disease related to systolic, diastolic, or valvular dysfunction increases the likelihood of both AF and heart failure. AF is associated with extracellular matrix remodeling involving atrial fibro-sis and atrial dilatation. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes responsible for myocardial extracellular protein degradation. Maze procedure for the treatment of AF is associated with significant atrial damage. It influences the function of MMPs. Changes of their levels in blood can explain changes in atrial myocardium before and after the maze procedure. In the study were included patients with persistent AF who underwent the maze procedure. Blood sample was collected before and right after procedure, then in 24 h, 2 months, and 6 months, promptly centrifuged, and stored at -70°C until final analysis. Values of pro-MMP1 and MMP9 were determined by immunoferment assay. In this study, we included 27 (18 men) patients (62±9 years old) without AF after successful maze procedure in a 6 month follow-up period. The value of pro-MMP1 before procedure was 4.9 ng/ml, and immediately after the procedure, the values decreased to 2.73 ng/ml (p<0.01). After 24 h, the level of pro-MMP1 was 3.19 ng/ml (p<0.03) and after 2 and 6 months were 3.99 and 4.09 ng/ml, respectively, which were comparable with those before the procedure. Values of MMP9 before the procedure was 8.63 ng/ml, after the

procedure, values decreased to 6.39 ng/ml (p<0.02) and increased after 24 h to 5.48 ng/ml. After 2 months, the level of MMP9 was 2.88 ng/ml (p<0.03) and increased to 4.4 ng/ ml after 6 months, which was comparable with that before the procedure. Our study has shown that restoration of pro-MMP1 function appears after 6 months after the maze procedure. But levels of MMP9 significantly changed through follow-up period and stabilized to 6 months.

3-4 Abstract 15-25

Insights into the electrophysiological substrate of lone atrial fibrillation using P wave wavelet analysis

George Dakos1, Vasilios Vassilikos1, Ioanna Chouvarda2, Stelios Paraskevaidis , Ioannis Chatzizisis , George Stavropoulos1, Nikolaos Maglaveras2, Ioannis Styliadis1 1lst Cardiology Dept, Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Medical Informatics Laboratory, Aristotle University of Thessaloniki, Thessaloniki, Greece

The aim of this study was to investigate the atrial excitation characteristics of lone paroxysmal atrial fibrillation (PAF) using P wave wavelet analysis. Methods: Group A consisted of 28 patients (18 men, mean age 50.7 ± 12 years) with lone PAF, while group B consisted of 30 normals (19 men, mean age 53.9 ± 9 years) with neither PAF nor hypertension history. During 6.3 ± 4.2 years of follow-up, 19 (68%) of group A patients had low AF recurrences (<5/ year), six (21%) had higher than five recurrences/year, while three (11%) had no recurrence. Recordings were obtained during sinus rhythm with a three-channel digital recorder for 10 min and digitized with a 16-bit accuracy at a sampling rate of 1,000 Hz. The P wave was analyzed using the Morlet wavelet, and the wavelet parameters expressing the mean and max energy were calculated in the three orthogonal leads (X, Y, Z) and in the vector magnitude (VM) in three frequency bands (first, 200-160 Hz; second, 150-100 Hz; and third, 90-50 Hz). In unrelated samples, t test was used for comparing continuous variables, while p< 0.05 was considered significant. Results: Group A patients showed lower mean and max energy values in the second and third frequency bands at X-axis along with lower max energy in the third band at Y-axis (max3Y) and in the first and second band at VM compared to group B patients. P wave duration at Z-axis (PdurZ) was also longer in group A patients. Multivariate analysis showed that longer PdurZ along with lower max3Y (p<0.001 and p=0.015, respectively) were significant and independent predictors of lone PAF. PdurZ and max3Y at cutoff values of 78.2 ms and 29.4 held sensitivity, specificity, and total predictive values of 84%, 75%, and 82%, respectively for the occurrence of lone PAF. Conclusions: It seems that lone PAF associated

with both slow conduction and specific atrial excitation characteristics.

Group A (n = 28) Group B (n=30) P

Pdur Z(ms) 83.6±13 69.9±14 <0.001

Mean2X 2.42±2.2 4.71 ±2.6 0.04

Mean3X 15±13.8 23.3±14 0.003

Max2X 12.6±3.5 15±4.4 0.027

Max3X 23.1±7.3 28.5±8.2 0.011

Max3Y 27.6±9.8 33.2±11 0.049

Max1VM 9.12±1.3 10.37±2.2 0.013

Max2VM 12.5±2.5 14.3±3.5 0.025

3-5 Abstract 29-04

Mini-invasive left thoracoscopic approach for ablation of refractory incessant symptomatic ventricular bigeminy

Luc De Roy1, Alexandre Targnion1, Benoit Collet1, Maximilien Gourdin1, Fabien Dormal1, Mark La Meir1 Cliniques Universitaires UCL Mont-Godinne, Yvoir, Belgium

Case report: A 46-year-old woman, with normal heart, suffered since 4 years of an extremely symptomatic incessant ventricular bigeminy. The ECG pointed towards a left ventricular outflow tract (LVOT) origin with a marked vertical QRS axis and a changing pattern in the right precordial leads with a sometimes clear positive deflection in V1 and V2. A small negativity was present in lead I. Several attempts of endocardial ablation were performed in the right ventricle and by a transeptal as well as a retrograde approach for left ventricular mapping. The persistent bigeminy could only be influenced transiently in the region of the LVOT. No real premature deflection could be obtained endocardially even in the aortic cusps. Because of the likelihood of an epicardial origin, we decided to set up a left lateral thoracoscopy. After opening of the pericardium, a careful dissection of the basal region of the left ventricle was performed after reclining the left atrial appendage. Pace mapping oriented towards the region of circumflex artery at ±1.5 cm from its origin. The bigeminy disappeared completely (touch map) at a site located behind and covered by the circumflex artery. A gently reclining part of this artery permitted to confirm repeatedly the disappearance and reappearance of the arrhythmia with a "touch map". Brief cautious applications of RF energy with a Max-3 PEN (Atricure®) while reclining carefully the coronary artery erased completely the arrhythmic focus. We observed twice a short-lasting transient reversible coronary spasm during manipulation. During early follow-up, all VPB disappeared on telemetry. Relief of symptoms was

spectacular. Conclusion: Persistent idiopathic ventricular extrasystoly could be extremely symptomatic and inaccessible to endocardial ablation. Some foci can be located at sites non-amenable to catheter epicardial ablation. A mini-invasive thoracoscopic epicardial approach can be an alternative in highly experienced hands.

3-6 Abstract 15-34

Low current radiofrequency ablation may decrease development of new atrial tachycardias in patients with long-standing persistent atrial fibrillation

Evgeny Mikhaylov1, Dmitry Lebedev1 Electrophysiology and Cardiac Pacing, Almazov Federal Heart, Blood and Endocrinology Centre, Saint-Petersburg, Russian Federation

Background: Long-term consequences of different radio-frequency (RF) current application techniques for longstanding persistent atrial fibrillation (LPAF) have not been investigated. Purpose: The aim of the study was to compare the efficacy of a single procedure with "high" and "low" RF current delivery for LPAF ablation. Methods: The study consisted of 39 patients with symptomatic LPAF. The patients were divided into two groups: group 1—open-irrigated ablation was performed with RF current power limited to 30 W; group 2—ablation was performed with energy limited to 45 W. Both groups were comparable according to mean age, history of AF, persistence of AF, and left atrial diameter. Ablation strategy included PV isolation, creation of left atrial roof line, and mitral isthmus line. A blanking period consisted of 3 months; the patients received treatment with sotalol or amiodarone for this period. Then, if the patient had no recurrence, antiarrhythmics were ceased. Arrhythmia monitoring was performed using 24-h ECG monitoring every 3 months and in the case of symptoms, possibly related to a recurrence. Follow-up was continued for 12 months. Results: Duration of the ablation procedure was shorter in group 2 (216±36 vs. 182±32 min, p<0.05). One major complication (pulmonary embolism) occurred in group 1. Free from any recurrences were 13 (68%) patients from group 1 and 11 (55%) patients from group 2 (p=ns). Analysis of type of recurrence revealed a trend towards increased prevalence of a sustained atrial tachycardia among patients with "high" RF current: two (10.5%) patients from group 1 and six (20%) patients from group 2 (p=0.2). Conclusion: The majority of new atrial tachycardias after RF ablation for AF are related to incompleteness of the circular or linear lesions. "High" RF current can lead to a fast drop in bipolar amplitude. Thus, fast movement of the ablation catheter may result in a delayed conduction recovery over the ablation line.

Abstract session 4: Mechanistic advances in cardiac arrhythmias

Friday, April 16, 2010, 10:30 am-12:00 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor)

4-1 Abstract 01-08

Pause dependent torsades de pointes—does the cause of bradycardia matter?

Preety Chawla1, Sam Hanon1, Paul Schweitzer1 Beth Israel Medical Center, New York, United States of America

Background: Pause-dependent torsades de pointes (TdP) are an important complication of heart block. However, reports linking sinus bradycardia to TdP are uncommon. One potential mechanism of TdP is bradycardia-induced QT prolongation and early afterdepolarization. Aim: The aim of this study was to compare the differences in the QT intervals in patients with sinus bradycardia and heart block. Methods: One hundred eighty-four patients with sinus bradycardia or second-degree/complete heart block were included in this study. Retrospective analysis of the ECGs was performed and the QT intervals compared. The following intervals were included in the analysis: computer calculated QT and QTc, QT interval in leads II, V2 and V5 calculated manually and the longest QTc (calculated using the longest QT interval in lead II, V2 or V5 and Bazett's formula). Also included was the presence of premature ventricular complexes and u-waves. Bivariate comparisons between sinus bradycardia and heart block groups were analyzed using Student's t tests for continuous variables and chi-square tests for categorical variables. Results: Continuous variables are expressed as mean. Categorical variables are expressed as count and percent. Conclusion: Despite no difference in baseline heart rate, patients with heart block have a significantly longer QT interval. The relative QT prolongation may explain why TdP is noted in hearty block and not in sinus bradycardia.

Sinus bradycardia Heart block P value

Number patients 95 89

Mean heart rate 48 47 NS (0.4)

Mean QT (ms) 457.9 524.9 <0.0001

Mean QTc (ms) 411.5 454.5 <0.0001

QT lead II (ms) 452.6 528.6 <0.001

QT lead V2 (ms) 456.6 529.2 <0.0001

QT lead V5 (ms) 463.2 533.4 <0.0001

Longest QTc (ms) 428.9 488.3 <0.0001

U waves 3.1 14.6 0.0059

PVC (%) 0 4.5 0.053

4-2 Abstract 01-10

Temporal and spectral analysis of ventricular fibrillation in humans

Decebal Latcu1, Olivier Meste2, Alexandre Duparc3, Marc Delay3, Philippe Maury3

1Cardiology, Centre Hospitalier Princesse Grace, Monaco, Monaco; Laboratoire d'Informatique, Signaux et Systèmes I3S, Université de Nice-Sophia Antipolis, Sophia Antipolis, France; Unité de Rythmologie et de Stimulation Cardiaque, Fédération de Cardiologie, University Hospital Ran-gueil, Toulouse, France

Objective: Analyzing VF rate and regularity at different sites and at different times may help in understanding some of the mechanisms underlying VF in humans. Methods: Twelve episodes of VF (19.4 ±5.6 s) were induced during an electrophysiology study in eight men (63 ±5 years old). Fast Fourier transform, short-time Fourier transform and analysis of the pitch frequency (VF cycle length duration: CL) were performed for the surface ECG and from ten near-field and far-field bipolar and three unipolar recordings by means of three quadripolar catheters positioned at the right ventricular apex (RV apex), right ventricular outflow tract (RVOT) and at the coronary sinus (exploring the lateral left ventricular epicardium, LV). Results: The dominant frequency (DF, 5.23±0.65 Hz) was identical on all surface ECG recordings for 10/12 VF. DF in intracardiac recordings correlated well with DF on surface ECG. CL was very stable on surface ECG and in some intracardiac recordings (ex: SD-CL on far-field recordings was <20 ms in every VF). VF rate globally correlated with VF regularity. Intracardiac sites displaying the fastest and most regular activations were those including RVapex. VF's stability increases between the beginning and the end of the recorded episodes. VF rate and stability were significantly with some clinical parameters such as age, beta-blockers or amiodarone therapy, serum level of potassium, LV systolic function and ischemic heart disease. Conclusion: Human VF is remarkably organized and spatially heterogeneous, which needs to be detailed in order to localize possible driving sources. Fastest VF is the most regular and fastest intracardiac sites are the most regular. Rate and stability increase during initial phases of VF.

4-3 Abstract 02-01

A novel approach to visualising three-dimensional connexin43 distribution in a rat infarct model

David Nicholson Thomas1, Chowdhury Rasheda A1, Fu Siong Ng , Emmanuel Dupont , Alexander R Lyon , Nicholas S Peters1

1Cardiac Electrophysiology, Imperial College, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Ventricular arrhythmias are a major cause of sudden death, the risk of which is increased in chronic heart failure (CHF) after myocardial infarction (MI). We have previously shown that gap junction remodelling occurs in the infarct border zone after MI. This is associated with the presence of reentrant circuits that support these arrhythmias. A novel approach to visualise the 3D distribution of connexin43 (Cx43) may help characterise changes in its localisation at the border zone and distant from the scar. We tested a novel approach to localise Cx43 in a post-infarct rat model of CHF. Methods: Biventricular cardiac tissue was collected 16 weeks post-MI. The apical 50% of the heart was serially sectioned (10-^.m thickness) perpendicular to the apical-basal axis. Every 300 |o.m, the tissue was stained with Evan's blue, immunolabelled for Cx43 and imaged by confocal microscopy. Images were combined to give a single high-resolution image of the entire section. Composite images were arranged

to generate a 3D reconstruction of the infarcted failing heart. Result: Infarct scar was visible 450 |o.m from the apex and extended to the mid-ventricular region, comprising roughly 60% of the thickness of the left ventricular wall, with surviving myocardium on the epicardial surface. Cx43 labelling was absent in the fibrotic scar except for isolated tracts of surviving myocytes. Adjacent to the scar, Cx43 labelling was seen away from the intercalated disc in roughly 10% of cells. Distant from the scar, Cx43 labelling was confined to the intercalated discs. A 3D reconstruction was achieved using computer-aided design (CAD) for the first time in this field. Conclusion: Changes to the localisation of Cx43 occur in CHF post MI in this model. This novel approach of obtaining high resolution reconstructions allows the identification of areas of Cx43 remodelling in a 3D manner which may be correlated with functional mapping data of ventricular arrhythmias.

4-4 Abstract 01-03

Modulation of gap junctional coupling

as an antiarrhythmic strategy to prevent reperfusion

ventricular arrhythmias

Fu Siong Ng1, Alexander R Lyon1, Iqbal T Shadi1, Eugene TY Chang1, Rasheda A Chowdhury1, Emmanuel Dupont1, Nicholas S Peters1

JCardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland

Background: Heterogeneities and abrupt changes in gap junctional coupling and action potentials during early reperfUsion are thought to contribute to reperfusion arrhythmogenesis. We tested the hypothesis that modulation of gap junctional coupling can reduce the incidence of reperfusion arrhythmias and used optical mapping to assess the mechanisms of any antiarrhythmic effect. Methods: Using a Langendorff apparatus, rat hearts were perfused with 50 nM AAP10 to increase coupling (n = 10), 30 ^M carbenoxolone (CBX) to reduce

coupling (n = 13) or control (n = 10). Hearts were then subjected to left anterior descending artery ischaemia for 8 min and reperfused. A further 18 hearts were loaded with a voltage-sensitive dye (RH237), perfused with an excitation-contraction uncoupler (blebbistatin) and AAP10, CBX or control (n=6 each), then subjected to ischaemia and reperfusion as above, whilst transmembrane voltage transients were recorded. Results: Both AAP10 and CBX reduced reperfusion VF incidence (AAP10 50%, CBX 77%, control 90%, P< 0.05). AAP10 reduced action potential duration dispersion in ischaemic myocardium (AAP10 2.3±0.8 ms; CBX 5.1± 1.2 ms; control 4.9±2.0 ms, P<0.05). AAP10 also improved conduction across the ischaemic anterior left ventricle (LV,

activation time: AAP10 15.3±1.3 ms; CBX 25.7±2.2 ms; control 23.2±2.0 ms, P<0.05) prior to reperfusion. CBX prolonged this activation time post-reperfusion (AAP10 10.3 ± 0.8 ms; CBX 15.8±2.8 ms; control 9.5±1.2 ms), thus resulting in smaller changes in conduction velocities pre-and post-reperfusion. Conclusion: Both increasing and reducing gap junctional coupling reduced the rate and delayed the onset of reperfusion VF. The antiarrhythmic effect of increasing gap junctional coupling may be mediated by its effects of reducing action potential heterogeneity and improving conduction during reperfusion. Further uncoupling may be protective via attenuation of the abrupt changes in coupling and conduction that occur at reperfusion.

4-5 Abstract 04-06

Transvenous cardiac sympathetic neural stimulation: anatomical and functional insights

Christian Meyer1, Thomas Schimpf2, Dainius Pauza3, Kay Nolte , Joachim Weis , Martin Martinek , Helmut Purerfellner , Patrick Schauerte6, Malte Kelm1

1University of Duesseldorf, Duesseldorf, Germany; 2KH Eschweiler, Eschweiler, Germany; 3Department of Human Anatomy, Laboratory of Neuromorphology, University of Kaunas, Kaunas, Lithuania; 4Institute for Neuropathology, Aachen, Germany; 5Elisabethinen Hospital, Linz, Austria; Division of Cardiology, Aachen, Germany

Background: Dynamic neural control of left ventricular contractility may offer a new approach to control chronic heart failure. The aim of the present study was (1) to characterize the left ventricular systolic response to trans-venous cardiac sympathetic neural stimulation (SNS) and (2) to present neuroanatomical insights from these sites. Methods: In 20 female sheep high-frequency stimulation (HFS, train duration 50 ms, frequency 200 Hz, 37.5 V, 2-ms pulse duration) during atrial refractoriness was performed with electrode catheters inside the coronary sinus (CS). Results: SNS inside the CS evoked a systolic LV pressure increase from 95± 17 to 130±21 mmHg (p<0.01) without changes of sinus rate or PR time. Likewise, the slope of end-systolic pressure-volume relationship increased as did cardiac output (both p < 0.001). During SNS, the trans-cardiac norepinephrine gradient increased. Systemic vascular resistance remained unchanged. Ultrasound strain analysis revealed a homogeneous increase of LV contractility. Two-way ANOVA demonstrated that the effect of HFS on LV contractility depends on the availability of beta-1 receptors. Programmed ventricular stimulation during SNS did not induce ventricular tachycardia or fibrillation. Macroscopic and microscopic histochemical analysis demonstrated a predominant adrenergic neural network besides the identified intravascular site. Conclusions: Neural structures which innervate the left ventricle are amenable to transvenous electrical catheter stimulation. This might open up new avenues for interventions targeting the left ventricular sympathetic tone.

4-6 Abstract 03-02

Phenotype difference between genotype of plakophilin-2 mutation and desmoglein-2 mutation in symptomatic Chinese patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy—a report from Chinese ARVD Registry

Liu Wenling1, Qiu Xiaoliang1, Hu Dayi1, Zhu Tiangang1, Li Cuilan1, Li Lei1, Qin Xuguang2, Liu Xingpeng3, Zhang Li4 1Cardiology Dept., Peking Univ. People's Hosp., Beijing, China; Cardiology Dept., Tsinhua Univ. First Hosp., Beijing, China; Cardiology Dept., Anzhen Hosp., Beijing, China; 4Cardiology Dept., Main Line Health Heart Center, Philadelphia, United States of America

Introduction: Arrhythmogenic right ventricular dysplasia/ cardiomyopathy (ARVD/C) is an inherited heart muscle disease associated mainly with the mutations of desmosome up to date. Plakophilin-2 (PKP2) and desmoglein-2(DSG-2) are reported as the two most common ARVD-causing genes in western countries. In this study, we aim to determine the prevalence of PKP2 and DSG2 mutations in Chinese ARVD/C patients and their phenotype characteristics. Methods: Genotype and phe-notype were investigated in a cohort of 23 symptomatic Han Chinese with a clinical diagnosis of ARVD. Direct sequencing of PKP2 and DSG2 was done by 3730XL DNA analyzer. Results: Five novel heterozygous mutations (R158K, Q211X, L419S, A793D, and N852fsX930) of PKP2 were identified in 30% (7/23) of ARVD patients (results have been shown). Three mutations (R46G, D494A, and F531C) in DSG2 were identified in 13% (3/23) of the patients. Among the positive patients, initial symptoms occurred at 30 ± 10 years. All of them documented VT. Symptoms of the patients with PKP2 mutation were severe than that of patients with DSG2 mutation. All of the patients with PKP2 mutation had syncope, but none of the patients with DSG2; they only had palpitation. Most of the patients with PKP2 mutation (6/7) showed epsilon waves in ECGs but only one in patients with DSG2. Six patients with PKP2 mutation showed inverted T wave in V1 to V3, but only one in patients with DSG2 mutation. Conclusions: There are some differences between patients with PKP2 mutation and that with DSG2 mutation including clinical symptom and ECGs. It seems that phenotype of PKP2 mutation was more severe than that of DSG2 mutation in this cohort.

Abstract session 5: Catheter ablation of AF (II) Saturday, April 17, 2010, 10:30 am-12:00 pm ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) 5-1 Abstract 18-15

Pulmonary vein antrum isolation for long-term maintenance of sinus rhythm in patients with drug-resistant atrial fibrillation

Ayman Hussein1, Walid Saliba1, David Martin1, Minerva Sherman1, Christina Magnelli-Reyes1, Mandeep Bhargava1, Mohamed Kanj1, Andrea Natale1, Oussama Wazni1 ICleveland Clinic Foundation, Cleveland, United States of America

Introduction: Little is known about the efficacy of pulmonary vein isolation (PVI) for long-term maintenance of sinus rhythm in patients with drug-resistant AF. Methods: All 831 patients who underwent PVI in 2005 for drug-resistant AF were followed. Recurrence was identified by symptoms with documentation, event monitoring, Holter recordings, and ECGs. Results: Patients' characteristics were: 77.5% male, age 58.7±9.9 years, 35.6% hypertensive, 14.2% had coronary disease, 8.1% diabetic, and left ventricular ejection fraction (EF) was 53.0±9.8%. All were symptomatic and underwent isolation of all four PVs. Median follow-up was 55 months (12-58), 198 (23.8%) had early recurrence within 12 months post-PVI, and 633 patients (76.2%) remained arrhythmia free at 1 year. Of these, 587 patients were followed (median 44 months, 3546). Seventy-four patients (8.9%) had late recurrence and 513 patients had no recurrence. A total of 188 patients underwent repeat ablations (27 in the late recurrence group revealing PV recovery in all. With isoproterenol testing, right-sided premature atrial beats initiating AF were identified and ablated in 15). At last follow-up, 660 patients were arrhythmic free of AAD (79.4%, 513 after a single ablation, 147 after repeat ablation), whereas 125 patients (15%, 41 after repeat ablation) continued to have AF controlled with AAD in 87 of them. Only 38 patients continued to have drug-resistant AF (4.6%). The complications rate was low: one asymptomatic pericardial effusion, two tamponades (one required surgery), three ischemic strokes (all reversible), seven groin hematomas (three required interventions), six PV stenosis, and one arteriovenous fistula. Conclusions: PVI is safe and efficacious for long-term maintenance of sinus rhythm in patients with drug-resistant AF. The incidence of very late recur-

rence is low. PV reconnection accounted for most late recurrences. Repeat ablations are very successful.

5-2 Abstract 18-07

The impact of CT image integration on clinical outcomes after catheter ablation of atrial fibrillation using three-dimensional electroanatomic mapping: a prospective study of 200 consecutive patients

Anton Hahnefeld1, Michael Ulbrich1, Nadine Haserueck1, Reza Wakili , Gerhard Steinbeck , Stefan Kaab Medical Department I, Klinikum Grosshadern, Munich, Munich, Germany

Background: Circumferential pulmonary vein isolation (CPVI) is a catheter-based therapy of paroxysmal and persistent atrial fibrillation (AF). Integration of multislice computed tomography (CT) into 3D electroanatomic mapping systems (EAM) to guide catheter ablation has been shown to be accurate and feasible. The aim of this prospective study was to determine the impact of CT integration on clinical outcome in patients undergoing catheter ablation of AF. Methods and results: A total of 200 consecutive patients (mean age 58.9± 10.1 years) with drug-resistant paroxysmal or persistent AF (71% paroxysmal AF) underwent CPVI using EAM system CARTO XP or EnSite NavX with or without CT integration into the 3D map (with CT: group A, n=98 pts.; without CT: group B, n = 102 pts.). The group randomization was consecutive. The acute procedural outcome (complete PV reconnection) was equal in both groups—98% of all PVs. Procedure duration was significantly longer in the CT group (3.9±0.9 vs 3.4±0.8 h, p<0.001), but the radiation dose showed no difference (4,385.65±2,470.73 vs 4,118.9±3,481.3 cGy/ cm2; n.s.). The primary endpoint of the study was therapy success (freedom of symptomatic AF) at 12 months of follow-up. Comparison of outcome data between the groups with paroxysmal or persistent AF resulted in a significant improvement in procedural success for the CT group (73.4% vs 68.8%, p<0.05). An analysis of the subgroups with paroxysmal AF showed no difference between the CT and conventional approach (group A, 76.6%; group B, 73.8%; n.s.). Conclusion: CT integration into electroanatomic mapping significantly improves the success of CPVI in total of consecutive patients with paroxysmal or persistent AF. Image integration did not significantly improve the clinical outcome for patients with paroxysmal AF. These results suggest a benefit of CT integration for advanced ablation procedures in patients with persistent AF.

5-3 Abstract 14-05

Updated survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation: a European perspective

Riccardo Cappato1, Hugh Calkins2, Shih-Ann Chen3, Wyn Davies4, Yoshito Iesaka5, Jonathan Kalman6, You-Hu Kim7, George Klein8, Douglas Packer9 1Center of Clinical Arrhythmia & Electrophysiology, I.R.C. C.S. Policlinico San Donato, San Donato Milanese, Italy;

Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Veterans General Hospital, Taipei, Taiwan Province of China; 4St. Mary's Hospital, London, United Kingdom of Great Britain and Northern Ireland; 5Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura Ibaraki, Japan; 6Royal Melbourne Hospital, Parkville, VIC, Australia; 7Cardiology Departement, Asan Medical Center, Seoul, Democratic People's Republic of Korea; 8Department of Cardiology, University Hospital, London, United Kingdom of Great Britain and Northern Ireland; Division of Cardiology, Mayo Foundation—St. Mary Hospital, Rochester, MN, United States of America

The purpose of this study was to provide an updated European report on the methods, efficacy and safety of catheter ablation (CA) of atrial fibrillation (AF). A questionnaire with 46 questions was sent to 521 centers representative of 24 countries in four continents. Of these, 37 were European centers. Complete interviews were collected from 182 centers, of which 85 reported to have performed 20,825 CA procedures on 16,309 patients with AF between 2003 and 2006. The median number of procedures per center was 245 (range, 2-2,715). All centers included paroxysmal AF, 85.9% included also persistent and 47.1% included also permanent AF. Success rate free of antiarrhythmic drugs (AADs) was significantly lower in European centers as compared to centers from other continents (58.4% vs 67.9%, p<0.001). This difference was maintained when comparisons were made among patients with paroxysmal, persistent and permanent AF. Efficacy free of AADs was counterbalanced by a significantly higher success rate of CA plus AADs in European vs centers from other continents (21.3% vs 12.2%, p < 0.001). Carto-guided ablation was more successful in centers from other continents (p < 0.001), whereas Lasso-guided ablation was similarly effective in the two groups (p=0.9889). Significantly more strokes, transient ischemic attacks, pulmonary vein stenoses, pneumothorax, arteriovenous fistulae and pseudo-aneurysms were found in European centers versus centers from other continents. Death rates were similar in the two populations.

Conclusions: When compared to centers from other continents, success rates are lower and complication rates are higher in CA of AF performed in European centers.

5-4 Abstract 18-12

Intracardiac echocardiography-guided pulmonary vein isolation in patients with paroxysmal atrial fibrillation: impact on outcome and complications

Salah Atta1, Sherif H. Zaki1, Mostafa Alrefaee1, Hesham Hegazy1, Jehan Abd Alhalim1, Laila Al-Hoty1, Mahmood S1

1Cardiology department, Saoud Albabtain Cardiac Center, Aldammam, Saudi Arabia

Conventional pulmonary vein isolation (PVI) using fluo-roscopy can guarantee neither the exact antral site of ablation nor the limit for radiofrequency power titration in patients with paroxysmal atrial fibrillation (PAF). The aim was to assess the role of intracardiac echocardiography (ICE) for visualization and proper ablation of the PV antrum and its effect on both short-term success and incidence of complications in PAF patients. Patients and methods: Thirty-one patients (21 men, mean age 41.3 + 5.1 years) underwent PVI for treatment of PAF. Each patient underwent antral isolation of all PVs using an 8-mm tip or irrigated tip ablation catheters. PVI was performed using electrophysiologic circular mapping (CM) alone (group, 14 patients), CM and ICE (group 2, 17 patients) with titration of radiofrequency energy based on visualization of microbubbles by ICE in the case of group 2 or impedance rise in the case of group1. Pulsed wave Doppler was done before and after ablation of PVs in group 2 patients to assess for PV stenosis. Results: There was a significant difference between both groups in terms of mean fluoroscopy time (85+32 in group 1 vs. 61 + 44 min in group 2, p<0.05) and mean number of RF lesions per vein for complete isolation (15.5 + 2 vs. 8.5 + 2, p<0.05), respectively. After a mean follow-up time of 12.5 ± 2.3 months, 35% (5/14) of patients in group 1 and 17.5% (3/17) in group 2 experienced recurrence of AF, respectively (p<0.05). Moreover, no one in group 2 patients experienced severe (>70%) PV stenosis postoperatively, whereas severe PV stenosis with dyspnea was documented in 3 out of 14 (3.5%) patients in group 1. No embolic events occurred in either group. Conclusion: Use of ICE improves the outcome of PVI and reduces both fluoroscopy time and number of lesions per pulmonary vein. Power adjustment guided by direct visualization of microbubble formation reduces the lesions sufficient for complete PVI and thus risk of PV stenosis and improves short-term cure.

5-5 Abstract 15-15

Combined radiofrequency and cryoablation

for paroxysmal atrial fibrillation: a novel technique

to reduce recurrences

Muzahir Tayebjee1, Edward Duncan1, Victoria Baker1, Mehul Dhinoja1, Mark Earley1, Simon Sporton1, Richard Schilling2

1Cardiology, St Bartholomews Hospital, London, United Kingdom of Great Britain and Northern Ireland; 2Cardiol-ogy, St Bartholomews and London Bridge Hospitals, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We hypothesised that electrical isolation of the pulmonary veins (PV) by wide area circumferential ablation with radiofrequency (RFA) followed by selective PV ostial ablation using a cryoablation balloon (Cryo) would create parallel lines of block and reduce the incidence of PV reconnection. This would therefore

improve first-time success rates for paroxysmal atrial fibrillation (PAF). Methods: A retrospective study examined 59 consecutive patients undergoing first-time PV isolation for symptomatic PAF (>1 year) and had failed at least two medical therapies. Patients received RFA alone, Cryo alone or combined RFA (to isolate PVs) followed by Cryo. Patients were followed up with 12-lead ECG, 7-day Holter monitoring and clinical review. Any atrial arrhythmia lasting greater than 30 s during a 3-month follow-up period was documented as a recurrence. Results: Significantly fewer patients had symptomatic palpitations (with documented PAF) in the combined group, with a trend towards need for less redo procedures (Table). Complications were one phrenic nerve palsy and one haematoma in the Cryo group, one grounding plate burn in the RF group and one phrenic nerve palsy, one pericardial effusion and one haematoma in the combined group. Total procedure time was greater in the combined group (Table). Conclusion: Preliminary results suggest that combination of RF and cryoabla-tion is superior to either alone. A prospective randomised trial is underway to confirm these findings.

Cryoablation only RFA only RFA and cryoablation P value

(n = 13) (n = 23) (n = 23)

Age (years) 55±12 56±10 55±12 NS

Male 8 (61%) 13 (57%) 19 (83%) NS

Hypertension 3 (23%) 7 (30%) 7 (30%) NS

Diabetes mellitus 0 (0%) 2 (9%) 0 (0%) NS

Coronary disease 1 (8%) 0 (0%) 1 (4%) NS

Left ventricular dysfunction 1 (8%) 3 (13%) 0 (0%) NS

Procedure length (min) 171±51 198±65 243 ±79 0.010

Fluoroscopy time (min) 38±16 29±14 38±19 0.141

Complications 2 (15%) 1 (4%) 3 (13%) NS

Median follow-up time in days (IQR) 83 (67-189) 99 (87-119) 97 (80-121) NS

Recurrent symptoms requiring medication or redo 6 (46%) 10 (44%) 3 (13%) 0.041

Repeat procedure performed 5 (38%) 7 (30%) 3 (13%) NS

5-6 Abstract 18-09

Catheter ablation of atrial fibrillation using remote magnetic catheter navigation: a case control study

Arash Arya1, Ruzbeh Zaker Shahrak1, Christopher Piorkowski1, Andreas Bollmann , Sommer Philipp , Thomas Gaspar , Wetzel Ulrike1, Hindricks Gerhard1

JHeart Center University of Leipzig, Leipzig, Germany

Introduction: A remote magnetic navigation system (MNS) has been used for catheter ablation of atrial fibrillation

(AF). However, irrigated tip catheter has not been evaluated in a large series of patients. This study was intended to evaluate acute and 6 months efficiency of the newly available irrigated tip magnetic catheter for radiofrequency ablation of AF. Methods: Between August 2007 and April 2009, a total of 70 patients with paroxysmal (n=35) and persistent (n=35) AF (46 men, mean age 58±11 years) underwent radiofrequency ablation (30-35 W/48°C) using a remote MNS and a magnetic irrigated tip catheter. During the same period, 286 patients (216 paroxysmal AF, 189 men, mean age 58±10 years) who underwent radiofre-quency ablation using manual catheter navigation were

used as control group. Freedom from AF was defined as lack of any atrial arrhythmia lasting longer than 30 s during the follow-up excluding the first week after catheter ablation procedure. Results: Complete isolation of all pulmonary veins was achieved in 79% and 87% of the patients in MNS and manual groups, respectively (P=0.10). During the 6 months of follow-up, 58% and 66% of the patients in MNS and manual groups remained free from AF after single-catheter ablation procedure, respectively (P= 0.19). The total procedure and fluoroscopy times were

223±44 vs.166±52 min and 14±8 versus 35±15 min in MNS and manual navigation groups, respectively (P< 0.05). The duration of radiofrequency energy application was 75±21 versus 53±21 min in MNS and manual navigation groups, respectively (P<0.05). Conclusions: Irrigated ablation of atrial fibrillation using remote MNS is an effective modality for the management of AF with minimal radiation exposure, but with longer procedure time. Further randomized studies are needed to clarify the role of this technology in catheter ablation of AF.

Abstract session 6: Advances in cardiac resynchronization therapy I

Saturday, April 17, 2010, 10:30 am-12:00 pm ROOM FURSTENSALON (Palais Montgelas, 2nd Floor) 6-1 Abstract 24-13

Improvement of care and outcomes using cardiac resynchronization therapy (CRT) in patients with advanced class IV heart failure

Dalia Giedrimiene1, Faisal Zaeem2, Detlef Wencker3, Christopher Clyne

Cardiology/Clinical Research, Hartford Hospital, Hartford, United States of America; Cardiology/Heart Failure Center, Hartford Hospital, Hartford, United States of America; 3Cardiology/Heart Failure and Transplant Center, Hartford Hospital, Hartford, United States of America; 4Cardiology/ ICD and Electrophysiology Clinic, Hartford Hospital, Hartford, United States of America

CRT has been shown to reduce symptoms and improve left ventricular function/geometry in patients with significantly reduced left ventricular function and cardiac dyssynchrony. It can also improve the quality of life and reduce the risk of death in patients who receive CRT in addition to standard pharmacologic therapy. We evaluated the effects of CRT on quality of life, improvement of care, and outcomes in patients with advanced heart failure (AHF) who were dependent on IV therapy (inotropes/diuretics) and were hospital-bound. Methods: From our database of 670 patients, the analysis included 31 pts with AHF (all HYHA class IV), 20 men and 11 women, aged 36-82 years (mean= 67.3 ±10.8), who received CRT device from December 2000 to March 2009. Twenty (64.5%) of them had ischemic cardiomyopathy, QRS duration 92-190 ms. Thirty out of 31 pts had QRS > 120 ms; LVEF 5-30%, mean = 17.3±5.7; LVEDd 4.8-7.6, mean=6.3±0.93. Seventeen (54.8%) pts had impaired renal function (as Cr > 1.5 mg/dL). Changes in hemodynamics, inotropes/diuretics dependence, renal function, NYHA functional class, and in-hospital duration from CRT to discharge were assessed. Endpoints included survival to discharge and at 6, 12, and 18 months postdischarge. Results: The study showed that all 31 (100%) patients survived CRT implantation; however, two (6.5%) die at the time of discharge due to significant comorbidities. Twenty-nine (93.6%) patients were discharged for ambulatory care. Only two of them were inotrope-dependent after CRT implantation. Survival at 6, 12, and 18 months was, respectively, 74.2%, 71.0%, and 71.0%. Conclusions: Study results show that majority of patients benefited from CRT,

which improved discharge ability from the hospital and significantly reduced the level of care for these patients. It also improved treatment outcomes and their quality of life.

Clinical variables Before CRT After CRT P value

Systolic BP (mmHg) 96.3±13.6 107.4±14.1 0.003*

Serum creatinine 0.8-4.5 0.5-4.1 0.128

(1.9±0.9) (1.5±0.8

Blood urea nitrogen 17-110 10-90 0.019*

(53.6±28.0) (38.7±19.7)

NYHA functional 4 2.9

class (mean)

Dependence on 31 (100%) 4 (12.9%)

inotropes/diuretics

Hospital stay (days) 9.6±11.1 5.1±5.6 0.05*

6-2 Abstract 24-09

Chronic kidney disease is an independent predictor of sustained ventricular arrhythmia in heart failure patients with primary prevention CRT-D devices

Girish Ganesha Babu1, Sanjeev Kumar2, Aerakondal Gopalamurugan3, Pier Lambiase3, Anthony Chow3, Oliver Segal3

1Cardiovascular Science, The Hatter Cardiovascular Institute, London, United Kingdom of Great Britain and Northern Ireland; 2Nephrology, Royal Free Hospital, London, United Kingdom of Great Britain and Northern Ireland; Cardiology, University College London Hospitals, London, United Kingdom of Great Britain and Northern Ireland

Objective: The objective of this study was to determine if baseline chronic kidney disease (CKD-III or worse) is independently associated with increased risk of VT/VF in heart failure (HF) patients undergoing primary prevention cardiac resynchronisation therapy with defibrillator (CRT-D). Methods: HF patients with LVEF <35% implanted with CRT-D devices for primary prevention between 2004 and 2007 were included for analysis. Baseline renal function before device implantation was determined by estimated glomerular filtration rate (EGFR). VT/VF incidence was determined by retrospective analysis of device follow-up records from stored electrograms (EGMs). The cohort was divided into two groups based on eGFR < 60ml/min per 1.73 m2 (G1) and eGFR> 60 ml/min per 1.73 m2 (G2) and incidence of VT/VF in the two groups compared using Fischer's exact test. Results: A total of 73 patients meeting inclusion criteria were analysed, with 28 (38%) in G1 (eGFR < 60) and 45 (62%) in G2 (eGFR> 60). The two groups matched with baseline LVEF and follow-up periods; however, G1 had older patients and more males. VT/VF

occurred in eight (28.5%) patients in G1 compared to four (8.8%) patients in G2 (OR=4.1, 95% CI = 1.10-15.25, p= 0.03). Kaplan-Meier survival analysis showed significantly lower event-free survival in G1, log rank=5.03, p=0.02. Cox proportional hazards model identified eGFR<60 ml/min per 1.73 m to be the only independent predictive factor for VT/VF occurrence in this cohort (HR 3.718, CI = 1.11212.438, p=0.033). Conclusion: Baseline chronic kidney

disease is a strong independent risk factor for ventricular arrhythmia in patients with HF implanted with CRT-D devices, albeit patients with eGFR<60 ml/min per 1.73 m2 were significantly older and predominantly male. To the best of our knowledge, this is the first study to demonstrate increased incidence of ventricular arrhythmias associated with CKD in the primary prevention setting. Prospective randomised trials are needed to establish this association.

6-3 Abstract 24-01

Can we predict early deterioration after CRT from patients' baseline characteristics?

Raed Abu Sham'a1, Eyal Nof1, Rafael Kuperstein2, David Luria1, David Bar-Lev1, Osnat Gurevitz1, Micha Feinberg2, Michael Eldar1, Michael Glikson1

1Cardiac Pacing and Electrophysiology, Sheba Medical Center, Ramat Gan, Israel; Non-Invasive Cardiology, Sheba Medical Center, Ramat Gan, Israel

Background: Two thirds of patients (pts) treated by CRT will show clinical improvement. Unfortunately, few pts may deteriorate after implantation. The aim of this study was to analyze clinical and echocardiographic parameters as predictors of clinical or echo deterioration following CRT. Methods: We reviewed our CRT database for pts with implanted CRT/D since 1998. Clinical deterioration was defined by a combined score of the change in NYHA class, QoL score and 6-min walk (6 MW) between baseline and follow-up at 1 year. Each component was classified as

improved +1, unchanged 0, or worsened —1. Deterioration was defined as a combined score of <1 at follow-up. During heart transplant or death, —1 > 5% and relative increase of LVESV by >10%. Results: A total of 509 pts were implanted with CRT/D during this period. Fifty-two pts were excluded due to incomplete data. Of the 457 pts analyzed, 67 (14.7%) clinically deteriorated within the first year. Pts with ischemic CMP had a trend toward higher incidence of clinical deterioration, as did those with higher LVESV and LVEDV (p > 0.05). Among those who clinically deteriorated, only 22.2% had a significant reduction in LVEF compared to 8.6% in the other group (p=0.005). Eighty-three pts (18.2%) had evidence of echo deterioration, of whom 47 (56.6%) clinically deteriorated. Thirty-six patients (7.9%) had evidence of echo, but not clinical deterioration. None of the baseline parameters were significant predictors of either clinical or echocardiographic deterioration. Conclusions: In this large cohort of CRT pts, approximately 15% and 18% of pts exhibited clinical and echocardiographic deterioration during the first year after implantation. There was poor correlation between echocar-diographic and clinical deterioration. Using baseline clini-

cal and echocardiographic parameters, we were unable to characterize those patients who were prone to deteriorate.

6-4 Abstract 24-08

Value of echocardiographic mechanical dyssynchrony assessment in selecting patients for cardiac resynchronization therapy

Ihab Diab1, Ravindu Kamdar1, Ross Hunter1, Thomas Berriman1, Dominic Abrams1, Mehul Dhinoja1, Mark Earley , Simon Sporton , Richard Schilling

St Bartholomew's Hospital, London, United Kingdom of Great Britain and Northern Ireland

Background: QRS duration is used to select patients for resynchronization therapy (CRT). Echo assessment for dys-synchrony has been used to refine patient selection with conflicting results. This prospective blinded study evaluated the effect of the presence (group 1) or absence (group 2) of dyssynchrony on the response to CRT. Methods: We recruited 60 (53 men, 42 ischaemic aetiology, mean age 66±9 years) heart failure patients (NYHA III-IV) with an indication for an ICD, QRS > 120 ms and LV ejection fraction (EF) <35%. Group 1 and 2 patients were identified using a criteria-based echo protocol. Group 1 patients received a CRT-D device (26 patients), whereas group 2 patients were randomised to CRT-D (group 2a, 16 patients) or an ICD (group 2b, 18 patients). At baseline and 6 months, patients' symptoms, exercise capacity and LV function were assessed using a Minnesota (MLHF) quality of life questionnaire, cardiopulmonary exercise for peak oxygen consumption (VO2), and an echo. Results: Group 1 had wider QRS (159±17 vs 138±19 ms, p<0.001) and lower EF (22±7 vs 26±6%, p=0.02) than group 2. There were no differences in QRS or EF between groups 2a and 2b. Group 1 showed significant improvements in NYHA class (3.1±0.3 to 1.9±0.7, p<0.001), EF (22±7 to 25±9%, p=0.04) and peak VO2(16.4±4.2 to 18.0±4.1 ml kg-1min—1, p=0.01). Group 2a also showed a significant improvement in NYHA class (3.1±0.3 to 2.2±0.7, p=0.005), but no change in EF or peak VO2. Group 2b showed no change in NYHA class or EF with a decline in peak VO2 (16.4±4.2 to 14.1 ± 4.1, p=0.03). The MLHF score significantly improved in groups 1, 2a and 2b to variable extents (27% vs 16% vs 12%, respectively, p for trend 0.04). Conclusion: Echo dyssynchrony identifies patients who derive the most benefit from CRT. Other patients with a wide QRS and no dyssynchrony show smaller benefit possibly through stem-

ming of the decline over time that is seen in heart failure patients. These patients should not be denied CRT.

6-5 Abstract 24-11

The comparative effectiveness of different pacing methods for patients with heart failure and atrial fibrillation after radiofrequency catheter ablation

Oskars Kalejs1, Nikolajs Nesterovics1, Maris Blumbergs1, Janis Ansabergs1, Ginta Kamzola1, Maija Vikmane1, Kristine Jubele1, Pavels Sipacevs1, Aivars Lejnieks2 1Arrhythmology, P.Stradins University Hospital, Riga, Latvia; 2Internal medicine, RAKUS, Riga, Latvia

The aim of study was to compare the effectiveness of different pacing sites for patients after catheter ablation of atrioventricular junction (AVJ) in permanent atrial fibrillation (PAF) and heart failure. Method: We analyzed the data from 90 patients with: PAF, mean QRS in ECG 100 ± 20 ms, left ventricular ejection fraction (LVEF) 43 ± 7%, enlarged left ventricular diastolic volume (LVDV) and heart failure class I-III NYHA. All patients had undergone AVJ ablation. Pacing groups: cardiac resynchronization therapy [CRT] (gr A, 30 pts) and ventricular septal pacing (VSP) (gr B, 30 pts). Data were compared with the results of previous (1997-2000) ablations with right apical pacing (gr C, 30 pts). LVEF was measured before and after the procedure as well as 6, 12 and 24 months after the procedures; the 6-min walk test was made, and for gr A and gr B, the levels of b-type natriuretic peptide (BNP) were measured. Results: Pacing threshold increased in group A and group B 1.8 ± 0.6 V with septal pacing, but it became stable after 4 h until 1.1 ± 0.3 V. LVEF after 6, 12 and 24 months was also different between gr A and gr B, gr A 53 ± 3% vs gr B 46 ± 4%, which was different from gr C 44 ± 4% (p<0.05). In gr A, after 24 months, LVDV decreased, there were no significant changes in gr B, but increased in gr C. The data of exercise tolerance and quality of life (SF-36 questionnaire) became different after 6 months, and after 24 months, we observed a substantial difference between gr A and gr C (p<0.05), less pronounced between gr B and gr C (p>0.05). The level of BNP after 12 months decreased more than twofold in gr A; however, the decrease in gr B was observed only in a selective part of patients. Conclusions: The techniques of CRT and VST in comparison with apical right ventricular pacing are more physiological methods for rate control after the catheter ablation of AVJ.

CRT not only improves the function of the left ventricle but also promotes the process of reverse remodeling.

6-6 Abstract 24-22

Non-responders of cardiac resynchronization therapy in long-term follow-up are identified by anatomical substrate in [18F]FDG-PET/CT and lack of reverse remodeling

Michael Ulbrich1, Christopher Ubleis2, Nadine Haseruck1, Anton Hahnefeld1, Nico Oversohl1, Gerd Juchem3, Marcus Hacker2, Gerhard Steinbeck1, Stefan Kaab1 Department of Internal Medicine I, University of Munich, Campus Grosshadern, Munich, Germany; Department of Nuclear Medicine, University of Munich, Campus Grosshadern, Munich, Germany; Department of Cardiac Surgery, University of Munich, Campus Grosshadern, Munich, Germany

Background: Despite improved implantation strategies, the rate of non-responders in cardiac resynchronization therapy (CRT) is still about 30%. The aim of this study was to evaluate the usefulness of the [18F]FDG-PET/CT in the identification of reasons for poor CRT response. Methods: CRT responders were defined by clinical improvement and reverse remodeling, measured by an increase in LVESV > 15%. [18F]FDG-PET/CT was performed 32±17 months

after implantation in seven consecutive non-responders and seven responders (68 ±8 years, nine male, mean LVEF 32 ± 13%) matched by age, sex, LV-EF and time of implantation. In addition to [18F]FDG-PET/CT, a clinical reevaluation was done by determination of NYHA class, BNP level, 6-min walk distance and transthoracic echocardiography. Results: CRT responders showed an increase in LV-EF of 15 ±11% and a reduction in LVESV of 82±36 ml (p<0.01). Other relevant differences were BNP values, the vitality of the left ventricular pacing site and a persistent intraventricular dyssynchrony, measured by global time to peak systolic velocity (TTPV) and global entropy in phase analysis (p < 0.05). Left ventricular lead placement in vital target regions and a low global scar load (<15% of LV) was associated with a higher incidence of reverse remodeling (p<0.05) regardless of the cardiac disease. In non-responders, the investigations led to further therapeutic consequence in five patients (two LV lead revisions, two heart transplants, one mitral clip). Conclusion: In CRT patients [18F] FDG-PET/CT can identify an anatomical substrate for insufficient CRT response. Left ventricular pacing sites in regions with adjacent scar tissue caused significantly less likely reverse remodeling and treatment success. In the vast number of CRT non-responders, the investigations had direct therapeutic implications. In the future, a merged visualization of myocardial viability and coronary venous anatomy could influence the implantation strategy and long-term success in CRT patients.

Abstract session 7: Sudden cardiac death

and pharmacological and non-pharmacological therapy

Saturday, April 17, 2010, 10:30 am-12:00 pm

ROOM GELBERSALON (Palais Montgelas, 1st Floor)

7-1 Abstract 17-06

Arrhythmogenic right ventricular dysplasia: evaluation of efficacy of antiarrhythmic drugs in 134 patients

Nicolas Badenco1, Guillaume Duthoit1, Jean-Louis Hebert , Françoise Hidden-Lucet , Caroline Himbert , Joelci Tonet , Robert Frank

Cardiologie-Unité de Rythmologie, Groupe Hospitalier Pitié Salpêtriere, PARIS, France; Department Of Human Physiology, University Paris XI, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France

Background: Arrhythmogenic right ventricular dysplasia (ARVD) is the cause for ventricular arrhythmias and sudden death in young patients. Antiarrhythmic drugs are important in the management of these patients, but few data are available. The purpose of this study was to identify the specific role and the efficacy of antiarrhyth-mic drugs in patients affected with ARVD. Methods: Antiarrhythmic pharmacologic therapies were retrospectively analyzed in 134 patients from a tertiary center between 2002 and 2008 with ARVD. Diagnosis was made according to international criteria and with morphological criteria based on right ventricular contrast angiography. Results: Mean and median duration of follow-up were 65 and 48 months, respectively. Minimal follow-up was 1 year. The combination of ^-blocker with flecainide was the most commonly used (35%), with an excellent tolerance. ^-blocker or the combination of ^-blocker with amiodarone was used in other patients (respectively, 29% and 11%). Antiarrhythmic drugs were maintained as long as no ventricular arrhythmias relapsed and often after serial electrophysiological studies searching for inducibil-ity of ventricular tachycardia (VT). VT catheter ablation was associated in 28% patients, and 35% were implanted with cardioverter defibrillator for hemodynamically unstable VT. Annual sudden death rate was 0.7%, mainly due to inadequate medical therapy. Conclusion: The management of patients with ARVD needs a hybrid strategy combining antiarrhythmic drugs identified with

serial testing, catheter ablation, and cardioverter defibril-lator in order to protect them from ventricular arrhythmias and sudden death.

7-2 Abstract 17-03

Indication, technique and results of radio frequency ablation of premature ventricular beats

Philippe Maury1, Alexandre Duparc1, Aurelien Hebrard1, Pierre Mondoly1, Anne Rollin1, Nicolas Detis1, Philippe Rumeau , Talia Chilon , Marc Delay

University Hospital Rangueil, Toulouse, France

Introduction: Radio frequency (RF) ablation of premature ventricular beats (PVB) has been only reported as isolated cases or in short series. Methods: Thirty-four successive patients (25 men, 53± 18 years old) underwent RF ablation of frequent or symptomatic isolated PVB at our institution from 2005 to 2009. Indication, technique, and results were reported. Results: Forty-three RF ablation of PVB was performed for post-ischemic electrical storm in seven patients (six men), for symptomatic PVB in seven (three men), and for suspected VPB-induced tachycardiomyopathy in 20 (16 men), with one to two procedures/patient. RF was performed in each case using pace mapping and activation mapping with conventional technique. RF ablation of PVB during intractable post-ischemic electrical storm was initially successful in each patient, but fatal electrical storm recurred in four during the following days. PVB were targeted in the left septal Purkinje network. Ten procedures were performed in seven patients for palpitations or syncope, leading to complete or partial clinical success in six (PVB reduction 9,400± 12,200 to 420±610/24 h, NS). Twenty-five procedures were performed for suspected VPB-induced tachycar-diomyopathy in 20 patients, leading to complete success in nine patients and to significant decrease in VPB in five patients. Mean VPB/24 h was 17,800±8,600 before and 3,410±8,150 after and 125±230 at 11 ±6 months follow-up (p=0.0005). EF increase from 41±8% to 53±7% (p< 0.0001). Main locations of the PVB were RVOT, right or left aortic cusps, left basal septum, LVOT, and latero-basal LV. Complications were asymptomatic mild pericardial effusion in one patient, transient AV block in one, and transient ischemic stroke in one. Conclusions: RF ablation of PVB may be indicated if highly symptomatic for electrical storm or for suspected tachycardiomyopathy with good although imperfect success rate.

7-3 Abstract 17-01

High incidence of Brugada-type ECG in patients with obstructive sleep apnea syndrome

Cuilan Li1, Bo Zhao1, Fang Han2, Wenling Liu1, Haiying Zhang1, Lei Li1, Dayi Hu1

1Heart Center, Peking University People's Hospital, Beijing, China; 2Respiratory Department, Peking University People's Hospital, Beijing, China

Introduction: Obstructive sleep apnea syndrome (OSAS) is a highly prevalent breathing disorder that is an independent risk factor for cardiovascular morbidity and mortality. Our previous study has shown that a patient with type 2 Brugada ECG pattern was finally diagnosed as OSAS rather than Brugada syndrome. The incidence of Brugada-type ECG in patients with OSAS was further observed in present study. Methods: Four hundred twelve patients diagnosed as OSAS with ECG recordings hospitalized in our hospital from 2000 to 2009 were retrospectively selected and the morphology of ST segment and T wave on lead V1-V3 was analyzed. Three Brugada-type ECG patterns (types 1 to 3) were defined based on the Second Consensus on Brugada syndrome in 2005. The incidence of each type of ECG in the selected cohort was analyzed and compared with that from literature using Binomial test by SPSS13.0. Results: Of all 412 patients with OSAS, male/ female 3.2:1, at the age of 54.3 ± 13.1, 71.1% has other diseases. A total 15 OSAS patients were found to have type 2 or type 3 ECG patterns (3.64%), and no type 1 ECG was found. The percentage of OSAS patients with Brugada-type ECG in group with other diseases was not significantly different from that in the group without (3.75% vs. 3.36%, P>0.05). Compared with the data from Japan (0.70%, from 13,929 inhabitants) and from China (0.75%, from 1,065 individuals; 0.5%, from 1,005 individuals), the incidence of Brugada-type ECG in our patients with OSAS is significantly higher than that from normal population (3.64% vs. 0.7%, P<0.01). Conclusion: For the first time, we found that there is a high incidence of Brugada-type ECG in patients with OSAS, though more studies will be needed to further clarify the real meaning and underlying mechanism behind. It might be proposed that the ECG pattern of ST segment elevation in V1-V3 should be thought of as a common electrical expression of abnormalities in the right ventricle that may have genetic, infective, or inflammatory origins.

7-4 Abstract 17-02

Mapping and catheter ablation of Brugada syndrome: a pilot study

YanYao1, Buncha Sunsaneewitayakul2, Luck Yongvanijchit2, Shu Zhang1

1Arrhythmia Center, Fuwai Heart Hospital of Peking Union Medical College-Chinese Academy of Medical Sciences, Beijing, China; 2Division of Cardiology, Department of Medicine, Faculty of Medicine,, Chulalongkorn University, Bangkok 10330, Thailand

Background: Arrhythmogenesis of Brugada syndrome (BS) with characteristic ECG has been attributable to the activation abnormalities of the right ventricular outflow tract (RVOT); modification of the abnormalities by catheter ablation should diminish the occurrence of ventricular fibrillation (VF). This study was aimed at assessing whether the modification on the abnormalities by catheter ablation could diminish the occurrence of ventricular fibrillation (VF) in BS patients. Methods: Nine symptomatic BS male patients (mean age of 37.6 + 12.6 years) with ICD implanted were enrolled in November and December 2007. Of which, patients 1, 4, and 5 had VFs and ICD shocks (42, 1, and 20 times, respectively) before mapping and ablation. Non-contact array mapping was used to identify the abnormal activation zone (AAZ) in RVOT where the endocardial ablation was applied after. The ST segment elevation between the baseline and that recorded at least 15 min after ablation were compared. Results: The AAZ in RVOT was identified in all patients with variable distribution. The ST segment elevation in V1 was modified significantly in two of nine, moderately in five of nine, unchanged in one of nine patients after ablation, and complete right bundle branch block was evident in one patient. All patients completed a 24-month follow-up. Five patients who had no VF episodes before ablation remained free thereafter. In those three patients who had VF episodes (42, 1, and 20 times) before ablation, the VF and shocks decreased to 25, 0, and 0, respectively. Moreover, all VF and shocks only occurred in the first 3 months postablation. There was no complication during ablation and follow-up. Conclusion: The results of this pilot study suggest that the ST segment elevation could be modified by endocardial catheter ablation on the zone with abnormal activation within the right ventricular outflow tract in patients with BS. The procedure is safe and may have beneficial effects in terms of preventing VF.

7-5 Abstract 19-06

ICD pulse generator longevity: a prospective multicenter study

Robert Hauser1, David Cannom2, Stephen Vlay3, David Hayes4, Linda Kallinen5, Susan Song6, Andrew Epstein7 1Cardiology, Minneapolis Heart Institute Foundation, Long Lake, United States Of America; 2Cardiology, Good Samaritan Hospital, Los Angeles, United States Of America; 3Cardiology, Stoneybrook Hospital, Stoneybrook, United States Of America; 4Cardiology, Mayo Clinic, Rochester, United States Of America; 5Cardiology, Minneapolis Heart Institute Foundation, Minneapolis, United States Of America; Cardiology, University Of Southern California, Los Angeles, United States Of America; 7Cardiology, University Of Alabama, Birmingham, United States Of America

Purpose: ICD pulse generator longevity (ICD-L) is a critical issue for patients at risk for sudden cardiac death with or without advanced heart failure. Accordingly, we assessed ICD-L for devices removed from service for reasons related to normal battery depletion (BAT), electronic failure (FAIL), or a manufacturer's advisory (ADV). Methods: Data for ICD pulse generators removed were prospectively entered into the Multicenter Registry. Information included manufacturer, model, dates of implant and failure, signs of battery depletion or failure, how the failure was verified, clinical consequences, and cause of failure including normal battery depletion. Results: During the past 10 years 2,541 ICD pulse generators were removed from service at our centers. The average ICD-L was 4.3 ± 1.7 years, including 4.7 ± 1.8 years for 1,128 single chamber (SC), 4.2 ± 1.5 years for 985 dual chamber (DC), and 3.3 ± 1.2 years for 428 ICD-CRT (CRT) devices (p < 0.0001). The average ICD-L for devices removed for BAT were 5.0 ±1.5 years for SC, 4.6 ±1.2 years for DC, and 3.6 ± 1.0 years for CRT (p < 0.0001). Medtronic SC battery longevity was longer (MDT, 5.6 ± 1.6 years) than either Boston-Scientific (BS, 4.9 ± 1.3 years) or St. Jude Medical (SJM, 4.5 ± 1.5 years, p < 0.01). Similarly, MDT DC battery longevity was longer (4.9 ± 1.4 years) than BS (4.4 years ± 1.0) and SJM (4.2 ± 1.2 years, p < 0.01). No differences in battery longevity were found between manufacturers for CRT models (p = 0.44). Overall, 169 ICDs were removed for FAIL (6.4%) and 263 for ADV (10.1%). Conclusions: Significant differences exist for ICD-L between SC, DC, and CRT, including battery longevity. Battery longevity was impacted by manufacturer for SC and DC, but not for CRT devices. A substantial proportion (17%) of ICDs was removed for reasons unrelated to battery performance. Since approximately a third of ICDs implanted today are CRTs, our data suggest

that improvements in battery technology are urgently needed.

7-6 Abstract 19-01

Left ventricular non-compaction: outcomes of patients with or without ICD implantation

Nestor Galizio1, José Gonzalez1, Federico Robles1, Luis Medesani1, Ramón Raña1, Marcelo Ramírez1, Lucas Valtuille1

¡Electrophysiology Division, Favaloro Foundation—University Hospital, Buenos Aires, Argentina

Introduction: Left ventricular non-compaction (LVNC) has been associated with high morbidity and mortality. Nonetheless, there are few reports about the outcomes of patients (p) with ICD and reasons for ICD implantation. Objective: The objective of this study was to describe the outcomes of p with LVNC with or without ICD and the reasons for implantation. Method: We analyzed 61 p, mean age 40 years, 39 men. Mean follow-up was 19.6 months. Criteria for LVNC were based on non-compacted/compacted ratio by echocardiogram and/or MRI. Eighteen (29.5%) p received an ICD. Results: Twenty-four p had NYHA classes II-IV heart failure, two previous sudden cardiac death (SCD), 11 NSVT, eight syncope, and two stroke. Non-ICD group (n=43): mean age 41 years, 29 men, NYHA III-IV seven p (16%), syncope two2 p (4.7%), and NSVT two p (4.7%). Mean left ventricular ejection fraction (LVEF) was 39%. Mean follow-up was 17.8 months. One p died of advanced heart failure and three underwent heart transplantation (HTX). ICD group (n = 18): Mean age 40 years, ten men, NYHA III-IV three p (16%), previous SCD two p (22%), syncope six p (33%), and NSVT nine p (50%). Mean LVEF was 30%. Reasons for ICD implantation: previous SCD two p (11%), sustained VT one p (5.5%), LVEF<30% four p (22%), LVEF<30% and family history (FH) of SCD one p (5.5%), LVEF<30% and syncope three p (16.5%), LVEF<30% and NSVT two p (11%), syncope and NSVT three p (16.5%), FH of SCD and NSVT one p (5.5%), and NSVT with sustained VT at EP study one p (5.5%). Four p (22%) had high defibrillator threshold (>20 J). Mean follow-up was 24 months. Three p (16.7%) received shocks due to VT/VF and four p (22.2%) due to sinus tachycardia. Two p underwent HTX. Conclusions: In our study population, the prevalence of ICD implantation was 30%. Most p received an ICD for primary prevention (83%). Low LVEF or two risk factors were the most frequent reasons for implantation. The rate of appropriate shocks was similar to previous trials about ischemic or non-ischemic cardiomyopathy. Death and HTX were due to heart failure progression.

Abstract session 8: Genetic aspects of cardiac arrhythmias

Saturday, April 17, 2010, 10:30 am-12:00 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor)

8-1 Abstract 03-08

10-Year experience treatment in patients with long QT syndrome

Amiran Revishvili1, Mrs. Irene Pronicheva1, Elena Zaklyazminskaya , Alexander Polyakov Tachyarrhythmia Surgery Department, Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation; 2Research Centre For Medical Genetics, Moscow, Russian Federation

Background: Long QT syndrome (LQTS) is an inherited cardiac arrhythmia characterized by QT interval prolongation on ECG, syncope and high risk of sudden cardiac death (SCD) due to polymorphic ventricular tachycardia/ ventricular fibrillation (VT/VF). Mutations in genes encoding cardiac ion channel proteins and their modulators cause this disease. Objective: The objective of this study was to analyse different gene mutations responsible for the development of LQTS for the choice of effective method of treatment. Material and methods: From 1999 to 2009, we followed 48 patients with LQTS (M-19; F-29, mean age 19.4±10.6). Blood sample was collected from Russian LQT family with a history of SCD, syncope and QTc prolongation. Genomic DNA was isolated from EDTA venous blood by standard methods. For mutation screening, original intronic primers were developed that encompassed the complete coding sequence, the splice sites and the adjacent areas of the five genes (KCNQ1, KCNH2, SCN5A, KCNE1 and KCNE2). Mutation screening was performed using PCR-SSCP analysis with sequencing of abnormal conformers. Mutations found by direct sequenc-

ing were confirmed by RLFP analysis. Clinical data included information on personal and family history of disease, electrocardiographic findings. Results: We have identified 30 (63%) mutations in 24 unrelated families: 15 (50%) KCNQ1 mutations (G306R-4, G314S-2, A341V-5, G589D-2, R243C-2), 6 (20%) KCNH2 mutations (P596T-2 de novo, G601S-3, K638N-1 de novo), 7 (24%) SCN5A mutations (F2004L-2, A572D-2, E1784K-2, S1431R-1), 1 (3%) mutation in KCNE1 (D85N) and 1 (3%) KCNE2 mutation (T8A). Genotype-phenotypes analysis found that clinical traits were gene-specific in large part. We found that patients with mutations A341V had a prolonged QT interval corrected for heart rate (QTc) expressed as the presence of a QTc >500 ms and increased dispersion of QT interval (183±35 ms). There were cases of SCD in unrelated families with A341V mutation. Patients with mutations R243C have a marked course of disease: QTc> 470 ms, syncope and SCD in young age. These patients were characterized by grave condition and by beta-blocker resistance. One proband had two different mutations in SCN5A (one mutation was inherited and the other had occurred de novo). This proband was affected more severely than her parent and required cardioverter defibril-lator (ICD) implantation. One member of the family with two different mutations died suddenly as a result of VF after beta-blocker therapy. Members of families with mutations G314S and R243C have not had cardiac events and demonstrate normal QTc interval. Patients with T8A, D85N, K638N and P596T mutations had rare syncopal episodes and bradycardia, and QTdc averaged 148±34.7, 45±11.7, 98.6±23.4 and 95±19, respectively. Twenty-six patients (54%) were operated. The QTc duration interval would seem normal (365-400 ms) after ICD 46% or pacemaker 54% implantation. The frequency of VT/VF decreased after the initiation drug therapy and pacemaker implantation for 56±15.6 months. Conclusion: We suppose that the presence of more than one mutation in LQTS genes in patients is a significant independent genetic factor of the SCD and may be considered a reason for ICD implantation. Moreover, some of the mutations are associated with stable poor prognosis (for example, A341V and R243C in KCNQ1). Exposure of these mutations is an indication of surgical therapy that is ICD implantation.

8-2 Abstract 03-07

Additional independent susceptibility markers for atrial fibrillation on chromosome 4Q25

Moritz F. Sinner1, Steven A. Lubitz2, Kathryn L. Lunetta3, Arne Pfeufer , Siegfried Perz , Annette Peters , Jonathan Rosand7, Patrick T. Ellinor8, Stefan Kääb1 IMedical Department I, University Hospital Munich-Campus Grosshadern, Munich, Germany; 2Cardiovascular Research Center, Massachusetts General Hospital, Boston, United States of America; 3Department of Biostatistics, Boston University School of Public Health, Boston, United States of America; 4Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany; 5Institute of Biological and Medical Imaging, Helmholtz Zentrum München, Neuherberg, Germany; Institute of Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany; 7Stroke Service, Massachusetts General Hospital, Boston, United States of America; 8Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, United States of America

Background: We sought to define the genetic architecture at chromosome 4q25 as it relates to atrial fibrillation (AF). Methods and results: Thirty-four haplotype-tagging SNPs spanning 200 kb at the 4q25 locus were genotyped in 790

cases and 1,177 controls from Massachusetts General Hospital (MGH) and tested for association with AF. Associated SNPs were genotyped in 2,145 cases and 4,073 controls from the German Competence Network for Atrial Fibrillation (AFNET), and the results were meta-analyzed. SNPs representing independent loci were tested in silico for association with incident AF in 7,927 individuals from the Atherosclerosis Risk in Communities (ARIC) Study, 743 of whom developed AF. The previously reported SNP, rs2200733, was most significantly associated with AF (OR for minor allele 1.80, 95%CI 1.50-2.15, P = 1.2x10-20) in the discovery sample. Adjusting for rs2200733 genotype in the MGH and AFNET samples revealed three SNPs that tag two additional susceptibility regions for AF (rs17570669 minor allele OR 0.65, 95%CI 0.56-0.75, P = 1.3x10-8; rs3853445 minor allele OR 0.80, 95%CI 0.73-0.87, P= 7.8 x 10-7; rs6838973 minor allele OR 0.80, 95% CI 0.740.86, P = 1.7x10-8). Genotypes at these three regions identified individuals at increased risk for developing AF relative to those with common genotypes, with the greatest risk occurring in approximately 0.7% of individuals in ARIC (HR 4.15, 95%CI 2.45-7.03, P = 1.2x10-7). Conclusions: In addition to the previously described chromosomal region tagged by rs2200733, we identified two novel AF susceptibility regions on chromosome 4q25. The biological basis for these associations requires further investigation.

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8-3 Abstract 03-04

Depolarization in long QT syndrome

Esben Vedel-Larsen1, Claus Graff2, Henrik K. Jensen3, Jimmy Nielsen4, Egon Toft2, Johannes Struijk2, Morten Skou Nielsen1, Michael Christiansen5, Prof. Jorgen Kanters1

laboratory of Experimental Cardiology, University of Copenhagen, Copenhagen N, Denmark; 2Aalborg University, Aalborg, Denmark; 3Dept. of Cardiology, Skejby Hospital, Aarhus, Denmark; 4Dept. of Psychiatry, Aalborg University Hospital, Aalborg, Denmark; 5Dept. of Clinical Biochemistry, Statens Serum Institute, Copenhagen, Denmark

Long QT syndrome is characterized by repolarization prolongation. In long QT type 1 (KvLQTl) and long QT type 2 (HERG), depolarization is not known to be altered. Methods: ECGs from 27 KvLQT1 and 43 HERG patients with verified mutations and 70 age- and gender-matched controls had a digital 12-lead ECG performed. P-wave width and QRS width were measured. Results: As seen in the table, there was no significant difference regarding depolarization between KvLQT1 and HERG patients, whereas healthy subjects have longer depolarization than LQTS patients. Both P-wave and QRS width were independent of treatment with beta-blockers. Females have shorter QRS width and P-wave width. Conclusion: LQTS patients have shortened depolarization with both shortened P-waves and QRS complexes

KvLQT1 (N = 27) HERG (N=43) KvLQT1+ HERG (N =70) Control (N=70)

QRS width 84.1±1.2* 86.5±1.4 85.6±1.0* 90.2±1.3

P-wave 100.7±1.9 97.0±1.7* 98.4±1.3* 103.4±1.4

width (ms)

*p<0.05 control group

8-4 Abstract 03-06

Reduction in cardiac Kir3.4 channel expression causes congenital long QT syndrome—a functional role of Girk currents in ventricular repolarization

Thomas Jespersen1, Bo Liang1, Yanzong Yang2, Yiqing Yang3, Jinqiu Liu2, Morten Grunnet1, Soren-Peter Olesen1, Yi-han Chen3

1Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Dalian Medical University, Dalian, China; Department of Cardiology, Tongji University School of Medicin, Shanghai, China

Ventricular repolarization is promoted by the delayed rectifier potassium currents. Mutations in the genes underlying these currents, primarily being IKr, IKs, and IK1, have previously been found to cause congenital long-QT syndrome (LQTS), which is an inherited disorder leading to sudden cardiac death from fatal cardiac arrhythmias. Here, we show that a mutation in KCNJ5, encoding the G protein-coupled inward rectifier potassium channel subunit Kir3.4 (GIRK4), co-segregates with an autosomal dominant trait of LQTS in a large family (four generations, 49 individuals). A total of ten individuals in the family had LQTS, of whom three also had atrial fibrillation. The genetic locus of the LQTS-associated gene was by genome-wide linkage analysis mapped to chromosome 11q23.3-24.3 where a heterozygous mutation, G387R, in the potassium channel subunit Kir3.4 was identified. No mutations were found in any of the 12 genes previously associated with LQTS. Electrophysiological investigations demonstrated Kir3.4-G387R to give a loss-of-function phenotype which was supported by biochemical analyses revealing a reduced surface membrane expression of the mutant channels. Kir3.4 has, together with Kir3.1, previously been ascribed a prominent role in atrial and nodal parasympathetic regulation where acetylcholine-mediated muscarinic stimulation leads to an activation of this channel complex, thereby generating IK,Ach. However, a functional role of these channels in ventricle has not previously been demonstrated in humans. Western blotting of human tissue demonstrates ventricular expression of both Kir3.1 and Kir3.4 which is 3.6- and 2.2-fold less then atrial expression, respectively. In conclusion, we provide evidence for Kir3.4 being associated with LQTS. This finding thereby reveals a functional role of Kir3 channels in human ventricular electrophysiology.

8-5 Abstract 03-05

Flecainide provocation reveals concealed Brugada syndrome in a long qt syndrome family with a novel L1786Q mutation in SCN5A

Jorgen K Kanters1, Michael Christiansen2, Morten Grunnet3, Paula Hedley2, Christian Jons4, Poul-Erik Bloch Thomsen4, Thomas Jespersen5

laboratory of Experimental Cardiology, University of Copenhagen, Copenhagen N, Denmark; 2Dept. of Clinical Biochemistry, Statens Serum Institute, Copenhagen, Denmark; Neurosearch A/S, Copenhagen, Denmark; 4Dept. of Cardiology, Gentofte University Hospital, Copenhagen, Denmark; Dept. of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark

Background: Mutations in SCN5A, encoding the cardiac sodium channel Nav1.5, can result in both long QT syndrome (LQTS) type 3 (LQT3) and Brugada syndrome (BrS). However, a few mutations have shown an overlapping phenotype in single patients as well as between family members. A prerequisite for a BrS diagnosis is an ST elevation in the right precordial leads of the ECG. These ST elevations are dynamic and may only appear after sodium channel blockage. Hence, diagnosing BrS patients can be difficult. Results: In a Danish family suffering from LQTS, a novel missense mutation in SCN5A, changing a leucine into and glutamine at position 1786 (L1786Q), was found to be present in heterozygous form and to co-segregate with prolonged QT-interval. The proband presented with an aborted cardiac arrest, and his mother had died suddenly and unexpectedly at the age of 65. Flecainide treatment revealed coved ST elevation in all mutation carriers. Electrophysiological investigations of the mutant in HEK293 cells revealed a reduced peak current, a negative shift in inactivation properties and a positive shift in activation properties, compatible with BrS. Furthermore, the sustained (INa,late) TTX-sensitive sodium current was found drastically increased, explaining the association between the mutation and LQT syndrome. Conclusion: The L1586Q mutation is associated with a combined LQT3 and concealed BrS phenotype, and this is explained by gating characteristics of the mutated ion channel protein. Flecainide treatment should be considered in clinical evaluation of apparent LQT3 patients.

8-6 Abstract 03-03

Transient ST elevation after ketamine intoxication a new cause of acquired Brugada syndrome

Anne Rollin1, Philippe Maury1, Céline Guilbeau-Frugier1, Alexandre Duparc1, Pierre Mondoly1, Nicolas Detis1, Marc Delay1, Josep Brugada2

University Hospital Rangueil, Toulouse, France; 2Cardiology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain

Background: Ketamine-induced Brugada syndrome has never been reported. Methods: A 31-year-old man was referred after massive toxic uptake. Initial ECG displayed type 1 major Brugada pattern. There was rhabdomyolysis, renal and hepatic impairment and acidosis, but without ionic blood levels alterations. Ventricular systolic function was altered (EF 40%). ST elevation resumed 12 h later. Two days

after, he presented with sudden congestive heart failure and non-sustained bidirectional or monomorphic ventricular tachycardia without recurrence of ST elevation. Results: Coronary artery angiography, left or right ventricular angiography and ergonovine tests were unremarkable. Toxicologic dosings found the presence of ketamine, but testing for cocaine was negative. MRI did not find necrosis, myocarditis, scar or abnormal perfusion. Endomyocardial biopsies showed cell ballonisation, myofibril degeneration with small areas of fibrosis consistent with a toxic myocarditis. A provocative test with ajmaline failed to induce any ST modification. Programmed ventricular stimulation did not induce any ventricular arrhythmia. Late potentials were lacking on signal-averaged ECG. The patient remained asymptomatic. At 3 months of follow-up, there was no recurrence of any cardiac event, repeated ECG remained normal and EF normalized. SCN5A gene screening is pending. Conclusion: We report here the first case of an acquired Brugada ECG pattern related to ketamine intoxication. Ketamine experimentally inhibited INa and has known toxic myocardial histological effects at high concentrations. This could explain some of the ketamine-related deaths. The risk of ketamine-induced Brugada syndrome and of potential malignant ventricular arrhythmias during general anaesthesia should be known, particularly in patients with preexisting Brugada syndrome.

Abstract session 9: Sudden cardiac death and ICD therapy Saturday April 17, 2010, 4:00 pm-5:30 pm ROOM KONIGSSAAL (Palais Montgelas, 2nd Floor) 9-1 Abstract 19-11

The impact of gender on survival and ventricular arrhythmia therapy among patients with implantable cardioverter defibrillators

Bhavnani Sanjeev1, Craig Coleman1, Danette Guertin1, Christopher Clyne , Jeffery Kluger

Cardiology, Hartford Hospital, Hartford, United States of America

Background: Several investigations have suggested an attenuated benefit to implantable cardioverter defibrillator (ICD) therapy among women as compared to men. A direct comparison of gender on mortality or therapy due to ventricular tachycardia/fibrillation (VT/VF) among a heterogeneous cohort of community-based ICD recipients is

unknown. Methods: We identified 1,445 individuals who underwent ICD implantation for the primary (n=833) or secondary (n=612) prevention of sudden cardiac death and identified 948 and 256 patients with ischemic (ICM) or non-ischemic cardiomyopathies (NICM) and 354 with biventricular ICDs, respectively. We compared the outcomes of all-cause mortality and shock or pacing therapy for VT/ VF by male (N = 1,123) or female (N=322) gender and were calculated using multivariable Cox regression analyses. Results: Our population had an average age of 65± 13 years, ejection fraction of 29±14% with a mean duration of follow-up 976±919 days. Overall, compared to men, no significant difference in mortality among women was observed (AHR 1.05, 95% CI 0.81-1.35, p=0.735). Mortality was not different among women as compared to men with primary or secondary prevention indications, ICM, NICM, or biventricular ICDs (figure). The incidence of shock or pacing therapy for VT/VF was significantly lower among women as compared to men (20% vs. 26%, p=0.02) Conclusion: Among a heterogeneous cohort of ICD recipients, mortality is not significantly different among women as compared to men, although women have a lower incidence of ICD therapy for VT/VF.

Primary Prevention Indications Secondary Prevention Indications Ischemic Cardiomyopathy Nonischemic Cardiomyopathy Biventricular ICD

Favors Female Favors Male

Adjusted Hazard Ratio (95% confidence interval)

1.16 (0.81 - 1.66) 0.99 (0.68 - 1.45) 1.09 (0.79 - 1.49) 1.42 (0.79 - 2.54) 1.57 (0.97 - 2.53)

9-2 Abstract 19-14

Prevalence of J point elevation in sudden arrhythmic death families

Laurence M Nunn1, Justine Bhar-Amato1, Syed Ahsan1, Jack McCready1, Martin D Lowe1, Perry M Elliott1, William J McKenna1, Pier D Lambiase1 Heart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: J point elevation (JPE) or early repolarisation, previously thought to be benign, has now been shown to have significantly higher prevalence in survivors of idiopathic ventricular fibrillation compared with matched healthy controls. Its prevalence in sudden arrhythmic death syndrome (SADS) families is unknown. This study examined the prevalence of JPE amongst the ECGs of SADS victims' family members referred for screening at a specialist clinic. Method: ECG recorded at initial clinic visit of 479 relatives (363 first degree, 66 second degree and 50 third degree) of 162

families referred for SADS family screening were evaluated. Established definition of JPE of at least 0.1 mV from the baseline present in two or more of the inferior (II, III and aVF) or lateral (1, aVL, V4-6) leads was used. The signal-averaged ECG (SAECG), when recorded, was examined for the presence of late potentials. Results: JPE was present on the ECG of 24% SADS family members (mean age 37.7 years, 63% female) versus 8% of age- and sex-matched controls (p < 0.001). Seventy-eight families (48%) had a relative with JPE, and 24 (15%) families had >1 positive family member following an autosomal dominant inheritance pattern. JPE is most common in inferior leads and present in an average of three leads. Of those with JPE, 64% had a SAECG recorded, but only eight (11%) were positive for late potentials. Clinical screening established a diagnosis in 20 JPE-positive cases (13 long QT syndrome, 5 Brugada syndrome and 2 arrhythmogenic right ventricular dysplasia), and a further 23 patients tested negative for an inherited channelopathy identified in other family members. Conclusions: There is a higher prevalence of infero-lateral J point elevation amongst the SADS family members compared to matched healthy controls. This suggests that an inherited early repolarisation abnormality may be the primary cause of sudden death or important disease-modifying factor promoting lethal arrhythmia in SADS families.

9-3 Abstract 19-13

Incidence of sudden cardiac death in northern Germany

Moritz F. Sinner1, Eimo Martens1, Britt Maria Beckmann1, Hans-Jörg Klottner , Volker Sohns , Stefan Kääb Medical Department I, University Hospital Munich-Campus Grosshadern, Munich, Germany; Department of General Surgery, Ubbo-Emmius-Klinik gGmbH Klinik Aurich, Aurich, Germany

Introduction: Sudden cardiac death (SCD) is among the most common causes of death in Germany; it is defined as death of cardiac causes within 1 h after the onset of symptoms. We studied SCD incidence based on data from the emergency medicine service (EMS) of a northern German county. Methods: The county of Aurich (Lower Saxony) operates a central EMS and two hospitals. EMS protocols and pre-hospital death certificates were reviewed for all rescue operations between 2002 and October 2009. Primary analyses encompassed EMS operation prompts. Those suggestive of cardiopulmonary resuscitation or death at the scene were investigated. For hospitalized patients, we reviewed all hospital charts with a billing diagnosis of "cardiovascular death". Results: Between 2002 and 2009, we reviewed 228,592 EMS operations. Patients with primary successful

resuscitations were admitted to county hospitals in 86% of cases. The remainder was not available for review. In 5,760 EMS operations, patients were presumably unconscious according to EMS prompts, though no cardiac condition was identified (n=3,487) and no cardiac pathogenesis was detected (n = 1,061). In 1,212 cases, resuscitation was performed for cardiac causes, and 12.5% of cases were declared dead at the scene. Age distribution peaked at age 70-80 years (018 years, 3.2%; 18-30 years, 5.9%; 30-40 years, 5.1%; 40-50 years, 10.4%; 50-60 years, 9.6%; 60-70 years, 16.8%; 70-80 years, 25%; 80-90 years, 20.9%; >90 years, 2.4%). Conclusion: Analysis of EMS operations of a single northern German county found an 8-year average SCD incidence of 151 cases/year, equivalent to 83/100,000 inhabitants. This is less than in comparable US studies. The accuracy of our results is thereby supported by the central collection of EMS operations and the hospital treatment of patients in two county hospitals. The ascertainment of SCD based on death certificates only is weaker. However, all SCD cases were adjudicated by EMS protocols, hospital charts, and discharge reports.

9-4 Abstract 19-18

Inappropriate ICD shocks: clinical risk factors and mortality

Ahmed El-Damaty1, John Sapp1, Magdy Basta1, Josee Michaud1, Martin Gardner1, Chris Gray1, Ratika Parkash1 Cardiology, QEII Health Science Centre, Dalhousie University, Halifax, Canada

Introduction: Recent data suggest that both appropriate and inappropriate ICD shocks are associated with mortality. Few data on predictors of inappropriate shocks or the effect of shocks in a real-world cohort are available. We studied these relationships in a large cohort of ICD patients from a single referral center registry. Methods: Consecutive ICD patients were included. All ICD events were adjudicated by two EPs blinded to clinical outcome. Survival analysis and Cox proportional hazard modelling were used to determine the effect of shocks on death. A Cox model was used to identify predictors of inappropriate therapy. Results: Seven hundred eighty-seven patients with a mean follow-up of 3.6 years were included. Eighteen per cent had inappropriate shocks, 33% had appropriate therapy and 42% had either. Patients were aged 61 ±14 years, 83% male, and 52% had CAD; 48% were secondary prevention. In a Cox model with appropriate therapy as a time-varying covariate, the time interaction was significant: Appropriate therapy had no effect on survival in the first 3 years, after which shocks were associated with a HR of 1.64 for death (p= 0.04). In a multivariate Cox model, age, any ICD therapy, EF,

PVD and diabetes were associated with worse survival, while appropriate shocks, secondary prevention indication, younger age and AF were associated with higher risk of inappropriate shocks, while diabetes was associated with lower risk. Conclusions: Shocks appear to be a long-term risk factor for mortality. Those at greatest risk for inappropriate shocks are younger, have AF, have appropriate shocks and have a secondary prevention ICD. Understanding risks for inappropriate shocks may help efforts at their prevention.

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Years Fo!iow-Up

9-5 Abstract 19-09

Should age influence programming to reduce ICD shocks?

Dr. Kousik Krishnan1, Christine Davis1

JCardiac Electrophysiology, Rush University Medical Center,

Chicago, United States of America

The SCD-HeFT and MADIT-II trials have lead to a large increase in the use of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death. A significant concern for physicians and patients is avoidance of inappropriate ICD discharges. Inappropriate ICD discharges lead to significant emotional distress for patients and are a deterrent for patients considering a new implant. The PAINFREE RX II trial tested a method to reduce ICD therapies by increasing the ventricular fibrillation (VF) detection rate in order to avoid overlap between truly life-threatening arrhythmias and non-life-threatening rhythms. Methods: We analyzed the mean rate of therapies detected in the VF zone for 139 patients implanted for SCD-Heft or MADIT-II indications between January 2006 and June 2008. Results: 22 patients received 109 therapies in the VF zone (>200 bpm). Patients under and over 50 had a mean VF rate for appropriate therapies of 226 and 242 bpm, respectively (P=0.04). Rates of supraventricular arrhythmias (inappropriate ICD therapies) were 200 and 219 bpm,

respectively. Our data suggest that VF rates may be age-dependent (higher VF rates with advancing age). Rates of supraventricular and ventricular arrhythmias do not differ significantly between age groups. Conclusions: These data suggest that empiric programming of higher VF detection rates in younger patients may result in some life-threatening arrhythmias not being detected and corroborate a strategy of programming a fast VT zone in patients where a higher VF detection rate is programmed. In older patients, it may be sufficient to program devices with a single VF zone at a higher rate. Further analysis of VF detection rates related to age and other comorbidities seems warranted to optimally program devices and avoid inappropriate shocks.

9-6 Abstract 19-16

Prevalence of early repolarization in patients with survived idiopathic ventricular fibrillation

Eimo Martens1, Britt Maria Beckmann1, Johannes Siebermair1, Nadine Haserück1, Michael Ulbrich1, Moritz F. Sinner1, Stefan Kääb1

1'Medical Department I, University Hospital Munich, Campus Grosshadern, LMU Munich, Munich, Germany

Introduction: Early repolarization (ER) is a common ECG signature with slurring or notching morphology located at the terminal down slope of the QRS complex. It was recently shown to be associated with idiopathic ventricular fibrillation. We retrospectively analyzed ER prevalence in our patient repository of patients with idiopathic ventricular fibrillation. Methods: We searched our patient and ICD database for patients who survived ventricular fibrillation or survived sudden cardiac death. Patients with structural cardiac diseases, complete bundle branch block or known familial arrhythmia syndromes like long QT syndrome, catecholamin-ergic polymorphic ventricular tachycardia and Brugada syndrome were excluded. In selected patients, all available ECGs were interpreted for the presence of ER, and ER was diagnosed based on the definition by Haissaguerre: ER in at least two leads, except for leads aVR and V1 to V3, and a minimum amplitude of 0.1 mV. Results: We identified 20 patients (16 men) with idiopathic ventricular fibrillation who fulfilled the criteria. The mean age at resuscitation was 45 ± 13 years. ER was present in 11 patients (nine men), equaling 55% prevalence. Nine patients (seven men) showed no or non-significant ECG changes. Discussion: We were able to confirm the high prevalence of ER in patients with idiopathic ventricular fibrillation. In our study, ER prevalence (55%) was even higher than previously described (Haissaguerre et al., 31%). Our analysis showed a higher proportion of men with idiopathic ventricular fibrillation (80%). ER was slightly more common in men than in women (56% vs. 50%).

Abstract session 10: Advances in cardiac resynchronization therapy I

Saturday April 17, 2010, 4:00 pm-5:30 pm

ROOM FURSTENSALON (Palais Montgelas, 2nd Floor)

10-01 Abstract 24-14

Sustained benefit at 1-year follow-up from transapical left ventricular endocardial pacing for end-stage heart failure

Attila Mihalcz1, Imre Kassai1, Csaba Foldesi1, Attila Kardos1, Tamas Szili-Torok2

1Electrophysiology, Hungarian National Institute of Cardiology, Budapest, Hungary; 2Electrophysiology, Erasmus MC, Thorax C., Rotterdam, the Netherlands

Introduction: Coronary sinus lead placement for transvenous left ventricular (LV) pacing in resynchronisation therapy (CRT) has a significant failure rate at implant and a considerable dislocation rate during follow-up. The aim of this prospective study was to assess the feasibility and the mid-term effects of a novel endocardial approach for LV lead implantation. Methods: Fourteen end-stage heart failure patients (NYHA functional class III or IV; QRS >130 ms; LV ejection fraction (LVEF) <35% and LV end-diastolic diameter

(LVEDD) >60 mm) were included. In each procedure, an active fixation lead was placed into the LV cavity using standard Seldinger technique through the LV apex. Follow-up visits were scheduled at 3, 6 and 12 months, and the following parameters were assessed: LVEF, LVEDD, LV end-systolic diameter (LVESD), and NYHA class. Results: There were no major complications related to the surgical intervention. During the follow-up period (mean 15.9 ± 4.52), 12 patients responded favourably to the treatment (85%). At 1-year follow-up, LVEF improved and LV diameters decreased significantly (LVEF 26.0 ± 7.8% vs. 35.5 ± 11.5%, p<0.01; LVEDD 73.5 ± 10.5 mm vs. 69.5 ± 10.5 mm, p<0.01; LVESD 62.6 ± 10.4 mm vs. 55.5 ± 13.0 mm, p<0.01). This was associated with a significant improvement of the NYHA class (3.5 ± 0.4 vs. 2.3 ± 0.4, p<0.01). Lead dislocation was detected in two patients in whom lead repositioning could be performed without reopening of the pleural cavity. One patient developed endocarditis. Transesophageal echocardi-ography and complete pacing system removal revealed right-sided vegetation attached to the shock coil of the right ventricular ICD lead. Conclusions: Our data suggest that transapical endocardial CRT is a feasible alternative for patients in whom percutaneous delivery of the LV pacing lead fails. Our data suggest that the beneficial effects of endocardial CRT are sustained at 1-year follow-up without increased complication rate.

10-02 Abstract 24-07

First experience with a novel quadripolar transvenous left ventricular lead

Magnus Prull1, Max-Olav Schrage1, Andrea Bittlinsky1, Georgios Gkiouras1, Thomas Butz1, Hans-Joachim Trappe1 Cardiology & Angiology, Marienhospital Herne, Ruhr-University Bochum, Herne, Germany

Introduction: Cardiac resynchronisation therapy with a defibrillator (CRT-D) has turned out to be a cornerstone in the therapy of severe heart failure. Besides symptoms, also prognosis is improved. A limiting factor of CRT-D is constituted by phrenic nerve stimulation. In up to 37% of all patients (pt), phrenic nerve stimulation (pns) occurs and is considered as a major reason for surgical repositioning of the left ventricular (lv) lead. With a novel quadripolar lv lead (Quartet 1458Q LV lead, St. Jude Medical, Sylmar

CA, USA), ten different stimulation vectors could be programmed so that pns is securely avoided. Methods: Within the course of this study, the quartet lead is implanted in three pt (two men). All pt fulfilled the criteria for implantation of a CRT-D (heart failure NYHA 3-4, QRS complex > 150 ms, left ventricular EF < 35%, completed medication). The lead exhibits a novel SJ4 connector and is connected to a novel CRT-D generator (Promote Q CD3221-36, St. Jude Medical, Sylmar CA, USA) into a special header port. The right atrial lead and the ICD lead are attached to standard connectors (IS-1, DF-1) in the header port. Results: All lead measurements shown were performed during the pre-hospital discharge (PHD) exam-

Lead Setting tested Pt 1

type Phrenic nerve stimulation (at 7.5 V) Lead impedance (A) Capture threshold (at 0.5 ms)

RA Bipolar 400 n.a.

RV Bipolar 350 1.0

LV Vector 1 Distal tip-mid2 Yes 1025 0,75

LV Vector 2 Distal tip-prox 4 No 1025 0.75

LV Vector 3 Distal tip-RVcoil No 650 0.5

LV Vector 4 Mid2-prox4 No 740 1.25

LV Vector 5 Mid2-RVcoil No 390 0.75

LV Vector 6 Mid3-mid2 No 760 1.0

LV Vector 7 Mid3-prox4 No 830 1.0

LV Vector 8 Mid3-RVcoil No 440 0.5

LV Vector 9 Prox4-mid2 No 840 2.0

LV Vector 10 Prox4-RVcoil No 400 1.25

10-3 Abstract 24-28

Exceptional response after cardiac resynchronization therapy: how does it influence the prognosis?

Elisabetta Daleffe1, Dr. Laura Vitali Serdoz1, Anita lorio1, Marco Merlo1, Davide Stolfo1, Giulia Barbati1, Bruno Pinamonti1, Massimo Zecchin1, Gianfranco Sinagra1 1Cardiology DPT, Hospital and University of Trieste, Trieste, Italy

Purpose: Many patients (pts) undergoing cardiac resynchronisation therapy (CRT) show clinical and functional improvement; "exceptional response" to CRT has been reported in a subgroup of pts. The aim of our study was to evaluate a population treated with CRT and the characteristics of "exceptional responders" and observe how this response influences the prognosis. Methods:

ination. The results of the PHD are shown in Table 1. All pt could be effectively shocked over the ICD with a minimum of 10-J distance to the maximum energy of the CRT-D delivered. Measurements were unremarkable. An optimal lv stimulation vector could be programmed. Discussion: In order to avoid pns, the new quartet lead with ten different stimulation vectors represents a promising option for the future. An intra-procedural repositioning of the lv lead within the coronary venous system did not take place in any case. Therefore, with an increasing numbers of implantations due to extended indications, the duration of the implantation will be minimized and the implantation of a CRT-D system is getting simplified.

Lead Capture Phrenic Lead Capture

impedance threshold nerve impedance threshold

(A) (at 0.5 ms) stimulation (A) (at 0.5 ms)

(at 7.5 V)

440 0.75 300 0.75

550 0.5 530 0.5

680 2.75 No 980 >7.5

700 2.75 No 1050 >7.5

490 2.0 No 640 >7.5

500 4.75 No 860 2.0

300 3.0 No 430 1.25

510 >7.5 No 790 2.0

510 >7.5 No 860 2.0

340 >7.5 No 460 1.25

500 >7.5 Yes 860 2.25

340 >7.5 Yes 490 1.5

From June 2002 to August 2009, 100 pts (mean age 62 11 years, 81% male) on tailored medical treatment, for moderate to severe chronic heart failure, received CRT alone or in combination with ICD. Results: Ischemic dilated cardiomyopathy was present in 35%, mean duration of disease was 96 months, and mean QRS duration was 166 ms. During a mean follow-up of 28 months, the percentage of pts in NYHA functional classes III-IV significantly decreased (73% vs 32%, p< 0.001). Left ventricular ejection fraction (LVEF) increased (33% vs 23%, p<0.001); there was LV reverse remodelling (left ventricular end-diastolic diameter 73 vs 68 mm, p< 0.001) and a significantly reduction of hospitalisations. Of pts, 15% were "exceptional responders" (stable LV reverse remodelling with a LVEF>50%) and 23% "no responders" (no echocardiographic response or increase of LVEF<5%). At multivariate analysis, the dose of ACE inhibitors (OR 1.07, CI 1.02-1.12, p=0.001) and area of

Pt 2 Phrenic nerve stimulation (at 7.5 V)

Yes Yes Yes Yes Yes Yes Yes

mitral regurgitation (MR; OR 0.82, CI 0.69-0.96, p=0.02) at baseline were found to be independent predictors of "exceptional response". Seventeen pts died and five underwent cardiac transplant. The survival curves free from death/cardiac transplant/hospitalisation for heart failure were significantly different between the groups of pts (Fig. 1). Conclusions: In a population of pts treated with CRT, 15% were "exceptional responders". The dose of ACE inhibitors and area of MR at baseline were independent predictors of this kind of response. "Exceptional responders" demonstrated a significant better survival compared with other pts.

'exceptional responders"

follow_up

Figure 1. Survival curve free from death/cardiac transplant/ hospitalisation for heart failure in the subgroup of "exceptional responders" (stable LV reverse remodelling with a LVEF >50%, continuous line), "other responders" (pointed line) and "no responders" (no echocardiographic response or increase of LVEF < 5%).

"Exceptional responders" vs "no responders", p<0.001 "Exceptional responders" vs "other responders", p=0.008 "Other responders" vs "no responders", p=0.009

Background: CRT through biventricular pacing aims to restore intraventricular synchronization among patients (pts) with advanced heart failure. Recent publications questioned the value of baseline dyssynchrony in the prediction of response to CRT. The aim of this analysis was to evaluate the relation between early resynchroni-zation and both clinical and echocardiographic outcomes. Methods: We evaluated all pts who were implanted with CRTP/D devices at our hospital since 1998. All pts with evidence of intraventricular dyssynchrony at baseline were included in this analysis. Mechanical resynchroni-zation, as detected by tissue Doppler during the first year of follow-up, was achieved if there was 30% or more reduction in either lateral to septal delay or Yu score (12 segment standard deviation). Clinical and echo outcome were defined by a combined score of the change in NYHA, QoL score, and 6-min walk between baseline and follow-up at 1 year. Echocardiographic response was defined according to absolute increase in LVEF by >5% and relative reduction LVESV by >10%. Results: A total number of 458 pts were implanted successfully since 1998. Two hundred fifty-four pts were excluded due to incomplete data or absence of baseline dyssynchrony. Two hundred four pts were included in this analysis. Of these pts, 52% showed evidence of resynchrony. There was no difference between the baseline characteristics of both groups except for baseline 6 MW and QoL. More severe intraventricular dyssynchrony predicted early resynchrony. There was no difference in clinical and echo outcome between the groups with and without resynchrony. Conclusion: Only half the patients with baseline dyssynchrony achieve mechanical resynchroni-zation after CRT. No baseline clinical or echocardio-graphic parameters predicted resynchronization. There is no correlation between early resynchronization and clinical or echocardiographic outcome. This finding adds to the debate regarding the value of TDI dyssynchrony parameters.

10-4 Abstract 24-02

Does early LV mechanical resynchronization affect the clinical and echocardiographic outcome among CRT patients?

Raed Abu Sham'a1, Eyal Nof1, Rafael Kuperstein2, David Bar Lev1, Osnat Gurevitz1, David Luria1, Micha Feinberg2, Michael Eldar1, Michael Glikson1

1Cardiac Pacing and Electrophysiology, Sheba Medical Center, Ramat Gan, Israel; 2Non-Invasive Cardiology, Sheba Medical Center, Ramat Gan, Israel

10-5 Abstract 24-12

Is cardiac resynchronisation therapy pro-arrhythmic? The first retrospective analysis comparing the incidence of ventricular tachyarrhythmias in patients with and without cardiac resynchronisation therapy

A B Gopalamurugan1, Girish Ganesha Babu1, Syed Ahsan1, Dominic Rogers1, Pier Lambiase1, Anthony Chow1, Martin Lowe1, Edward Rowland1, Oliver Segal1 1The Heart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Despite the proven mortality and symptomatic benefits of cardiac resynchronisation (CRT), there is increasing, yet still largely anecdotal, evidence that this therapy may be pro-arrhythmic in some patients. We explored this issue by retrospectively analysing our primary prevention device cohort. Methods: Patients with ischemic (ICM) or non-ischemic cardiomyopathy and CRT-D devices or ICDs implanted between 2005 and 2007 without prior history of sustained ventricular arrhythmia were included for analysis. Ventricular arrhythmia episodes were identified from stored electrograms and defined as sustained ventricular tachycardia (VT) if device therapy was delivered or non-sustained VT (NSVT) if not. Therapies were classified as anti-tachycardia pacing (ATP) or shocks. Statistical comparison was made using the chi-squaredtest. Results: A total of 137 patients were included in the analysis. Eighty-one patients (55 male) were included in the CRT-D group, 47 ICM, ejection fraction (EF) 25.7±8.8%, with mean follow-up of 24.4± 10.3 months, range 1-52 months. Fifty-six patients (47 men) were included in the ICD group, 33 ICM, EF 28±8.1%, with mean follow-up of 25.7± 10.4 months, range 5-49 months. Overall, there were no difference in the incidence of ventricular arrhythmia between the CRT-D and ICD groups (30.9% vs. 37.5%, ^=0.53) and neither for sustained VT (16% vs. 29%, p=0.12) or NSVT (15% vs. 11%, p=0.67). There was no significant difference in the incidence of ATP (8.6% vs. 17.8%, p=0.178) or shocks (7.4% vs. 10.7%, ^=0.714) between the two groups. Conclusion: In this single-centre analysis, there was no significant difference in the incidence of ventricular tachyar-rhythmias in patients with CRT-D compared to patients with ICDs for primary prophylaxis. From this well-matched single-centre cohort data set, there is no evidence that cardiac resynchronisation increases the risk of developing ventricular tachyarrhythmia in a primary prophylaxis population.

Kaplan Meier Survival probability Event free Survival analysis-(All Ventricular Arrhythmias)

10-6 Abstract 24-17

Esophageal left ventricular electrogram to measure interventricular and intra-left-ventricular conduction delay in CRT patients

Kirsten Rotter1, Bruno Ismer1, Matthias Heinke2, Ibrahim Akin1, Katharina Kroll1, Stephanie Schell-Dieckel1, Christoph Melzer3, Frank Weber4, Christoph A. Nienaber1 Kardiologie, Universitätsklinikum Rostock, Rostock, Germany; 2Kardiologie, Universitätsklinikum Jena, Jena, Germany; 3Kardiologie, Charité Berlin, Berlin, Germany; 4Kardiologie, Frankenwaldklinik, Kronach, Germany

Response to cardiac resynchronization therapy (CRT) was reported in patients presenting distinct interventricular dyssynchrony. Despite wide QRS with left bundle branch block, individual interventricular conduction delay (IVCD) as well as intra-left-ventricular conduction delay (ILVCD) cannot be measured in surface ECG. Bipolar esophageal left ventricular electrogram (LVE) promises a new approach to determine IVCD and ILVCD to select heart failure patients for CRT. We studied inter-individual relations between QRS duration, IVCD, and ILVCD in CRT patients by LVE. Following implantation of CRT systems for heart failure in 44 patients (35 men, 10 women, age 64.9 ± 9.5 years), TOslim electrode was per orally applied to record the LVE using the Esophageal Rostock Filter (Dr. Osypka GmbH, Rheinfelden, Germany). IVCD was measured between onsets of QRS in surface ECG and left ventricular deflection in LVE. ILVCD was determined as duration of the left ventricular deflection in the LVE. In 41 patients in sinus rhythm and three in atrial fibrillation, LVE was recorded in electrode position of 46±4 cm, at mean, from upper front teeth row. In all of the patients, individual ventricular desynchronization was quantifiable. Mean QRS duration was 174±24 ms (118-214 ms). The LVE uncovered the IVCD to be of 74±20 ms (44-122 ms) and ILVCD of 121 ±31 ms (56-224 ms) at mean. Correlation between IVCD and QRS was 0.53 and between ILVCD and QRS 0.33. The IVCD/QRS relation was 0.43±0.10 (0.300.64). Conclusions: Individual duration of IVCD and ILVCD can semi-invasively be measured by LVE to quantify ventricular desynchronization in heart failure patients. LVE uncovers the relations between QRS duration, IVCD, and ILVCD as to be considerably differing inter-individually. In this study, implantation of CRT systems was linked with IVCD of 44 ms and up. The predictive values of IVCD, ILVCD, and IVCD/QRS ratio for individual CRT response or non-response shall be identified in follow-up studies.

Abstract session 11: Tools for evaluating patients with heart disease

Saturday April 17, 2010, 4:00 pm-5:30 pm ROOM GELBERSALON (Palais Montgelas, 1st Floor) 11-1 Abstract 01-09

A new way of assessing beat-to-beat repolarization variability in man—the deltaT50 method

Christina Abrahamsson1, CorinaDota1, Bo Skallefell1, Leif Carlsson1, Dunia Halawani1, Lars Frison1, Anders Berggren1, Nils Edvardsson2, Göran Duker1

IAstraZeneca R&D Mölndal, Mölndal, Sweden; 2Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden

Background: Repolarization lability, measured as the beat-to-beat QT interval variability, has been suggested to be a marker of risk of torsades de pointes in patients with acquired or congenital long QT syndromes. To assess such variability, we developed a new, automatic and operator-independent method based on the temporal variability of the T-wave down slope. Method: To define criteria for acceptable signals, the temporal repolariza-tion variability at 20%, 50%, and 80% of the T-wave down slope, deltaT20, deltaT50, and deltaT80 were measured from ECGs recorded in ten healthy subjects (21-29 years, six men) under resting conditions before and after addition of noise and before and after 21 points smoothing, respectively. Measurements were also undertaken during stress and bicycle exercise in these and an additional 32 subjects (18-68 years, 16 men) in order to evaluate the influence of altered autonomic tone and age on the repolarization variability. Results: Resting deltaT20, deltaT50, and deltaT80 were almost identical (1.56±0.69, 1.57±0.70, and 1.62±0.69 ms, n.s.), and deltaT50 was thus chosen as the primary variable. DeltaT50 was measured with an accuracy of 1 ms on 10-30 pairs of ECG complexes with a signal-to-noise ratio, before smoothing, of more than 10 and under conditions of changes in the RR interval of <150 ms. During conditions of stress and during bicycle exercise, deltaT50 was a stable measure and deviated on average <1 ms from the resting value. Furthermore,

deltaT50 did not change by age, but was slightly higher in women than in men (on average 0.43 ms, p<0.0001). Conclusion: The deltaT50 method provides continuous assessment of the beat-to-beat repolarization variability. In healthy subjects, the variability was low and stable during rest, stress and bicycle exercise, independent of heart rate and age and slightly higher in women than in men.

11-2 Abstract 07-06

Pulse pressure variation: a novel risk predictor after acute myocardial infarction

Petra Barthel1, Alexander Müller1, Simon Schneider1, Kurt Ulm2, Georg Schmidt1

1Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, München, Germany; 2Institut für Medizinische Statistik und Epidemiologie, München, Germany

Increased pulse pressure (PP) is associated with increased risk of cardiovascular events. Little is known about PP beat-to-beat variation. The aim of this study was to assess PP variation and its association with mortality in post-infarction patients. Methods: Nine hundred thirty-eight consecutive post-infarction patients in sinus rhythm aged <80 years were prospectively included. Noninvasive 30-min recordings of arterial pressure (Portapres) were obtained 7±2 days after index infarction. PP variation was quantified by PP standard deviation (PPSD) and PP phase rectification (PPPR) assessed by modified phase-rectified signal averaging. Figure shows PPPR examples. Follow-up period was 5 years. Primary endpoint was total mortality. Results: During follow-up, 61 patients (6.5%) died. Mortality was moderately correlated with PPSD (p < 0.05), strongly correlated with PPPR (p<0.0001), but not correlated with the mean values of PP (p=0.??). High values of PPSD and PPPR indicated increased mortality risk. In the multivariable Cox regression adjusted for known risk predictors (age, history of a previous infarction, diabetes mellitus, LVEF, mean heart rate, heart rate turbulence, and deceleration capacity), PPPR was significantly associated with mortality (p=0.001). Conclusions: Increased beat-to-beat pulse pressure variation is a strong and independent predictor of mortality after myocardial infarction.

11-3 Abstract 07-03

Prognostic value of nonlinear dynamics in myocardial infarction

Morten Skou Nielsen1, Esben Vedel-Larsen1, Berit T Jensen , Jens Christian Jacobsen , Fan Wang , Steen Abildstrom4, Niels-Henrik Holstein-Rathlou3, Christian Torp-Pedersen5, Jorgen Kanters1

laboratory of Experimental Cardiology, University of Copenhagen, Copenhagen N, Denmark; 2Dept. of Cardiology, Rigshospitalet, Copenhagen, Denmark; 3Dept. of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark; 4Dept. of Cardiology, Glostrup University Hospital, Copenhagen, Denmark; 5Dept. of Cardiology, Gentofte University Hospital, Copenhagen, Denmark

The aim of the study was to determine whether nonlinear dynamics adds prognostic power to conventional measures in myocardial infarction. Methods: Holter recordings were done in 366 patients with an acute myocardial infarction. Ejection fraction (EF) was determined by echocardiography. Patients were followed for 3 years with a 3-year mortality of 23%. Survival analyses were performed using Cox models. Nonlinear dynamics were measured as correlation dimension D2 expressing the degree of freedom in the heart rate regulating system and as the Lyapunov exponent expressing the short time instability in the heart rate. Classical predictors such as EF, age, SDNN, heart rate, and ventricular premature beats per hour (VPC) were also included in the Cox analysis. Results: Mean and SE of the investigated parameters are shown in the table. Univariately, the Lyapunov exponent (p<0.0001) and correlation dimension (p<0.0001) predicted mortality better than heart rate, age, EF, and VPC. In multivariate Cox analysis, all variables (Lyapunov exponent, correlation dimension, heart rate, age, EF, and VPC) entered the final model. Conclusion: Nonlinear dynamics have strong predictive power in myocardial infarction

Deceased Survivors

Mean±SE Mean±SE

Lyapunov exponent (1) 0.36±0.01 0.27±0.01

Correlation dimension (1) 9.6±0.2 10.5±0.1

Mean RR (ms) 789±17 856±8

EF (%) 40.8±1.2 47.7±0.6

Ventricular premature beats (h-1) 45±9 12±2

Age (years) 74±1 64±1

11-4 Abstract 07-05

Value of T-wave alternans testing in pacemaker patients: comparison of various pacing modes and prognostic relevance during long-term follow-up

Marc Dorenkamp1, Christoph Breitwieser2, Andreas Morguet2, Steffen Behrens3, Markus Zabel1

1Dept. of Cardiology and Pneumology, Georg-August-University of Göttingen, Heart Center, Göttingen, Germany;

Dept. of Cardiology and Pneumology, Charite-Universi-tätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; Dept. of Cardiology, Vivantes HumboldtKlinikum, Berlin, Germany

Introduction: T-wave alternans (TWA) is a predictor of malignant ventricular tachyarrhythmias. TWA testing requires controlled increase of heart rate which can be achieved through physical exercise or atrial pacing. In patients (pts) with permanent pacemakers, its prognostic relevance and the impact of other pacing modes on TWA are unclear. Methods: Sixty-three pts (mean age 68 ± 13 years) with structural heart disease and implanted DDD pacemaker were enrolled. Left ventricular (LV) function was normal or moderately impaired (mean LV ejection fraction, 61 ± 15%). All pts underwent sequential TWA testing using an atrial- (A) and a ventricular- (V) paced protocol. Pts with complete atrioventricular block were excluded. Microvolt TWA was measured using the spectral

method. TWA measurements during A pacing were used as reference standard. Results: During A pacing, 21% of TWA tests were positive, 50% negative, and 29% indeterminate. When using V pacing, 18% of tests were positive, 41% negative, and 41% indeterminate. When positive and indeterminate tests were grouped as non-negative, the concordance between A and V pacing was 70%. After a mean follow-up of 8.1 ±2.8 years, 26 (41%) patients had died. Better survival was predicted by a negative TWA test result during A pacing (P =0.0324; see Fig. 1). In contrast, TWA measurements during V pacing were not predictive of outcome (P = 0.82). Conclusions: In pts with permanent pacemakers, there is a low concordance rate between TWA test results when using different pacing protocols. During long-term follow-up, only A pacing was of prognostic relevance and should therefore remain one of the standards of TWA measurements.

1 " P= 0.0324

m 0.4 -

-------TWA negative

-TWA non-negative

0.0 4-.-1-.-1-.-1-.-1-.-1-■

0 500 1000 1500 2000 2500 Time of Follow-up (days)

Figure 1. Kaplan-Meier survival curves for 63 pacemaker patients based on negative of non-negative T-wave alter-nans (TWA) testing using an atrial pacing protocol. Mortality was significantly higher in patients with nonnegative TWA test (P = 0.0324)

11-5 Abstract 07-07

Respiration rate dynamics: a novel predictor of mortality after acute myocardial infarction

Petra Barthel1, Alexander Müller1, Simon Schneider1, Kurt Ulm2, Prof. Georg Schmidt1

1Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, München, Germany; 2Institut für Medizinische Statistik und Epidemiologie, München, Germany

Respiration rate abnormalities are common in heart failure. Little is known about respiration rate dynamics (RRD) in post-MI patients and its prognostic value. The aim of the study was to assess RRD and its association with mortality in post-MI patients. Methods: A total of 941 consecutive post-MI patients in sinus rhythm aged <80 years were included. Thirty-minute recordings of respiration intervals (noninvasive continuous monitoring of thoracic movements, Portapres) were obtained 7 ±2 days after index infarction. RRD was quantified by a modified phase-rectified signal averaging of inspiration and expiration intervals. Follow-up was 5 years. Primary endpoint was total mortality. Results: During follow-up, 72 patients (7.7%) died. Mortality was negatively correlated with mean respiration interval and positively correlated with expiration RRD and inspiration RRD (p < 0.0001, respectively). In multivariable Cox regression adjusted for age, history of a previous infarction, diabetes mellitus, LVEF, mean heart rate, heart rate turbulence, and deceleration capacity, inspiration RRD was significantly associated with mortality (HR 2.1, p=0.005). The association of inspiration RRD with mortality was particularly strong in patients with LVEF<35% (figure). Conclusion: Decreased inspiration RRD is a strong and independent predictor of mortality after myocardial infarction and might prove useful in the selection of patients with depressed LVEF for prophylactic therapy.

11-6 Abstract 05-07

Feasibility of measurement of endocardial T-wave alternans prior to onset of ventricular arrhythmias in ICDs (ETWAS Study)

Philippe Maury1, Jean-Luc Pasquie2, Frank Raczka2, Lionel Beck , Jerome Taieb , Alexandre Duparc , Benoit Hallier , Fujian Qu5, Rhiddi Shah5

University Hospital Rangueil, Toulouse, France; 2Cardiol-ogy, University Hospital Arnaud de Villeneuve, Montpellier, France; 3Cardiology, University Hospital Carremeau, Nimes, France; 4Cardiology, General Hospital, Aix en Provence, France; 5St Jude Medical, Sunnyvale, United States of America

Introduction: ICD-stored intracardiac electrograms (IEGM) present a unique opportunity for detecting temporal relationship between the occurrence of T-wave alternans (TWA) and spontaneous arrhythmia. The aim of the ETWAS Study was to assess the feasibility of detection of TWA preceding the onset of VT/VF in IEGM. Methods: Fifty-six implanted patients with St. Jude Medical ICDs (44 men, 63±12 years old, mean EF 34±15%) were prospectively enrolled and monitored for 1 year. Thirteen different T-wave parameters were extracted from IEGM

(T amplitude, T peak time, Bazett and Hodges corrected T peak time, T end time, T duration between baseline crossing and between points of maximal slopes, T peak to T end, maximal ascending and descending slopes, timing of points of maximal slopes, and T-wave area). Successive beat-by-beat differences in each parameter in recordings prior to VT/VF were compared to control recordings in the same pts. TWA was considered if beat-by-beat variations for at least one parameter was significantly higher than baseline with a p value <0.01. Results: Twenty-two VT/VF episodes (24±13 beats, 71 ± 17 bpm) and 13 baseline (25±9 beats, 72±18, ns) were analyzed in 12 pts. TWA was presentbefore VT/VF onset in 13 episodes (seven pts) with one to nine differing parameters. Significant beat-by-beat differences before VT/VF onset were observed in amplitude, timing, slopes, area, and duration of the T-wave. Paired and unpaired comparisons of the averaged values of beat-by-beat variations, however, did not reveal significant difference between baseline and episodes, except for T-wave amplitude (0.07 ± 0.006 vs 0.14 ± 0.03 mV,p=0.03 paired and 0.04 unpaired). Conclusions: Detection of TWA prior to VT/VF might be useful in predicting imminent arrhythmia occurrence. TWA can be detected before VT/VF onset in more than half of episodes using a simple time domain technique and multiple T-wave measurements. T-wave amplitude seems the most discriminant parameter.

Abstract session 12: Cardiac pacing and follow-up monitoring

Saturday April 17, 2010, 4:00 pm-5:30 pm

ROOM MONTGELASSAAL (Palais Montgelas, 2nd Floor)

12-1 Abstract 21-03

Right ventricular pacing in apical versus septal position: a prospective randomized long-term study

Giulia Domenichini1, Henri Sunthorn1, Eric Fleury1, Huberdine Foulkes1, Carine Stettler1, Dipen Shah1, Haran Burri1

1Service de Cardiologie, Hôpitaux Universitaires de Genève, Genève, Switzerland

Introduction: Chronic stimulation from the right ventricular (RV) apex may impair left ventricular (LV) function. The ventricular septum is an alternative pacing site, but available data are limited to short-term follow-up. Methods: A total of 59 patients (pts) (45 men, age 77 ±7 years) requiring ventricular pacing were enrolled. RV lead implantation was randomized to either the apex or to the mid-septum. Lead position was confirmed by transthoracic echocardiography. LV ejection fraction (LVEF) was determined at baseline and after 1 and 4 years by radionuclide ventriculography. Results: Of the 59 pts, 28 were randomized to the apical and 31 to the septal group. Of these, 14 died before end of follow-up (7/28 from the apical group, 7/31 from the septal group, p = 1), 12 dropped out, and 33 pts completed follow-up after a median of 4.4 years (range 2.5-6.2) of pacing. Significant changes in LVEF at follow-up compared to baseline were observed in the septal (50± 14% at baseline, 44±15% at 1 year (p=0.014) and 47±15% at 4 years (p=0.12)), but not in the apical group (56 ±7% at baseline, 56±9% at 1 year (p=0.80) and 53±12% at 4 years (p=0.19)). Echocardiography performed in 26 septal group pts confirmed a true septal position in only 14; an anteroseptal or anterior free wall position was found in the remaining pts. At follow-up, a significant reduction in LVEF was observed in the pts in whom a true septal position was not attained (48 ± 17% at baseline, 38±17% at 1 year (p=0.008) and 40±15% at 4 yeas (p=0.035)), but not in the true septal pts (53±9% at baseline, 52±10% at 1 year (p=0.75) and 53±10% at 4 years (p=0.84)). There were no significant changes in LVEF at baseline and at follow-up between apical and true septal pts. Conclusions: At long-term follow-up, pacing at the RV septum confers no advantage in terms of LVEF compared to the apical position. Furthermore, obtaining a true septal position is essential to avoid the detrimental effects on LVEF that might result from RV pacing in non-conventional sites.

12-2 Abstract 23-01

Indications for permanent pacing: the 3-s pause is an arbitrary and inappropriate discriminator

Honey Thomas1, Andrew Turley1, Christopher Plummer1, Janet McComb1

Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland

Background: It has been generally accepted that pauses of >3 s particularly if associated with symptoms constitute an indication of permanent pacing. The ISSUE classification, however, also recognises that bradycardia with a decrease in heart rate >30% (type 2a) or <40 bpm for 10 s (type 2b) can cause symptoms in a minority (5%), as documented by the implantable loop recorder (ILR). We evaluated the type and length of pause, reproducibility of symptom rhythm correlation and outcome in patients with symptomatic pauses documented by ILR. Methods: All patients who had received a permanent pacemaker in our centre following diagnosis of symptomatic bradycardia using an ILR were identified. Clinical data including outcome after pacing and downloaded ECG rhythm strips were reviewed by two cardiologists who evaluated the rhythm and pause length. Results: We identified 36 patients who received a pacemaker following ILR-documented brady-cardia. There were no differences in age, sex, average length of pauses, rhythm abnormality or symptoms of the patients grouped according to clinical outcome after cardiac pacing. The figure summarises the length of pauses and clinical outcome in our cohort. At least one symptomatic short (<3 s) pause was documented in 13 of 36 patients (33%), of whom six had complete symptom resolution and six had partial resolution (one was unknown). The seven patients who had only short pauses identified experienced both syncope (three) and presyncope (four), and five had complete symptom resolution. Discussion: When symptoms are associated with pauses, they respond to permanent pacing independent of the duration of the pause or rhythm. The arbitrary requirement of a 3-s pause before pacing is not supported by our data.

12-3 Abstract 22-02

Optimization of the AV delay by Quick-Opt algorithm compared to multiple pacing programming

Daniel Flammang1, Nicolas Girerd1

1Croix Rousse University Hospital, Lyon, France

Introduction: Based on echo-Doppler hemodynamic assessments, the Quick OptR (Q-Opt) algorithm embodied in the recent St. Jude Medical (SJM) pacemakers proposed to optimize the AV delay especially for CRT patients. Methods: The SJM 5826 and 2112 dual-chamber models have been implanted in 24 successive patients hospitalized for syncope. The cardiac output (CO) and the systolic volume (SV) was assessed, at each systole, by measuring thoracic impedance (Task ForceR, CNSystems, Austria) 2 days after implantation using six programming: sinus rhythm (SR) + 110, 150, 300 ms, and Q-Opt AV delays and DDD pacing at 70 bpm + 110 and 150-ms AV delays. Results: Thirteen women and 11 men, mean age 74.1 years, were implanted for syncopal complete AV bock with normal QRS (20) and BBB (4). Underlying cardiac disease was present in four patients. The hemodyamic efficiency was ranked from 1 (highest CO and SV) to 6 (lowest CO and SV). Echocardiogram was not systematically performed. CO and SV were higher during DDD pacing, especially with 150-ms AV delay. Paradoxically, the worst hemo-dynamic features were observed during sinus rhythm whatever the AV delay, favoring the spontaneous ventricular contraction. Q-Opt results were close to DDD pacing with 150-ms AV delay. Conclusions: The noninvasive hemodynamic parameters, measured on a few number of systoles by the Task ForceR system, may define the optimized AV delay. The Q-Opt algorithm provides similar results as those obtained with DDD pacing. This method of measure is faster and seems to be reliable; more clinical studies should confirm these results.

Ranking of Programming

efficiency SR+Q- SR SR SR DDD70 DDD70

OPT +AVD110 +AVD150 +AVD300 +AVD110 +AVD150

(%) (%) (%) (%) (%) (%)

1 30 10 10 10 40 40

2 20 10 30 10 20 10

3 20 20 10 10 20

4 20 30 10 10 20

5 10 30 40 20

6 10 30 20

12-4 Abstract 23-03

The Wenckebach point is a good predictor of ventricular pacing percentage in patients with sick sinus syndrome and dual-chamber pacemakers

David Laflamme1, Lyne Lavallee1, Jean Roux1, Prof. Felix Ayala-Paredes1 Cardiology, Université de Sherbrooke, Sherbrooke, Canada

Background: In patients with sick sinus syndrome, atrial pacing with a single-chamber pacemaker (AAI) provides physiological and less costly pacing than a system with double chamber (DDD). The incidence of AV block of second or third degree in these patients varies between 0.6% and 3% per year. Objective: The objective of this study was to evaluate the Wenckebach point as a predictor of ventricular pacing (% V-Pace) in patients with sick sinus syndrome and implanted with dual-chamber pacemakers. Methods: In this retrospective study, different Wenckebach points, measured once or twice yearly at routine pacemaker follow-ups, were associated with different percentages of ventricular pacing (% V-pace) in patients with sick sinus syndrome in whom a DDD pacemaker was installed between 2003 and 2005. Each patient had at least three Wenckebach point measurements done. Results: Two hundred eleven patients were included in this study. The maximum follow-up was 72 months and the mean 17 months. In patients with a Wenckebach point >120 bpm, the mean %V-pace was 9%, while in patients with a Wenckebach point of <120 bpm, the mean %V-pace was 34% (p<0.001). The mean Wenckebach point and the mean %V-pace of the study population did not fluctuate significantly during the follow-up (mean follow-up of 17 months). A mean decrease of Wenckebach point of 27 bpm was associated with a mean increase of the %V-Pace of only 2%. Conclusion : The Wenckebach point could act as a predictor of %V-Pace needed in the evolution of sick sinus patients; it could determine the type of pacemaker to install (AAI vs. DDD) at implant as a value >120 bpm >could be safe enough to implant a single atrial chamber device.

12-5 Abstract 22-03

Centralized daily wireless remote home monitoring in a prospective, multicenter study: effort and effect on the clinical management of patients with devices

T Vogtmann1, A Marek1, M Gomer2, S Stiller3, V Kühlkamp4, G Zach5, S Löscher6, S Kespohl7, G Baumann1

1CC 13, CCM, Cardiology and Angiology, Charité Universitätsmedizin Berlin, Berlin, Germany; Diakonissenkrankenhaus, Mannheim, Germany; Cardiology, University Ulm, Ulm, Germany; 4Herzzentrum Bodensee, Konstanz, Germany; 5LKH Bruck, Bruck, Austria; Cardiology, Hospital St Georg, Leipzig, Germany; 7Biotronik, Berlin, Germany

Introduction: The Model Project Monitoring Center (MoniC) evaluated the efficacy of centralized daily remote device monitoring in a prospective multicenter study. Nine satellite clinics were affiliated to the MoniC at Charité (Universitatsmedizin Berlin), which was blinded for clinical data. Following a predefined algorithm, a specially trained study nurse classified the events based on severity: high urgent (immediate physician's attention), relevant (mail to satellite clinic), and no action required. Methods: One hundred twenty-one pts (59 ICD: 26/59 primary prophylaxis, 62 PMs) were included for a follow-up period of 391 ± 156 days, resulting in 47,343 monitored patient-days. Of all days, 89% were covered by automatic transmitted event and/ or status reports. The influence of the forwarded home monitoring status reports on the clinical management and/or change of therapy and the time spent for analysis and communication was evaluated. Results: Out of 2,219 incoming reports, 174 were forwarded to the satellites (1.3 per monitored patient year). Of forwarded reports, 36.8% had clinical consequences (e.g., 29 FUs with 11 device reprogramming, six times change of medication, eight times hospitaliza-tion). Of the status reports, 15.5% triggered a change of either device (N = 11), medical (N = 14), or other (N = 2) therapy. On average, the time spent for home monitoring data analysis in MoniC was 25.6 min per 100 monitored patient-days (study nurse), 7.4 min for communication with the satellites. Conclusion: Even with access to the remote data only for analysis, one third of the reports were followed by clinical consequences and 15.5% by a direct intervention in the therapy of the patient. The manually performed data analysis covering 386/365 days needed 25.6 min per working day per 100 monitored patient-days. New automatic filtering functions integrated in remote monitoring systems will reduce this time effort even more.

Centralized home monitoring is an effective tool for remote monitoring of devices.

12-6 Abstract 22-06

Comparison between two different implant techniques to attain a right ventricular septal lead position

Giulia Domenichini1, Vincent Ganiere1, Henri Sunthorn1, Carine Stettler1, Haran Burri1

1Service de Cardiologie, Hôpitaux Universitaires de Genève, Genève, Switzerland

Introduction: It is known that right ventricular (RV) septal pacing preserves left systolic function, but attaining a true septal position may be difficult, and the lead may be inadvertently placed on the anterior free wall. Methods: A stylet with a classic 45° curve (2D stylet) was compared to a stylet shaped with an additional posterior 90° curve (3D stylet) to assess the capability to obtain a true septal RV lead position in consecutive patients (pts) undergoing a pacemaker (PM) implant. Both curves were obtained by manually shaping a straight stylet. After PM implant, blinded evaluation of RV lead position was performed by transthoracic echocardiography. Results: A total of 48 pts were implanted (35 men, age 80 ±7 years): 24 with 2D stylet (of whom two were excluded due to insufficient echocardiogram quality) and 24 with 3D stylet. A true septal position was obtained in 10 of 22 pts (45%) in the 2D stylet group vs 21 of 24 pts (88%) in the 3D stylet group (p =0.004). No significant differences were observed in the two groups in terms of fluoroscopy time and total procedure duration, as well as electrical parameters at implant and at device follow-up. Conclusions: Compared to a classical 2D stylet, the RV lead implanted using a 3D stylet allows a better result in terms of lead positioning at interventricular septum.

ECAS 2010 Poster Session Presentations FRIDAY APRIL 16, 2010, 9:00-12:00 Chaired Poster Session A Part 1

Abstract Cardiac Resynchronisation Therapy (CRT) 13-1 Abstract 24-03

C-reactive protein and response to cardiac resynchronization therapy

Roberto Matia1, Antonio Madrid1, Maria Jesus Esteban1, Ana Garcia Martin , Guadalupe Salado , Concepcion Moro Ramon y Cajal Hospital, Madrid, Spain

tion of clinical and ECO criteria in a medium-term follow-up after CRT.

U-CRP mg/L

13-2 Abstract 24-06

Ultrasensible C-reactive protein (u-CRP) levels have been related to the incidence of cardiovascular events and atrial fibrillation. Aims: The aim of this study was to assess the relation between u-CRP levels and the response to cardiac resynchronization therapy (CRT). Material and methods: We obtained in 64 patients u-CRP levels on average 2 years and 7 months after CRT. Ten cases were excluded from the analysis because of u-CRP levels >10 mg/L. Patients were 70.4 ± 8.3 years old, 17 (31%) women, 22 (40%) had idiopathic dilated cardiomyopathy, 20 (37%) ischemic, 7 (13%) valvular, 4 (7.5%) hypertensive, and 1 (2%) congenital cardiomyopathy. We defined clinical response by a decrease in at least one point in NYHA functional class and the absence of hospitalization related to heart failure and echocardiographic response (ER) as an increase in the ejection fraction of the left ventricle (LVEF) >5%. We considered responders to those patients who fulfilled both clinical and echocardiographic criteria. Results: Mean U-CRP level in our population was 2.89 mg/L, performed at a mean of 2.6 years after CRT; 35 patients (65%) met the criteria for clinical response. U-CRP levels were lower, although not significantly different, in clinical responders (2.6 ± 1.7 vs 3.3 ± 2.4 mg/L, p=0.1). An echocardiogram showed that 38 patients (76%) met the ER criteria. Pre-CRT LVEF was 29.4 ± 7.7% and post-CRT 43 ± 15.8% (p< 0.0001). U-CRP levels were significantly lower in ER patients (2.4 ± 1.8 vs 4.6 ± 2 mg/L, p=0.004). Twenty-seven patients (54%) were considered responders by combining clinical and echocardiographic criteria. U-CRP levels were significantly lower in responders (3.6 ± 2.1 vs 2.4 ± 1.9 mg/L, p=0.04). Conclusions: U-CRP levels are significantly lower in patients with ECO response as well as in those considered responders based on the combina-

Does the echocardiographic positive response to CRT precede the clinical improvement?

Michela Brambatti1, Maria Vittoria Matassini1, Marco Marchesini1, Sabatino Guardiani1, Silvano Molini1, Alessandro Capucci1

1Clinica Di Cardiología, Universita' Politécnica Delle Marche, Ancona, Italy

AIM: The aim of this study was to identify the predictive value of clinical and instrumental parameters in response to patients with cardiac resynchronization therapy (CRT) and to evaluate the prognostic role of echocardiographic indices in "responder's eco" but no clinical improvement. Methods and results: Twenty-four patients (19 men, 5 women, age 72± 6.4 years old) with dilated cardiomyopathy, NYHA functional classes III-IV, left ventricular ejection fraction (LVEF)<35%, and QRS >120 ms who underwent CRT during the period March 2007-May 2009 were analyzed. All patients were investigated with clinical evaluation, Minnesota Living with Heart Failure Questionnaire (MLHFQ), electrocardiography (ECG), echocardiography including tissue Doppler imaging (TDI), and implant control. The patients were divided into four groups: four "responders clinical+echo" (17%), two "non-responders" (8%), eight "clinical responders" (33%), and ten (42%) "echocardiographic responders." In 18 patients (75%), there was a reduction of intraventricular dyssynchrony and of the amplitude of the QRS (<120 ms); a reduction of dyssynchrony compared with a wide QRS resulted in only one case (4%). In four (17%) patients, despite the absence of dyssynchrony, LVEF was<35%. From a clinical point of view, the "non-responders" showed ischemic heart disease (100%) complicated by prior necrosis (both with myocardial infarction

scar in the posterior side) and diabetes mellitus type II (100%). On the other hand, the "responders clinical+echo" had idiopathic dilated cardiomyopathy (50%) or ischemic heart disease without previous revascularization or necrosis (50%). Conclusions: The presence of diabetes mellitus type II and ischemic heart disease complicated by prior necrosis (especially posterior-lateral) is associated with lack of echo parameters and clinical status improvement by CRT. It is well possible that the only echocardiography initial improvement may subsequently lead to better survival. Further studies are needed.

13-3 Abstract 24-20

Successful cardiac resynchronization therapy

in a 6-year-old pacemaker-dependent child with dilated

cardiomyopathy

Attila Kardos1, Imre Kassai1, Laszlo Ablonczy1, Attila Mihalcz1, Csaba Foldesi1, Laszlo Kornyei1 IGottsegen Gyorgy Hungarian Institute of Cardiology, Budapest, Hungary

Background: Development of congestive heart failure and dilated cardiomyopathy occurs in a small but significant subset of children undergoing chronic RV-based pacing systems. Indication criteria in this population are controversial, and transvenous implantation can be challenging. Methods: Patient's atrial septal defect was surgically closed at 9 months of age, and 1 year later for heart block, epicardial VVI pacemaker system was implanted. He (6 years old, 13 kg, 106 cm) was admitted with diminished exercise tolerance and failure of weight gain for cardiologic evaluation. The paced ECG revealed QRS duration of 180 ms. Echocardiography showed left ventricular end diastolic diameter of 57 mm and left ventricular ejection fraction of 22%. Severe LV dysfunction with inter- and intraventricular dyssynchrony caused by long-term right ventricular free wall pacing was presumed, and CRT was regarded an appropriate therapeutic option. Under general anesthesia, unipolar electrode was implanted in the left lateral side branch of the coronary sinus, and bipolar active fixation electrode to the right atrial wall percutaneously via the left subclavian vein. The electrodes were tunneled and connected to the abdominally placed atrio-biventricular pacemaker. Results: Atrial, left, and right ventricular thresholds were optimal. AV delay was optimized by conventional echocardiography using iterative method; the BiV QRS was 80 ms. After 1 month, there was a moderate improvement in clinical symptoms and LV function. Discussion: This report describes technically challenging and successful upgrade from a single-chamber to a dual-chamber biventricular pacing system in a small child with dilated cardiomyopathy caused by right ventricular free wall pacing. Upgrading to biventricular pacing systems should be considered in the management of these

patients prior to listing for cardiac transplantation, and using percutaneous techniques is safe even in this small pediatric patients.

13-4 Abstract 24-23

Evaluating the quality of life in patients with refractory heart failure undergoing cardiac resynchronization regarding the type of therapeutic response

Elisabete Nave Leal1, Luís Pais Ribeiro2, Mário Oliveira3, Manuel Nogueira da Silva3, Joana Feliciano3, Rui Soares3, Sofia Santos3, Sandra Alves3, Rui Ferreira3 1Escola Superior de Tecnologia da Saúde de Lisboa, IPL; Faculdade de Psicologia e Ciencias da Educagao, UP, Lisboa; Porto, Portugal; 2Faculdade de Psicologia e Ciencias da Educagao, UP, Porto, Portugal; Centro Hospitalar de Lisboa Central, Hospital de Santa Marta, Lisboa, Portugal

The benefits of cardiac resynchronization therapy (CRT) in the quality of life (QOL) are largely demonstrated in selected patients (P) with severe congestive heart failure (CHF). However, the differences between responders and non-responders, with regard to the effect of CRT in the various dimensions that constitute QOL, are still a matter of discussion. Objective: The objective of this study was to evaluate the impact of CRT on the QOL of P with CHF refractory to optimal pharmacological therapy within 6 months after CRT. Population and methods: Forty-three patients, submitted to successful implantation of CRT, were evaluated in hospital just before intervention and in the outpatient clinic within 6 months after CRT. QOL was analyzed based on the Kansas City Cardiomyopathy Questionnaire (KCCQ). P were classified as super-responders (ejection fraction of left ventricle (LVEF) > 45% post-CRT, n = 15, 65±8 years, 46.7% male, LVEF pre-TRC 30±5%, 100% in NYHA class III), responders (sustained improvement in functional class and LVEF increased by 15%, n = 19, 63±11 years, 84.2% male, LVEF pre-TRC 23 ±6%, 100% in NYHA class III), and non-responders (no clinical or LVEF improvement, n=9, 63±6 years, 77.8% male, LVEF pre-CRT 24±7%, 22.2% in class II, 66.7% in class III, and 11.1% in NYHA class IV). Results: In the group of super-responders, CRT was associated with an improvement in QOL for the various fields and sums assessed (p<0.05). In responders, CRT has been associated with an improvement of QOL in the various fields and sums, except in the self-efficacy dimension (p<0.05). In non-responders, CRT was not associated with improvement of QOL. Conclusion: In a population with severe CHF undergoing CRT, the P with clinical and echocardiographic positive response obtained a favorable impact in all dimensions of QOL, while the group without response to CRT showed no improvement. These data reinforce the importance of QOL as a

multidimensional tool for the assessment of benefits in clinical practice.

13-5 Abstract 24-10

Hemodynamic benefit of cardiac resynchronization therapy requires left bundle branch block: a case report

MargotBogaard1, Barbara Dijkman1, Peter Loh1, Vincent Van Driel1, Richard Hauer1, Pieter Doevendans1, Mathias Meine1

1Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands

Background: The effect of cardiac resynchronization therapy (CRT) in the absence of left bundle branch block (LBBB) is disputable. This case report describes a patient with chronic congestive heart failure and rate-dependent LBBB receiving CRT. Results: QRS width was 90 ms during intrinsic rhythm at 70 bpm and prolonged to 160 ms with LBBB during atrial overdrive pacing at 80 bpm. This was accompanied by a prolongation of the interventricular electrical delay on the intracardiac electrogram from 60 to 130 ms. The acute hemodynamic effect of CRT at different atrioventricular delays was assessed by invasive measurement of the maximum rate of pressure rise (dP/dtmax) in the left ventricle during the implantation procedure. Initiation of LBBB caused acute significant decrease of 19% in dP/dtmax compared to narrow QRS. During LBBB, biventricular pacing with the optimal atrioventricular delay improved dP/dtmax by 20%. In the absence of LBBB, biventricular pacing did not improve acute hemodynamics and decreased dP/dtmax at shorter AV delays. Conclusions: Onset of LBBB caused a sudden decline in the left ventricular systolic function of 19% that could be completely restored by optimized CRT In the absence of LBBB, there was not any acute improvement of left ventricular systolic function by CRT.

13-6 Abstract 24-26

Usefulness of QRS duration measured immediately after implantation to predict response to cardiac resynchronization therapy

Alexandra Toste1, Mario Oliveira1, Manuel Nogueira da Silva1, Pedro Cunha1, Joana Feliciano1, Luisa Branco1, Ana Timoteo1, Sofia Santos1, Rui Ferreira1 1Hospital de Santa Marta, Lisboa, Portugal

Identification of responders in patient (P) selection for cardiac resynchronization therapy (CRT) remains a controversial topic. One of the most important criteria is baseline QRS duration (wQRS), which should be >120 ms. However, there is also interest in the clinical impact of wQRS change after CRT. Aim: The aim of this study was to analyze the relationship between wQRS prior and immediately after device implantation and clinical response to CRT. Population and methods: We included 46 P (65% males, 63.3 years) who underwent successful CRT implantation. wQRS was assessed before and immediately after device deployment. 37 P (80%) were classified as "responders" (R; improvement of at least one functional class at 6-month and significant reverse remodeling—reduction of > 15% in left ventricle end-diastolic volume and/or increase of > 15% of ejection fraction) and nine P as "non-responders" (NR). Results: Baseline wQRS showed a trend to be higher in the NR group (195±20 vs. 178±28 ms, Mann-Whitney test, ^=0.06). After implantation, wQRS was significantly higher in NR group (155± 16 vs. 140±22 ms, ^=0.02), and the absolute variation was 40±17 vs.38±22 ms, respectively (p =NS), without statistically significant difference in percentage change (20±8% vs. 21 ± 11%, p =NS). By analyzing each group separately, as paired samples, wQRS prior vs. after implantation was significantly different in the two groups (Wilcoxon, NR group: p=0.008; R group: p<0.001). Correlation between wQRS immediately after implantation and clinical response was significant (Pearson's, r=0.28, ^=0.03), while baseline wQRS did not reach statistical significance (r=0.242, p= 0.053). Conclusions: R group had a baseline wQRS which had a trend to be less prolonged than the NR group. Despite the reduction of wQRS of similar magnitude in both groups, R group had a wQRS significantly narrower after implantation. wQRS measured immediately after implantation seems to be a better predictor of clinical response than baseline wQRS.

13-7 Abstract 24-25

Echo-guided VV and AV delay programming: impact on response to cardiac resynchronization therapy

Hanaa Fereig1, Amal Hamdy1, Ahmed Abdel-Aziz2, Mervat Nabih3, Rehab Hamdy1

1Cardiology, Al Azhar university, Cairo, Egypt; 2CCU, Cairo University, Cairo, Egypt; 3Cardiology, Ain Shams University, Cairo, Egypt

Background: Echo-Doppler is an effective method allowing immediate evaluation of cardiac efficacy in response to changing the interventricular (VV) and atrioventricular (AV) delays after cardiac resynchronization therapy (CRT). This work aimed at studying the impact of echo-guided programming of VV delay (simultaneous versus sequential) or programming of VV delay followed by AV delay on the response to CRT. Patients and methods: Thirty-four heart failure patients treated with CRT were evaluated with echo-Doppler and tissue Doppler parameters at different settings of VV delays ranging from 0 to 50 ms, followed by different settings of AV delay ranging from 80 to 150 ms. Echo-Doppler measures included ejection fraction (EF), mitral, and aortic velocity time integrals (M-VTI and Ao-VTI, respectively). Tissue Doppler dyssyn-chrony index (Ts-SD) was calculated as the standard deviation of times to peak systolic velocities (Ts) at six LV basal segments. We compared the effects of simultaneous versus sequential VV delays with LV pre-activation on these parameters without changing the preset AV delay. The effect of programming AV delay after optimizing the VV delay was further evaluated. Results: Both EF and Ao-VTI significantly decreased with simultaneous biventricular pacing compared to the basic preset VV and AV delays. The EF, M-VTI, and Ao-VTI were significantly higher and TS-SD was significantly lower at sequential VV delay with LV pre-activation compared to either basic preset VV and AV delays or simultaneous VV activation and preset AV delay. The EF and M-VTI significantly increased (p<0.001 andp< 0.005, respectively) and TS-SD significantly decreased (p< 0.005) with further programming of AV delay after VV optimization compared to only optimizing VV delay Conclusion: Sequential ventricular pacing with LV pre-activation is more beneficial than simultaneous biventricular pacing. Echo-guided optimization of both VVand AV delays has a good impact on cardiac function post-CRT.

13-8 Abstract 24-24

Biventricular pacing versus LV only pacing in congestive heart failure patients

Haitham Badran1, Samir Rania1, Mazen Tawfik1, Hayam Eldamnhory1, Mervat Aboelmaaty1, Said Khaled1 Cardiology department, Ain shams University, Cairo, Egypt

Aims: Biventricular (BiV) pacing is the most commonly used configuration to treat patients with indications for CRT as it corrects both electrical and mechanical dyssynchrony. Left

ventricular (LV) pacing may be an alternative treatment method. This study was designed to examine whether LV pacing is as safe and effective as BiV pacing in CRT for heart failure patients. Methods and results: Paired data were collected on 20 patients (18 men) with refractory heart failure symptoms(15 ischemic, 5 dilated), sinus rhythm, and LBBB with QRS duration > 120 ms. Patients were randomized to an initial 6 weeks of either BiV or LV pacing, followed by 6 weeks of the other mode, in a blinded crossover design. Echocardi-ography was used to optimize atrioventricular delay for both modes and right ventricular-left ventricular offset for BiV mode. NYHA functional class (baseline 3, BIV 2, LV 2.21), improvement in LV dimensions (EDD baseline 84.25 ± 5, BIV 82 ± 4.9, LV 82 ± 5.7, ESD baseline 75.5 ± 5, BIV 71.3 ± 4.7, LV 71.9 ± 5.8), and ejection fraction (baseline 21.9 ± 3.7, BIV 24.95 ± 4.8., LV 26 ± 3.9) did not differ between BiV and LV modes. Scores on Minnesota Living with Heart Failure Questionnaire were marginally better in LV than in BiV mode (baseline 76 ± 16, BIV 64.15 ± 12, LV 53.7 ± 17), 6-min walk distance (baseline 162 ± 49.8, BIV 240 ±51.4, LV 260 ± 50 m) was significantly better in LV only pacing P<0.01. Conclusion: In this study, we found similar reduction in LV volumes; reverse remodeling, and equivalent improvement in patients' symptoms; there were no differences in major clinical outcomes between the two modes of resynchronization.

13-9 Abstract 24-16

X-ray visualization of cathodes related to shortening of paced QRS width in patients with permanent atrial fibrillation and bifocal (BFP) or biventricular (BVP) stimulation

Barbara Malecka1, Andrzej Zabek1, Jacek Lelakowski1 Department of Electrocardiology, John Paul II Hospital, Krakow, Poland, Krakow, Poland

Background: Cardiac resynchronization therapy affects the QRS width also in patients with permanent heart stimulation. Objective: We analyzed the relationship between changes in paced QRS width and distance between cathodes. Methods: Thirty-four patients (nine women) with chronic HF, previously treated with right ventricular stimulation, were upgraded to BFP in ten pts and to BVP in 24 pts. We evaluated the influence of distance between the cathodes on the change of paced QRS width in both groups. We performed the measurements between the cathodes on thorax X-ray scans in posterior-anterior (PA) and left lateral (LL) projections recorded in DICOM format with the use of proper software. We calculated absolute, 3D distance between the cathodes (D3D). We related the achieved results to the heart size (C) in PA projection according to the following formula dDPA=DPA/C, dDL=DL/C, dD3D=D3D/C, where DPA,

dDPA, DL, dDL, D3D, and dD3D are absolute and relative distances between the cathodes in PA and LL projections and in 3D. Absolute (dQRS) and relative (dRQRS) paced QRS shortening were calculated according to the following formula : dQRS=QRS2 - QRS1, dRQRS=(QRS2 - QRS1)/QRS2, where QRS1 is a paced QRS width before the upgrade and QRS2 is a paced QRS width after the upgrade to BFP or BVP without right or left ventricular pre-excitation. Results: Differences in BFP and BVP groups were not statistically significant in terms of paced QRS width before the upgrade, size C, and cardiopulmonary index. Significantly shorter distance between cathodes in BFP group than in BVP group after upgrade, presented in lateral and 3D X-ray projections calculated absolutely and relatively, translated into significantly smaller absolute and relative QRS shortening. Conclusions: (1) Radiological 3D reconstruction is especially useful in the evaluation of distance between ventricular cathodes. (2) Distance between cathodes has a probable connection with the range of reduction of the QRS width.

13-10 Abstract 24-15

Presence of chronic renal failure and anemia confers higher mid-term mortality despite more frequent defibrillator implantation in patients receiving cardiac resynchronization therapy

Pal Abraham1, Attila Kardos1, Attila Mihalcz1, Csaba Foldesi1, Andras Temesvari1, Tamas Szili-Torok2 1Hungarian Institute of Cardiology, Budapest, Hungary; Erasmus Medical Center, Rotterdam, Netherlands

Introduction: Chronic diseases as diabetes (DM), chronic renal failure (CRF), and anemia are conditions that worsen the clinical course and mortality of chronic heart failure (HF). Data are sparse regarding the impact of these comorbidities on the outcome of CRT. Methods: We retrospectively analyzed clinical data and left ventricular ejection fraction (LVEF) of 60 consecutive patients (age 58.1 ±11.7 years, M/F ratio 4:1, DM, 24 pts, 40%; CRF, 22 pts, 37%; anemia, 10 pts, 17%) who underwent CRT-P/D implantation. Change in LVEF and NYHA class was analyzed after a mean post-implantation period of 9.6± 3.0 months, whereas all-cause mortality and change in the number of annual hospitalizations due to HF was assessed after a 3-year-long follow-up period. Results: CRF patients were significantly older (62.1±12.0 vs. 55.8± 11.1, p< 0.05), had worse initial NYHA class (3.1±0.5 vs. 2.6±0.6, p<0.01), and more hospitalizations before CRT implantation (3.4±2.4 vs.1.7±1.1, p<0.01). CRF and anemic patients received CRT-D devices more frequently (73% vs. 45%, p<0.05 and 90% vs. 48%, p<0.05). The change in

NYHA class and the reduction in hospitalizations showed clearly significant improvement (p<0.01) in all subgroups after CRT implantation. The improvement in LVEF was significant only in DM patients (DM +6.2±5.5% vs. non-DM +2.2±5.2%, p<0.05). Survival rates were not significantly different among DM and non-DM patients. CRF and anemia was associated with significantly higher mortality rates (p=0.007 and 0.01, respectively). Predictors of excess mortality were the presence of CRF, anemia, and the history of atrial fibrillation. Conclusions: Our data suggest that the response to CRT among diabetic patients was not inferior compared with non-diabetic ones. In our retrospective study, chronic renal failure and anemia were associated with worse baseline conditions and higher midterm mortality despite the more frequent use of defibrilla-tors in these subgroups.

13-11 Abstract 24-05

Evaluation of the utility for the selection of patients responder to cardiac resynchronization with a gammagraphic study with MIBG

Roberto Matia1, Prof. Antonio Madrid1, Patricia Paredes1, Oscar Gutierrez2, Jose Julio Jimenez Nacher1, Jose Luis Moya1, Jose Manuel Castro Beiras1, Concepcion Moro2 1Ramon y Cajal Hospital, Madrid, Spain; 2Medicine, Alcala University, Madrid, Spain

Introduction and objectives: Severe heart failure in most of the cases is accompanied by neurohormonal alterations and alterations of the local nervous system. With the objectives to study the innervation of the heart previous to the implant of a cardiac resynchronizator and to correlate the findings of Meta-iodo-bencil guanidine (MIBG) with the clinical and echocardiographic evolution of the patients to evaluate its effectiveness in the prediction of response, we designed the present prospective and open study. Material and methods: Twelve patients were included (age 71 ±7 years, 25% female). A complete basal study and a gammagraphy were performed (gated-SPECT) with mIBG in rest before the implant of a resynchronizator. The myocardial index of 123I-mIBG was quantified throughout the time by means of the planar and SPECT images acquired 30 min and 3 h post-injection. The index early (15 min) and delayed (2 h) heart/mediastinum as well as the index of washing or washout were calculated. Results: In a patient, we could not implant the electrode of coronary sinus (8.3%). With the criteria

of response established previously, ten (83%) patients responded to the therapy and two (17%) did not present positive response. Basal index H/M for the respondent patients was 1.46±0 for 15 min and 1.29±0.16 for 2 h. Index H/M for the two non-responder patients was not significantly different with respect to the responders from the therapy at 15 min (1.6±0.18) and nevertheless was even slightly superior at 2 h (1.58±0.07, p=0.047). In the responder patients, we found no significant differences in the percentage of washing of mIBG, being 12.7±7.4 and 0.34±15.8 in the non-responders, (p=0.11). Conclusions: Cardiac resynchronization therapy benefits a great number of patients, but it is not possible yet to preselect what candidates can benefit more with the mIBG study

13-12 Abstract 24-19

Relationship between age and major adverse cardiac events or basal blood level of NT-ProBNP and interleukin-6 in real clinical world patients on cardiac resynchronization therapy using a long-term follow-up

Laura Perrotta1, Francesco Sofi1, Simone Vignini1, Anna Maria Gori1, Fabiana Luca1, Luigi Padeletti1, Gian Franco Gensini1, Rosanna Abbate1, Antonio Michelucci1

1University of Florence, Florence, Italy

Background: The aim of the present study was to examine whether age can influence inflammatory markers and clinical outcome of real clinical world patients on cardiac resynchronization therapy (CRT). Methods: We prospec-tively studied 140 patients [112 men; 28 women; median age, 75 years (range, 49-93), III-IV NYHA class; ejection fraction (EF), 29.9±9.6%, left bundle branch block, intraventricular dyssynchrony] who underwent CRT with (n=86, 61.4%) or without defibrillator (n=54, 38.6%). We evaluated NT-ProBNP and interleukin-6 (IL-6) in each patient before CRT. Results: We analyzed two groups of patients: very old patients (>80 years, n=38) and patients <80 years (n = 102). At baseline, IL-6 and NT-proBNP proved to be significantly (p<0.05) higher in patients >80 years with respect to those <80 years [interleukin-6: >80 years, 8.74 (1.25-53.91)pg/mL vs. <80 years, 5.94 (0.67-56.13) pg/mL and NT-proBNP: >80 years, 5,040 (553.6-28,485)pg/mL vs. <80 years, 1,909 (5-32,079)pg/ mL]. At the end of a long-term follow-up (at least 3 years, max. 5 years), 92 major adverse cardiac events (heart failure death, sudden death, cardiac re-hospitalization)

occurred. No significant difference for number of adverse cardiac events was evidenced at the end of follow-up according to age. Conclusions: Even if older patients have higher levels of interleukin-6 and NT-proBNP, they do not show a risk of adverse events different from those <80 years.

13-13 Abstract 24-27

Outcomes of biventricular pacemaker upgrade

Joao Brito1, Pedro Carmo1, Diogo Cavaco1, Katya Santos1, Francisco Morgado1, Pedro Adragao1 JHospital Santa Cruz, Lisboa, Portugal

Introduction: Chronic right ventricular (RV) pacing induces left ventricle (LV) dyssynchrony with detrimental effects on LV function. On the other hand, some patients with an implantable cardioverter defibrillator (ICD) need cardiac resynchronization therapy (CRT) due to worsening heart failure (HF). This study aims to evaluate the outcomes of CRT upgrade. Methods: From 2003 to 2009, 401 patients underwent CRT in our hospital. Of these, 45 (11.2%) corresponded to upgrade from either RV pacemaker (n = 22) or ICD (n = 23). In a population with 86.7% male and a mean age of 68± 11 years, we evaluated the incidence of cardiovascular death and hospitalization due to HF as well as improvement of NYHA functional class, LV ejection fraction (LVEF), and QRS duration. Results: All the patients with previous RV pacemaker had chronic RV pacing and worsening HF. In the group of patients with ICD, the reason for the upgrade was worsening HF plus left bundle branch block (74%) or chronic RV pacing (26%). In the whole population, 46.7% had ischemic cardiomyopathy (CM), 33.3% had valvular disease, and 20% had idiopathic dilated CM. During the mean follow-up period of 26 ±23 months, there were five deaths (11.1%), of which two (4.4%) occurred due to cardiovascular cause. One patient underwent heart transplantation 65 months after the upgrade procedure. In the period of 1 year before the upgrade, 69% of the patients had been hospitalized due to HF, a number which was reduced to 13% in the period of 1 year following the procedure (p<0.0001). Mean survival free of hospitalization due to HF was 21 ±14 months. There was improvement of NYHA functional class in 82% of patients, with a mean decrease of 0.98±0.6 grades (p<0.0001). The QRS duration decreased 44.8±25.2 ms on average (p<0.0001),

and there was a mean increase of LVEF of 5.2±8% (p= 0.006). Conclusion: Upgrade to CRT shows favorable long-term outcomes, leading to improvement of functional status, with decrease of hospitalizations due to heart failure.

13-14 Abstract 24-18

Programmer ICS3000 esophageal left heart electrogram feature to measure interventricular and intra-left-ventricular conduction delay in CRT patients

Ms. Katharina Kroll1, Bruno Ismer1, Matthias Heinke2, Kirsten Rotter1, Ibrahim Akin1, Stephanie Schell-Dieckel1, Ulrich Trautwein5, Christoph Melzer3, Frank Weber4, Christoph A. Nienaber1

Kardiologie, Universitätsklinikum Rostock, Rostock, Germany; Kardiologie, Universitätsklinikum Jena, Jena, Germany; Kardiologie, Charité Berlin, Berlin, Germany; 4Kardiologie, Frankenwaldklinik, Kronach, Germany; 5Klinik für Innere Medizin Universitätsklinik Rostock

The feature for esophageal left heart electrogram (LHE) combined with the three-channel surface ECG of the Biotronik ICS3000 programmer enables quantification of ventricular desynchronization by individually measuring the interventricular (IVCD) and intra-left-ventricular conduction delay (ILVCD). Aims: The aim was to study the relations between QRS duration, IVCD, and ILVCD in patients with cardiac resynchronization therapy (CRT) for heart failure. Methods: After implantation of CRT systems in 20 patients with heart failure (15 men, 5 women, age 70.2±11.3 years.), TOslim electrode (Dr. Osypka GmbH, Rheifelden, Germany) was perorally applied and connected via PK199 cable with ICS3000 programmer to record the LHE. IVCD was measured between onsets of QRS in surface ECG and left ventricular deflection (LV) in LHE. ILVCD was measured as duration of LV in LHE. Results: In 15 patients in sinus rhythm and five in atrial fibrillation, desynchronization was quantifiable by LHE through transesophageal electrode positioned at the point showing maximal left ventricular deflection. Mean QRS was 172 ±24 ms (125-217 ms). The LHE uncovered the IVCD to be of 69±18 ms (40-108 ms) and ILVCD of 107±28 ms (52-159 ms) at mean. Correlation between IVCD and QRS was 0.12 and between ILVCD and QRS 0.69. IVCD/QRS ratio was 0.40±0.11 (0.27-0.64). Conclusions: The LHE feature of the ICS3000 programmer

enables a semi-invasive IVCD and ILVCD measurement in heart failure patients. In this study, implantation of CRT systems was linked with IVCD of 40 ms and up. As relations between QRS duration, IVCD, and ILVCD

considerably differ inter-individually, the predictive values of IVCD, ILVCD, and IVCD/QRS ratio for individual CRT response or non-response shall be identified in follow-up studies.

Session A Part 2

Issues in cardiac pacing 13-15 Abstract 21-02

Right ventricular systolic function in right ventricular pacing: a long-term evaluation

Dr. Giulia Domenichini1, Henri Sunthorn1, Eric Fleury1, Huberdine Foulkes1, Carine Stettler1, Dipen Shah1, Haran Burri1

1Service de Cardiologie, Hôpitaux Universitaires de Genève, Genève, Switzerland

Introduction: If chronic right ventricular (RV) pacing is known to impair left ventricular function, its effects on the right ventricle has not been well established, partly due to the difficulty in assessing RV systolic function in device patients (pts). Radionuclide ventriculography allows accurate quantification of right and left ventricular ejection fractions (RVEF and LVEF) in these pts. Methods: A total of 47 pts (38 men, age 77 ±6 years) requiring ventricular pacing were evaluated. Radionuclide ventriculography was performed at baseline, at about 1 year, and at long-term follow-up to assess RVEF and LVEF. Results: After a median of 1.1 years (range 0.5-1.7) of pacing, there was a significant reduction in LVEF from baseline to follow-up (54±11% and 50±13%, respectively, p=0.007), whereas RVEF was not significantly impaired (45 ±7% at baseline and 44±6% at follow-up, p=0.26). A total of 33 pts completed long-term follow-up (six pts died, eight pts dropped out). LVEF was significantly reduced at follow-up compared to baseline (see figure), whereas RVEF was not affected. Pacing site, either apical (16/33 pts) or septal (17/33 pts), did not influence RVEF at long-term follow-up. Conclusions: Contrary to a

significant reduction in LVEF, RV pacing does not result in impairment in RVEF at mid- and at long-term follow-up.

13-16 Abstract 22-05

Extraction of old broken leads with proximal ending in cardiovascular system—different difficulties, necessity of different tools and techniques

Barbara Malecka1, Andrzej Kutarski2, Agnieszka Kolodzinska3, Marcin Grabowski3

1Dept. of Electrocardiology, Jagiellonian University of Cracow, Cracow, Poland; 2Dept. of Cardiology, Medical University of Lublin, Lublin, Poland; 31 Department Of Cardiology, Medical University Of Warsaw, Warsaw, Poland

Introduction: Popular subclavian approach increases the risk of crush syndrome. It generates possibility of proximal lead ending drop-in that is the overmuch of lead's length in cardiovascular system. The consequences are as follows: arrhythmias, embolism, tricuspid valve dysfunction, and lead's external tube abrasions. Aim of study: The aim of our study was to estimate the consequences of dropped-in lead presence in cardiovascular system and to compare the effectiveness and safety of their extraction procedures. Methods: During the last 3 years, we extracted grown-in leads in 389 pts. In 24 of them, we extracted dropped-in leads due to local infection (5), endocarditis (4), and other indications (15). In both groups, the following parameters were compared: patients' age, the age of the leads extracted, external tube abrasions, the duration of the procedure, possible complications, and technical problems. Results are presented in the table. Conclusions: In our material, the patients with dropped-in leads were substantially younger than those in the control group. Extractions of dropped-in leads proved more time-consuming, however not more hazardous than other extraction procedures. Results: The results are presented in the table below:

No. of pts

Pts age (years) mean Age of oldest lead in system (month) mean Possible external tube abrasions (%) Definite external tube abrasions (%) Radiological success (%)

Major complications (%)

Minor complications (%)

Full procedure duration (min) mean

Technical problems (%)

Pts with dropped-in leads 24

3 (13%)

7 (29%)

21 (88%) 0 (0%) 1 (4%) 178

9 (38%)

Remaining P

64 0.04

88 0.02

37 (10%) 0.7

89 (24%) 0.6

339 (93%) 0.4

5 (1%) 1

7 (2%) 0.4

113 <0.0001

48 (13%) 0.004

13-17 Abstract 19-17

Initial experience with the evolution mechanical dilator sheath for lead extraction: a safe and efficacious extraction tool

Ayman Hussein1, Bruce Wilkoff1, David Martin1, Saima Karim1, Mohamed Kanj1, Thomas Callahan1, Bryan Baranowski1, Walid Saliba1, Oussama Wazni1 ICleveland Clinic Foundation, Cleveland, United States of America

Introduction: The Evolution mechanical dilator sheath is a new lead extraction tool that uses a rotational mechanism with a bladed tip to overcome fibrosis. We report the initial experience with this device. Methods: Between March 2008 (first use of Evolution) and September 2009, Evolution was used for the extraction of pacemaker (PM) or defibrillator (ICD) leads in 29 patients (41 leads). We defined success and complications according to the Heart Rhythm Society expert consensus document on lead extraction. Results: Patients' characteristics were: 79.3% male, age 64.5± 18.9 years, 44.8% with coronary disease, 31% diabetic, 34.5% hypertensive, and 44.8% had heart failure. Indications for extraction were infection in 20 patients (69%) and lead malfunction in nine patients (31%, four with lead fracture). Median implantation time was 65 months (12409 months, mean 115 months). Eighteen were atrial (43.9%) and 23 ventricular (56.1%); ICD leads in 14 patients (48.3%) and PM leads in 15 patients (51.7%). Evolution was used as first choice in 12 patients (16 leads, 39%) with 100% clinical success. Complete procedural success was achieved in 11 patients, and in one, only the distal electrode was retained. It was used for rescue when other tools failed on 25 leads (61%) in 17 patients with success, with Evolution alone in 13 of those (76.5%, short Evolution sheath (Shortie) was used in two, complete procedural success 76.9%). However, in four patients (23.5%), Evolution was useful but not sufficient (femoral workstation required in two, reuse of laser in two). In all, the Evolution system was sufficient for success in 25 patients (86.2%, 33 leads). Overall clinical success was 100%. No complications occurred. Conclusions: The Evolution mechanical sheath for lead extraction is safe, efficacious, simple to use, and cost-effective. It adds a

promising tool to the instruments available for lead extraction.

13-18 Abstract 23-02

No differences in cardiac indexes between right ventricular apex and outflow tract pacing sites over acute different AV delays measured by thoracic impedance

Christian Steinberg1, Prof. Felix Ayala-Paredes2 internal Medecine, Faculte de Medecine, Sherbrooke, Canada; 2Cardiology, Universite de Sherbrooke, Sherbrooke, Canada

Aims: The optimal ventricular pacing site in exclusive right ventricular dual-chamber pacing remains a subject of controversy. In this prospective pilot study, we performed noninvasive hemodynamic measurements in 26 patients with DDD pacemaker and normal QRS to evaluate if stimulation of different right ventricular pacing sites results in detectable short-term changes of the cardiac index. Methods: All patients were independent of their pacemaker, with 17 subjects presenting a right ventricular electrode in the apex (RVA) and nine in the right ventricular outflow tract (RVOT). Cardiac index was measured by thoracic impedance during atrial pacing/ventricular sensing (APVS), atrial sensing/ventricular pacing (ASVP), and atrial pacing/ ventricular pacing (APVP) at a rate of 80 and 100 bpm. AV delay during APVP was assessed at 20-ms intervals from 60 up to 20 ms beyond the intrinsic AV delay. Each measurement of cardiac index took 30 s, and a mean value was obtained. Results: In the group of RVA pacing, a very short to low normal AV delay led to a significant higher cardiac index compared to APVS and ASVP at a rate of 80 bpm and to ASVP at a rate of 100 bpm. RVOT-APVP resulted over a larger range of AV delay in a significantly higher cardiac index compared to ASVP at rates of 80 and 100 bpm. No differences in the cardiac index were found between RVA- and RVOT-APVP over the dynamic range of AV delay. Conclusion: Thoracic impedance is sensitive to detect acute changes of cardiac index according to different pacing modalities. RVA and RVOT dual-chamber pacing are superior to ASVP single-chamber pacing at either site. Short-term dual-chamber pacing with right ventricular stimulation at the apex or in the right ventricular

outflow tract leads to equivalent changes of myocardial contractility.

13-19 Abstract 23-04

Which patients to upgrade from VVI to DDD pacing: role of left atrium size and function

Dragos Cozma1, Lucian Petrescu1, Dan Gaita1, Dan Lighezan1, Stefan Iosif Dragulescu1

institute of Cardiovascular Medicine, Timisoara, Romania

Background: A significant proportion of pacemakers currently implanted are VVI, and controversy of cost-effectiveness is still debatable. Usually, DDD pacing recipients are more likely to be younger, but pacemaker syndrome is a crucial factor. Aim: The aim of the study was to assess who benefits from DDD upgrading from VVI pacemakers in the treatment of bradycardia due to sick sinus syndrome and atrioventricular block by assessing main echocardiographic characteristics, left atrium (LA) size, and function. Methods: One hundred twenty-four consecutive pts (65 men) aged 53 ±17 years implanted with VVI pacing system and atrial sinus rhythm were included. Main echocardiographic parameters were assessed including left ventricular ejection fraction (LVEF), wall thickness, LA volume (LAV), and function. Results: Eleven pts (seven women) aged 65.5±6.7 years presented over time severe congestive heart failure (after a follow-up of 10.5±4.5 months after first implantation). The symptoms and findings of congestive heart failure were refractory to medical treatment and resolved with the upgrade of the VVI to a DDD system. The average LVEF was 43±6%. LAV was 87± 12 ml. LV hypertrophy and diastolic dysfunction were present in all patients. Three pts had permanent ventriculo-atrial retrograde conduction. After DDD pacing, diastolic filling was improved and atrial contribution characteristics showed significant contractile function, with no patient presenting restrictive pattern (mitral conventional Doppler, TDI, and LA active ejection fraction). In younger pts with normal left ventricular function, the lack of atrial contraction had little effect on cardiac function and no pacemaker syndrome was found. Conclusions: Older patients with LV hypertrophy and mild LV systolic and diastolic dysfunction but preserved LA function needed DDD upgrade; in the presence of early LV dysfunction, the absence of atrial

contraction while VVI pacing causes pacemaker syndrome because atrial conduit function is unable to provide compensatory ventricular filling.

13-20 Abstract 23-05

Tracheostomy to pacemaker pocket fistula: an unexpected late complication

Dr. Javier Banchs1, Jerry Luck1, Erica Penny-Peterson1, Soraya Samii1, Deborah Wolbrette1, Mario Gonzalez1, Gerald Naccarelli1

Penn State Hershey Heart & Vascular Institute, Hershey, United States of America

System infection and erosion are well-recognized complications of implantable cardiac rhythm management devices. Fistulas between the venous and the arterial system or airway have been described. Communication between the device pocket and the skin is usually the product of device or lead erosion. We describe a case of a fistula between the device pocket and a recent tracheostomy 2 years after the original pacemaker (PPM) implant. The patient was an 81-year-old man with severe aortic stenosis and atrial fibrillation when he underwent aortic valve replacement followed by a ventricular PPM implant. Recovery was satisfactory with no complications. Two and a half years later, the patient presented with squamous cell carcinoma of the base of the tongue requiring a tracheostomy, chemotherapy, and radiation therapy. Four months later, the patient presented with fever and change in mental status. A skin opening with drainage at the tracheostomy site was found. Manual pressure on the PPM pocket resulted in air and fluid emanation from the tracheostomy opening. CT of the chest (figure) showed a sinus tract extending from the tracheostomy site anteriorly to the right chest wall muscles with subcutaneous emphysema anterior to the clavicle and the first rib communicating to air found in the PPM pocket. Due to the underlying advanced metastatic cancer and general deterioration of the patient's health, conservative management with chronic antibiotics was decided. Fever and systemic signs of infection subsided. The patient was referred to hospice care until his death 2 months later. To our knowledge, this is the first description of a fistula extending from a tracheostomy to a PPM pocket. With

expanded indications for cardiac rhythm management devices and improved life expectancy, more patients with multiple comorbidities are expected to receive device

implants. The use of a protective pocket envelope may need to be considered in patients at increased risk of infection or erosion.

13-21 Abstract 22-01

Pacemaker recall—a single-center experience

Moti Haim1, Jairo Kuznietz1, Ronit Zabarsky1, Yosef Perek1, Boris Strasberg1

1Cardiology Department, Rabin Medical Center, Petach-Tikva, Israel

Background: In May 2009, Medtronic (MDT) issued an advisory warning for certain subsets of pacemakers (PM) due to "separation of wires that connect the electronic circuit to other pacemaker components". Objective: The

objective of this study was to describe the management of this advisory in our institution. Methods: The method used is retrospective analysis of charts. Results: Eighty-six pts were identified with the affected PMs (45 women). The indications for PM were: heart block (49), sinus node dysfunction (21), and slow atrial fibrillation (7). Forty-two pts were PM-dependent. Thirty-seven pts died prior to issuing of this recall. Of the 42 dependent pts, 19 had died before the advisory, and six had their PM replaced before the advisory. Thirteen had their PM replaced in response to the advisory. Of the 44 non-dependent pts, five were scheduled for PM replacement. One patient with complete AV block was admitted with syncope and with an escape

rhythm of 20/min. A temporary PM was inserted and he later had his PM changed with no further complications. A second pt had her PM changed in response to the recall and was readmitted a week later with syncope and bradycardia. During a lead revision, a break was found on the insulation and a new electrode was implanted in the right ventricle. Conclusions: Of 86 pts from the relevant series, two pts (2.3%) were adversely affected by the recall: one with a malfunction of electrode and one with a complication of PM change. Eighteen of the 86 (21%) had (or were planned to have) their PM changed.

13-22 Abstract 09-01

Takotsubo cardiomyopathy—a rare complication of dual-chamber pacemaker implantation

Moti Haim1, Gabriel Greenberg1, Boris Strasberg1 1Cardiology Department, Rabin Medical Center, Petach-Tikva, Israel

Background: Takotsubo Cardiomyopathy (TC) is a rare condition that was seldom described as a complication of pacemaker (PM) implantation (four cases in Medline) and always in pts that required ventricular pacing. Objectives: The objective of the study was to describe a case of TC complicating PM implantation in a pt with sinus node disease and only atrial pacing. Methods and results: A 74-year-old woman was admitted for PM implantation to allow medical rate control of her paroxysmal atrial fibrillation. Twelve hours after having a dual-chamber PM implantation which was uneventful, she complained of chest pain and shortness of breath, and the ECG showed ST elevation and giant T-wave inversion in the precordial leads. An urgent echocardiogram revealed apical dyskinesis (Fig. 1) and apical ballooning. An urgent coronary angiography was normal, but left ventriculography revealed findings similar to those seen in the echocardiogram. She was treated with beta-blockers, angiotensin-converting enzyme inhibitors, and fluids. Within several hours, her symptoms subsided, and several days later, the ECG normalized to baseline and so was her echocardiogram. Of interest is that previous cases of acute TC after PM implantation involved PM-dependent pts with continuous right ventricular pacing. In contrast, in the present case only, the patient was exclusively paced in the right atrium. Conclusions: TC is a very uncommon complication of PM implantation. However, in pts presenting with the appropriate symptoms and electrocardiographic features, it should be considered and followed by appropriate imaging and medical therapy. This case demonstrates that TC can occur even with PM with only atrial pacing.

Part 2 (Cont.) Mechanisms of syncope 13-23 Abstract 10-01

Vasovagal syncope interrupting sleep: description of a series of patients with an unusual condition

Filippo Rabajoli1, Catia Checchinato1, Cosimo Tolardo1, Massimo Bonzanino , Alberto DeBernardi , Maria Teresa Spinnler1

1Cardiology, S.Croce Hospital Moncalieri, Turin, Italy;

Neurology, S.Croce Hospital, Moncalieri, Turin, Italy

Introduction: Sleep syncope is a seldom-described form of vasovagal syncope (VVS) which interrupts sleep. We describe the clinical presentation and treatment of a group of patients (pts) affected by recurrent episodes of waking from sleep with abdominal discomfort, followed by syncope also in supine position. Results: six pts were selected out of 2,130 pts (0.28%, 5 women/1 men, age 54.1 years).Clinical data are shown in Table 1. All the pts have also daytime VVS. Instrumental data and treatment are shown in Table 2. Only two pts have positive tilt test (33%). EEG was negative in five and abnormal in one (normal EEG after 2 years). Loop recorder demonstrated asystolic pause of >5 s during a recurrence in one patient. Pacemaker (PM) was implanted in two (asystole documented by loop in one, by tilt test: 13 s in the other). PM was effective on symptoms. Counter pressure maneuvers gave partial benefit in two out of three pts. Discussions: Nocturnal syncope seems to be a particular form of VVS with great discomfort for pts. Pathophysiology is not clear, particularly if abdominal discomfort is an effect rather than a cause of vasovagal reflex. Conclusions: Pts with sleep vasovagal syncope are a rare group of patients, particularly

women, with frequent recurrences. When tilt test and loop recorder demonstrated cardio-inhibitory reflex: PM implant had a good impact on symptoms. Counter pressure maneuvers could be partially helpful.

13-24 Abstract 07-10

Syncope after myocardial infarction has frequently

several causes

Sellal Jean Marc1, Aliot Etienne1, Dr. Béatrice Brembilla-

Perrot1

1Cardiology CHU of Brabois, Vandoeuvre les Nancy, France

Background: Syncope after myocardial infarction (MI) can be related to a ventricular tachycardia (VT). However, multiple other causes have been reported. The mortality after ICD implantation remains relatively high. The purpose of study was to evaluate the main causes implicated in syncope after MI. Methods: Three hundred fifty-eight patients (pts), 302 men and 56 women consecutively admitted for syncope and history of MI (>1 month), without VT underwent echocardiography, Holter monitoring, head-up tilt test, exercise testing, signal-averaged ECG, electrophysiological study (EPS), and evaluation of coronary status. They were followed 4±2 years. Results: The presumed cause was a ventricular arrhythmia in 151 pts (monomorphic VT, 88; ventricular flutter or fibrillation (VF), 63), a supraventricular tachyarrhythmia (SVT) in 39 pts, and a conduction disturbance in 23 pts. Fifty-seven pts had several electrophysiological abnormalities, 26 pts had inducible VT or SVT and coronary ischemia, and hyper-vagotonia was noted in eight pts with induced VT or SVT. In the case of negative EPS, coronary ischemia alone was identified in 39 pts and hypervagotonia in 27 pts. All studies were negative and syncope remains unexplained in 84 pts (23.5%), mainly women (p<0.001, 27% vs 20% ***). Male gender (90% vs 80%**), a longer QRS duration (139±31 vs 115±28 ms**), a lower ejection fraction (EF, 36±11.5% vs 46±12%***), and grade IVa, b of Lown on Holter ECG (53% vs 31.5%***) were associated with the induction of VT. EF<40% and VT/ VF induction were predictors of cardiac mortality, VT predictor of sudden death, and low EF and advanced age predictors of death by heart failure. Conclusions: Several causes were frequently implicated; complete evaluation remains necessary. Coronary ischemia was present in 18% of pts with syncope after myocardial infarction; it was the only cause in 11% of our population. Syncope remained unexplained more frequently in women than in men. Hypervagotonia explains syncope in only 8% of our population.

13-25 Abstract 10-02

The role of biofeedback in the treatment of vasovagal syncope

Michela Madalosso1, Franco Giada1, Arianna Di Natale2, Giulia Buodo , Daniela Palomba , Antonio Raviele

Ospedale dell'Angelo, Mestre, Italy; Generale Psychology, University of Padua, Padova, Italy

Introduction: Biofeedback treatment, a behavioral training program that enables an individual to gain voluntary control over an autonomic bodily function, using feedback provided by a monitoring device has been proposed for the treatment of patients (pts) with blood injury phobia. The aim of this prospective, randomised, placebo-controlled study was to evaluate the efficacy of biofeedback treatment in pts with recurrent vasovagal syncope (VVS). Methods: We studied 20 consecutive pts (mean age 34±10 years, 65% females) with recurrent VVS (median 5.5 syncopal episodes), positive head-up tilt testing and no other comorbidities. Pts were randomised 1:1 to biofeedback treatment (biofeedback-assisted heart rate stabilisation using Biofeedback 2000 X-PERT version 1.0 -V SCHUHFRIED GmbH) or to placebo (educational counseling) with one visit a week for 5 weeks and were followed up for at least 1 year. Results: No significant differences in baseline clinical characteristics and syncopal frequency were found between the active and placebo groups. The median follow-up was 13 ±1 months. The mean number of syncope during follow-up was significantly lower, and the percentage of pts with at least one syncopal recurrence was slightly lower, although not statistically significant in active group with respect to the placebo group (0.1 ± 0.31 vs 0.5±0.52, p= 0.0008; 40% vs 60%, p=ns). Conclusions: The results of this preliminary study suggest that the biofeedback treatment might be proposed as a non-pharmacological therapeutical approach in very symptomatic vasovagal fainters.

13-26 Abstract 11-01

Endothelial function in patients with vasovagal syncope

Mateusz Wnuk1, Artur Pietrucha1, Ewa Wojewodka-Zak1, Irena Bzukala1, Wieslawa Piwowarska1, Jadwiga Nessler1 department of Coronary Heart Disease Institute of Cardiology, John Paul II Hospital, Cracow, Poland

The aim of study was the evaluation of endothelial function measured by flow-mediated dilation of brachial artery in young patients with suspected vasovagal syncope. Study population: We observed 22 pts (7 men, 15 women) aged 17-41 years (mean age 28.7 years) with suspected vasovagal syncope

referred to head-up tilt test (HUTT), without any concomitant disorders. All patients underwent standard head-up tilt test (acc. to Westminster protocol) and evaluation of flow-mediated dilation of right brachial artery assessed by ultrasound vessel examination. Flow-mediated dilation (FMD) and endothelial-independent dilation (EID) of brachial artery were also evaluated, as well as FMD/EID ratio. All measured parameters were compared according to HUTT results. Results: HUTT was positive in 17 pts (77.3%). Mean values of FMD (15.7% vs 4.9%, p<0.02), EID (29.3 vs 14.6%, ^<0.01), and FMD/ EID ratio (0.53 vs 0.34) were significantly higher in patients with positive result of HUTT. There were no significant differences before the type of vasovagal response to ortho-static stress during HUTT. Conclusions: Higher reactivity of both endothelium-dependent and endothelium-independent brachial artery dilation was observed in patients with vasovagal syncope and positive result of head-up tilt test.

13-27 Abstract 13-03

Electrophysiological significance of syncope in Wolff-Parkinson-White syndrome

Zahra Emkanjoo1, Amir Aslani1, Siamak Kazemi1, Amir Tavoosi1, Mazdak Khalili1, abolfath Alizadeh1, Mohammad Sadr-ameli1

IRajaie Cardiovascular, Medical and Research Centre, Tehran, Iran (Islamic Republic of)

Background: Syncope in patients with Wolff-Parkinson-White (WPW) syndrome may be related either to a rapid rate of reciprocating supraventricular tachycardia or to rapid ventricular response over the accessory pathway during atrial fibrillation (AF). The aim of this retrospective study was to define the incidence of syncope in a population of patients with WPW syndrome and to compare electrophysiological findings of patients with a history of syncopal episodes with those of patients without syncope. Methods: We reviewed the records of 150 consecutive patients with Wolff-Parkinson-White syndrome. There were 20 patients (13.3%) who reported at least one episode of syncope and 130 patients (86.7%) without a history of syncope. All patients underwent electrophysiologic study. Results: Short tachycardia cycle length during electrophysiological testing was the only predictor of syncope occurrence in WPW patients (P= 0.01). Occurrence of syncope was not related to the age, incidence of congenital heart disease, frequency of supra-ventricular tachycardia, incidence of multiple accessory pathways, or pathway location. Conclusion: Patients with WPW and syncope did not demonstrate a more malignant electrophysiological profile than patients without this symptom.

FRIDAY APRIL 16, 2010, 2:00 pm-5:00 pm Chaired Poster Session B Part 1. Ablation of atrial fibrillation 14-28 Abstract 18-21

Atrial fibrillation ablation with therapeutic INR: a safe strategy

Martha Bouzin1, Diogo Cavaco1, Pedro Adragao1, Leonor Parreira , Katya Reis-Santos , Pedro Carmo , Susana Marcelino , David Cabrita , Miguel Abecasis Arrhythmia Unit, Hospital da Luz, Lisbon, Portugal

The best strategy for managing anticoagulation at the time of atrial fibrillation ablation is not defined. Most centers choose to interrupt oral anticoagulation a few days before the procedure and restart it the day after. Low-molecular-weight heparin is used in the peri-ablation period and maintained until a therapeutic INR is again achieved. Goal: The goal of this study was to evaluate the security of maintaining oral anticoagulation (INR within therapeutic range) during the atrial fibrillation ablation procedure when compared with the conventional strategy. Population/methods: We evaluated two groups of patients in a total of 163 atrial fibrillation ablation procedures performed from July 2007 to December 2009 according to the INR value on the day of the procedure. Group A (n = 106) included patients who were not on warfarin and those who had stopped it and had an INR below 1.8. Group B (n=57) encompassed patients who had INR >1.8 (and <3) on the day of the procedure. All patients underwent transesophageal echocardiogram or cardiac Angio-CT to exclude thrombi on the left atrium up to 24 h before the ablation. For all, the procedure consisted on percutaneous isolation of pulmonary veins with magnetic navigation system (NIOBE) guided by electroanatomical mapping and a LASSO catheter. Periproce-dural embolic/hemorrhagic complications were compared in both groups. Results: One vascular complication occurred in group A (femoral pseudo-aneurysm with the need of surgical intervention) and none on group B. There were no cases on any of the groups of cardiac tamponade, stroke, or major bleeding. Conclusion: Maintenance of oral anticoagulant drugs during pulmonary veins isolation is safe and effective

in our experience. This strategy can be an alternative to the use of low-molecular-weight heparin, keeping stable levels of anticoagulation during and after the procedure, simplifying hospital discharge and reducing risks of insufficient or excessive levels of anticoagulation.

14-29 Abstract 15-05

Localization of foci of focal atrial tachycardia after atrial fibrillation ablation can be predictable by CFE (continuous fractionated electrograms) and DF (dominant frequency) mapping findings

Shigeru Ikeguchi1, Shinsaku Takeda1, Yuzo Takeuchi1, Yoshitaka kawata , Takeshi Harita , Mitsuru Ishii , Masaharu Okada1, Tatsuhiko Hata1, Kunihiko Kosuga1 1Cardiology division, Shiga Medical Center for Adult, Moriyama, Japan

Background: Continuous fractionated electrograms (CFE) and dominant frequency (DF) are useful markers for substrate of atrial fibrillation (AF). However, the relationship between CFE or DF and origin of atrial tachycardia after AF ablation is not well demonstrated. Method: Seven patients of persistent atrial fibrillation underwent ablation procedures (pulmonary vein isolation and CFE-guided ablation). Before radiofrequency current application (RFCA), CFE mapping was performed using EnSite CFE and DF mapping software. After PV (pulmonary vein) isolation and CFE ablation, AF was terminated by RFCA or electrical defibrillation. After RFCA, isoproterenol infusion and electrical stimulation were performed to re-induce AF or AT (atrial tachycardia). Result: AF was terminated during PV isolation in one patient and in three patients by CFE ablation. CFE and DF mapping in left atrium demonstrated multiple sites of short CFE mean cycle length (CFECL) and high DF. The sites with AF termination showed shortest CFECL and highest DF (49± 11 ms and 12.9±0.8 Hz, respectively). After AF termination, AT was inducible in four patients and AF was inducible in two patients. The foci of the atrial tachycardia was located at the high DF (11.9 ±1.3 Hz) and short CFECL (56±13 ms) sites in three patients. Sites without AF termination or sites not close to AT foci showed low DF (6.3±2.7 Hz) and long CFECL (78±22 ms). Moreover, at these AT foci with high DF and short CFECL,

burst pacing could induce AF or AT. After additional RFCA at these sites, AT or AF could be no longer inducible. Conclusion: CFE and DF analysis are useful options to search

AT foci after AF ablation. CFE ablation might help in the eradication of the AT after AF ablation as well as the elimination of AF substrates.

Pie PVI Dominant Frequency Map

Low Frequency 4Hz. High Frequency 11 Hz

Site A: AF termination site. Site B: Focus of AT

14-30 Abstract 18-14

Coumadin cessation after successful atrial fibrillation ablation

Ayman Hussein1, Seby John1, Tchou Patrick1, Thomas Dresing1, Mohamed Kanj1, Walid Saliba1, Bruce Lindsay1, Andrea Natale1, Oussama Wazni1

1Cleveland Clinic Foundation, Cleveland, United States of America

Introduction: Little is known about Coumadin cessation in patients with no documented arrhythmia recurrence in the year after pulmonary vein isolation (PVI). We aimed to determine the safety of stopping Coumadin after a successful PVI. Methods: We included all 513 patients who underwent PVI in 2005 and remained arrhythmia-free at 1-year follow-up. Patients were divided into two groups based on whether Coumadin was stopped (group 1) or not (group 2) in the absence of documented recurrence. Results: Of 513 patients with successful PVI, Coumadin was stopped in 386 patients (75.2%). Patients in both groups had similar ejection fraction (53.2% vs. 53.1%, p=0.89), left atrial size (22.6 vs. 24.4 cm2, p=0.097), and similar distribution of gender (men 79.7% vs. 76.2%, p=0.33), hypertension (35.4% vs. 32.0%, p=0.39), and coronary disease (14.6% vs. 14.4%, p=0.96). However, when compared to patients in group 2, patients in whom Coumadin was discontinued were younger (56.3±10.0 vs. 61.9±8.8 years, p<0.0001), had less diabetes (4.9% vs. 9.9%, p=0.038), lower CHADS2 score (0.66 vs. 1.4, p<0.001), and less non-paroxysmal AF

at baseline (19.6% vs. 35.3%, p<0.0001). No patients with a stroke history were considered for Coumadin cessation. Over a median follow-up of 44 months (range 35-46), only one patient (0.23%) had an ischemic stroke (70 years old, with hypertension, paroxysmal AF, left atrial scarring, and was off Coumadin) with minimal residual deficit. Conclusions: Over a follow-up of more than 3.5 years, the occurrence of stroke in patients with no arrhythmia recurrence in the year after PVI was very low. Careful selection of patients (young, non-diabetic, no stroke history, low CHADS2, paroxysmal AF) allowed safe discontinuation of Coumadin in a substantial proportion of patients with successful PVI. Further studies will help better stratify patients in whom Coumadin can be discontinued.

14-31 Abstract 15-13

A new numerical method to quantify pulmonary vein potential parametric distribution

Mervat Abou Al Maaty1, Ahmed Nassar1, G Shaaban2, M ElMaghawry2, H Damanhoury1, R Samir1

Cairo, Egypt; 2Heart, National,

Iain Shams university, Cairo, Egypt

Introduction: Identification of pulmonary vein potentials (PVPs) using a circular decapolar electrode catheter still represents the most crucial point in ablation of atrial fibrillation (AF). There is no unified protocol for the description of PVP distribution around the PV Ostia. Aim

of study: This study was planned to postulate a new quantitative method for the description of PVP distribution around each PV before RF PV isolation during ablation of AF. Patients and methods: This study was conducted on14 pts who had paroxysmal AF and were set to undergo PV isolation using a conventional circular decapolar electrode mapping catheter to guide RF ablation. It was decided to postulate a new method to quantify the distribution of PVPs around the circumference of the PV Ostia. The parametric distribution of PVPs was given a number out of 10, indicating the number of electrodes recording PVPs. This was done during sinus rhythm while the mapping catheter was placed at the most stable position around the PV Ostia. Results: Left superior PV (LSPV) was found inll pts (78.57%), left inferior PV (LIPV) in 11 pts (78.57%), right superior PV (RSPV) in 14 pts (100%), and right inferior PV (RIPV) in 12 pts (85.71%). Left common trunk (LCT) was found in three pts (21.43%). During Ostia mapping of PVs, PVPs were present at variable percentages of the Ostial circumference, reflecting the parametric distribution of LA-PV muscular connections. There was a significant difference between the distributions of the PVs (F=4.91, p= 0.03). The LSPV PVPs were found to be significantly denser than the RSPV (p=0.07) and RIPV (p<0.001) PVPs. The LIPV PVPs were significantly higher than the RIPV PVPs (p=0.009). There was no significant difference in the parametric distribution of PVPs in LSPV and LIPV or LCT. Age, sex, or the duration of AF history did not affect the density of PVPs. Conclusions: PVP distribution around the PV Ostia can be quantified numerically. The parametric distribution of PVPs is higher at the left PVs than at the right ones.

14-32 Abstract 15-10

A speckle tracking study for the evaluation of atrial function after surgical ablation of atrial fibrillation

Elisa Rondano1, Miriam Bortnik2, Eraldo Occhetta2, Giovanni Teodori , Philippe Primo Caimmi , Paolo Nicola Marino2

Cardiology Unit, St. Andrea Hospital, Vercelli, Italy;

Clinical Cardiology, Maggiore Hospital, Novara, Italy;

Cardiosurgical Department, Maggiore Hospital, Novara, Italy

Purpose: AF surgery has become more engaged in everyday practice of cardiosurgical centres, and the development of novel echocardiographic technique has enhanced our ability to assess myocardial function. The aim of our study was to evaluate the usefulness of speckle tracking to assess atrial function in patients (pts) who underwent AF surgical ablation. Methods: From February 2006 to April 2008, in

11 pts with paroxysmal AF (six men, mean age 69.6± 9.7 years) undergoing mitral (four pts) or aortic valve (one pt) replacement, mitral valve repair (five pts) and coronary artery bypass (one pt), concomitant AF surgical ablation with linear atrial lesions was performed. These pts, all in sinus rhythm, were echoed after a mean follow-up of 14.6± 9.3 months. Speckle tracking was used to estimate global left atrial (LA) strain. We evaluated, also, LA volume, trans-mitral pulsed wave Doppler (MPWD) and pulmonary venous flow velocities. Results: These pts showed a mild LA enlargement (mean volume indexed to body surface area 43.4 ±11.6 ml/m2). In five of them (45.4%), no A waves were detected on MPWD and on pulmonary flow, but speckle tracking showed preserved atrial function with a mean global strain of 5.9±3.4%. Conclusions: The development of speckle tracking has enhanced the ability to assess regional myocardial function noninvasively. Our study seems to confirm that surgical AF ablation preserves atrial function as documented with strain value even if in 45.4% of cases, no atrial activity could be detected with conventional evaluation (MPWD and pulmonary venous flow). This is probably related to a higher sensitivity of this type of evaluation, but this finding must be confirmed by other trials.

Patients E wave A wave TD E A Strain

(m/s) (m/s) (ms) pulmonary (cm/s) pulmonary (cm/s) tot (%)

1 65 NO 210 59.2 NO 6.46

2 118 38 443 48.6 32.8 6

3 114 52 280 65 25.9 3.53

4 58 33 148 43.7 43.1 7.51

5 98 78 230 54.8 34.6 11.35

6 138 NO 320 63.9 NO -0.28

7 87 NO 178 74.8 NO 4.05

8 90 NO 220 70.2 NO 2.39

9 132 NO 316 43.9 NO 5.9

10 97 75 240 51 33.7 8.7

11 125 80 316 68.9 23.7 9.7

Table 1. Evaluation of atrial function with MPWD, pulmonary venous flow velocities and speckle tracking

14-33 Abstract 18-22

Magnetic navigation ablation of atrial fibrillation: single-center experience

Diogo Cavaco1, Pedro Adragâo1, Martha Bouzin1, Pedro Carmo , Leonor Parreira , Katya Reis-Santos , Susana Marcelino , David Cabrita , Miguel Abecasis Arrhythmia Unit, Hospital da Luz, Lisbon, Portugal

Percutaneous isolation of pulmonary veins is a first-line therapy for the treatment of drug refractory paroxysmal/ short-term persistent atrial fibrillation. Recently, technological advances allow this treatment to be performed semi-automatically. The goal of this study was to report our experience with the Magnetic Navigation System (MNS; NIOBE, Stereotaxis) in the ablation of atrial fibrillation. Population/Methods: Between June 2007 and November 2009, we performed 157 ablations of atrial fibrillation with the MNS. Of the patients, 78% were male. The mean age of the population was 56 years. Seventy percent had paroxysmal atrial fibrillation. Results: Complete isolation of the pulmonary veins (confirmed with a Lasso catheter) was possible in 97%. An 8-mm tip ablation catheter was used in 53% and an irrigated tip (NAVISTAR-THERMOCOOL-RMT) catheter in the remainder. A 0.08-T magnetic field was used in 83% and a 0.1-T magnetic field in the remainder. The mean duration of the procedures was 2 h and 30 min. The only complication was a femoral pseudo-aneurysm. There were no pericardial effusions or strokes. In a mean follow-up of 9±5 months, 72% were free of atrial fibrillation (symptoms and 24-h Holter recording). In our experience, the MNS is safe and effective in isolating pulmonary veins, allowing a successful ablation of atrial fibrillation with a low rate of complications.

14-34 Abstract 15-26

A fixed approach for catheter ablation of chronic atrial fibrillation

Sang Cai-Hua1, Dong Jian-zeng1, Liu Xing-peng1, Yu Rong-hui1, Long De-yong1, Tang Ri-bo1, Ning Man1, Jiang Chen-xi , Ma Chang-sheng

Department of Cardiology, Beijing Anzhen Hospital, Beijing, China

Introduction: Stepwise ablation is an effective approach for catheter ablation of chronic atrial fibrillation (AF). This study is to report a fixed approach for catheter ablation of chronic AF. Methods: Consecutive 100 patients with persistent AF underwent catheter ablation guided by CARTO system. Circumferential pulmonary veins isolation (PVI) was performed followed by complex fractionated atrial electrogram (CFAE) ablation in the first 50 patients (group A) or additional atrial linear ablation including left atrial roof, mitral isthmus (MI), and cavotricuspid isthmus (CTI) with an endpoint of bidirectional conduction block in the second 50 patients (group B). All the organized atrial tachycardias (ATs) were mapped and ablated in group A, and only the induced AT was ablated after linear block was

achieved at all the ablated lines in group B. Results: There were no differences in baseline characteristics between group A and B. Both the procedure duration (227 ± 68 vs 146 ± 45 min) and fluoroscopy time (47 ± 12 vs 36 ± 14 min) were longer in group A (all p < 0.05). More ATs were mapped and ablated (2.2 ± 1.1 vs 0.3 ± 0.1, p < 0.05) in group A during the ablation procedure. PVI was successful in all the patients. Linear block was achieved in all the ablated lines except three at the MI and one at the CTI in group B. Twenty-three (46%) in group A and 33 (66%) in group B remained in sinus rhythm in the absence of antiarrhythmic drugs at the 12-month follow-up (p < 0.05). The occurrence of procedure-related LA conduction delay was 26% in group A and 0 in group B. Conclusion: The ablation strategy, PVI plus atrial linear ablation at the LA roof, MI, and CTI, is fixed, simple, physiologic, and effective for catheter ablation of chronic atrial fibrillation.

14-35 Abstract 18-15

Ablation of atrial fibrillation with magnetic navigation system: comparison of different types of catheters

Pedro Carmo1, Diogo Cavaco1, Katya Santos1, Leonor

Parreira1, Pedro Adragao1

1Cardiology, Hospital da Luz, Lisboa, Portugal

Introduction: Ablation of atrial fibrillation (AF) using magnetic navigation (MN) with non-irrigated catheters (NIC) showed to be not inferior to conventional ablation. Moreover, irrigated catheters (IC) are more effective than NIC. Objective: The objective of this study was to compare the efficacy of IC and NIC in AF ablation with MN in our centre. Methods: We studied 165 consecutive AF ablations preformed in our center using MN (Stereotaxis, Inc). The first 18 cases (all NIC) were excluded since they belong to our early learning curve of MN. Comparison was made between 62 cases performed with NIC (8-mm Navistar RMT) and 85 cases with IC (Navistar Thermocool RMT). The procedures consisted of bilateral isolation of pulmonary veins (IPV) confirmed by duodecapolar circular catheter. The procedure time, time of fluoroscopy exposure, time of electroanatomic map (CARTO) construction, time of total CARTO use, and time of radiofrequency application (RF) were compared between the two groups. Results: There were no differences in baseline characteristics or AF type between groups. The complete IPV was achieved in 59 of 62 (95%) cases with NIC and in all cases with IC (p= 0.07). All times evaluated were shorter in the IC group (total procedure, 226±47 vs 293±71 min, p<0.001;

fluoroscopy exposure, 16±7 vs 33± 13 min, p<0.001; CARTO map construction, 19 (15, 25) vs 26 (22, 32)min, p=0.001; total CARTO use, 133±35 vs 173±51 min, p< 0.001; RF application, 57±19 vs 78±25 min, p<0.001). There were no cardiovascular or neurological complications. The AF recurrence at the first year of follow-up was 22/125 = 18% and was similar for the two groups (NIC, 21% vs IC, 14%). Conclusions: The MN ensures a high rate of pulmonary vein isolation with no complications in this population. IC has been as effective as NIC with a significant reduction of the procedure duration.

14-36 Abstract 15-31

Early and late arrhythmia recurrence following catheter ablation of atrial fibrillation

Gergely Klausz1, Robert Pap1, Gabor Bencsik1, Attila Makai1, Laszlo Saghy1, Tamas Forster1 12ndDep. of Internal Med., Cardiological Center, University of Szeged, Faculty of Medicine, Szeged, Hungary

Introduction: The significance of early arrhythmia recurrences after atrial fibrillation (AF) ablation is controversial. We investigated the relationship and the predictors of early and late AF recurrences. Methods and results: Fifty consecutive patients with drug refractory, symptomatic paroxysmal (78%), or persistent (22%) AF were included. Pulmonary vein isolation with or without additional linear ablation was performed in all patients. Early recurrence, defined as AF or regular atrial tachycardia in the first 8 weeks after ablation, occurred in 47% of patients, while 24% had late arrhythmia recurrence beyond this period. Patients with and without early recurrence did not differ in baseline clinical variables except for a larger left atrial diameter in patients with early recurrence (53 vs. 46 mm, p=0.037). Patients with late recurrence more commonly had early recurrent AF (80% vs. 31%, p=0.007), tended to be older (60 vs. 52 years, p=0.031), and more likely to have significant valvular disease and persistent AF (30% vs. 3%, p=0.036 and 40% vs. 13%, p=0.053) than patients without late AF. Late recurrence occurred in 44% of patients with early arrhythmias compared to only 8% in patients without early recurrence. Multivariable logistic regression analysis identified age and early recurrence as independent predictors of late recurrent AF (p=0.036 andp= 0.005, respectively). Conclusion: Arrhythmia recurrence in the first 8 weeks after catheter ablation of AF is experienced by almost 50% of patients, especially those with large left atria. Although more than half of these patients can be AFfree after this period, early recurrence of AF after ablation makes long-term success much less likely.

14-37 Abstract 15-27

Efficacy and safety of epicardial ablation of canine pulmonary veins with ethanol

ManNing1, Sang Cai-Hua1, Tang Ri-bo1, Miao Cheng-long1, Dong Jian-Zeng1, Dong Jian-Zeng1

1Beijing Anzhen Hospital, Beijing, China

Introduction: Percutaneous endocardial pulmonary vein (PV) isolation using radiofrequency (RF) current has become an effective treatment for atrial fibrillation (AF). However, this technique is associated with a significant risk of PV stenosis, perforation, and conduction recurrence. The aim of this study was to identify the efficacy and safety of epicardial PV ablation with ethanol and explore a new energy source for catheter ablation of AF. Methods: Twelve mongrel dogs were randomized into ethanol ablation group and control group. In ethanol ablation group (n=6), encircling injection was performed using a 1-ml injector to circumferentially ablate the root of each PV (0.2 ml each site, 3 mm apart) using 95% ethanol. In the control group (n=6), saline was injected instead of ethanol. PV isolation was confirmed with Lasso immediately after the procedure and at follow-up of 30 days. PV isolation was defined as the absence of PV potentials at each electrode of the Lasso catheter positioned at the PV side of the lesions as well as complete conduction block into left atrium (LA) during PV pacing. Transthoracic echocardiography indices were collected at baseline and at 30 days. Histologic analysis was performed at 30 days. Results: PV electrical isolation with complete bidirectional conduction block was achieved with ethanol immediately and 30 days, while saline injection caused only transient conduction changes between LA and PVs. In the ethanol group, histologic analysis showed transmural lesions at 30 days, and there was no evidence of PV stenosis or thrombus formation. Mean LA diameter was not significantly different between baseline and 30 days (20.5 ±3.5 mm vs. 22 ± 2mm, P<0.05). Conclusions: Epicardial injection of 95% ethanol is a feasible and safe method to create permanent PV electrical isolation in canine model without stenosis and perforation.

14-38 Abstract 18-16

Importance of magnetic field strength in atrial fibrillation ablation using stereotaxis

Pedro Carmo1, Diogo Cavaco1, Katya Santos1, Leonor Parreira , Pedro Adragao Cardiology, Hospital da Luz, Lisboa, Portugal

Recent data suggest that remote magnetic navigation (Steor-eotaxis, Inc.) is a helpful tool in ablation (Abl) of atrial fibrillation (AF). The application ofa higher density magnetic field (MF) has the advantage of increasing the catheter stability and the contact with the inner surface of the left atrium. The aim of this study was to compare the results of a MF of 0.1 vs 0.08 T used in the earliest procedures. Methods: We studied 84 consecutive patients (pts), average age 58±13 years, 24% female, undergoing wide area circumferential pulmonary veins isolation guided by Lasso catheter. Additional lesions were created in some patients particularly those with persistent atrial fibrillation. We used an irrigated catheter of 3.5 mm (THER-MOCOOL NAVISTAR RMT) in all cases guided by magnetic navigation. Demographics characteristics, AF type, the success rate (isolation of all veins (IPV)), complication rate, total time of procedure, of fluoroscopy, ofradiofrequency application, of construction of electroanatomic map (CARTO), and of full use of CARTO were compared. Results: Groups (0.08 vs 0.1 T) were similar with respect to demographics and AF type (persistent in 21% vs 25%). The volume of the left atrium was similar (86±27 vs 76±25 mL). The IPV was achieved in all pts. There were no complications. There was a reduction in the total time of the procedure that did not reach statistical significance (231±49 vs 213±40 min,p=0.10). There was no difference in CARTO map construction time (18 (14, 24) vs 21 (17, 25), p=0.17). There was a reduction in fluoroscopy time (18±6 vs 10±6 min, p<0.001) and in time of radiofrequency application (59±19 min vs 52±15 min, p= 0.04). Conclusions: The use of a more intense magnetic field (0.1 T) in AF Abl guided by magnetic control reduced the time of radiofrequency application, suggesting a better contact with the atrium surface, and reduced the time of fluoroscopy, suggesting a greater stability of the catheter.

14-39 Abstract 15-03

Reduction in heart rate variability parameters after AF ablation is greater for robotically assisted ablation than for manual ablation

Louisa Malcolme-Lawes1, Phang Boon Lim1, Ross Hunter2, Laura Richmond , Darrel Francis , Prapa Kanagaratnam , Richard Schilling2

JCardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland; 2Cardiac Electrophysiology, Barts and the London Hospitals, London, United Kingdom of Great Britain and Northern Ireland; Cardiac Electrophysiology, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Background: Heart rate variability (HRV) is an indirect measure of cardiac autonomic activity and has been consistently noted to reduce following atrial fibrillation (AF) ablation. This reduction is thought to be mediated via modification of the autonomic ganglionated plexi (GP). Since these are epicardial structures and animal studies have shown that robotic ablation lesions are consistently more transmural than manual lesions, we proposed that the reduction in HRV parameters would be greater following robotic than manual AF ablation. Methods: HRV has typically been measured from 5- or 10-min ECG recordings; however, we demonstrated that shortened ECG recordings of 40 s produced equivalent results for LF and HF indices of HRV. Thirty-seven patients undergoing ablation for paroxysmal AF were randomised to either robotic or manual ablation. Five-minute ECG segments were recorded on Bard EP systems at the beginning and end of the procedure. Five 40-s ectopy-free segments were exported to MatLAB to calculate LF and HF parameters. Results: LF and HF parameters underwent log transformation to normalise the data. The reduction in log LF and log HF for all PAF patients was 0.88 and 0.78 (p<0.001 for both). The log LF reduction for robotic (1.3) was greater than manual (0.6, p<0.05). There was also a trend to greater log HF reduction for robotic (1.1) compared to manual (0.6) ablation (p=0.09). Conclusion: Our results suggest that there may be an increase in the degree of autonomic modulation with robotic ablation compared to manual ablation of paroxysmal AF. This may the result of increased transmurality of robotic ablation. This may not affect clinical outcome if AF recurrence is the result of gaps between linear lesions rather than failure of transmurality.

Session B Part 2

Ablation of atrial fibrillation Cont. 14-40 Abstract 15-19

Increasing the role of robotic catheter navigation in the CATHLAB—first experience in redo persistent atrial fibrillation ablation

Edward Duncan1, Muzahir Tayebjee1, Upul Wickramarachchi1, Neville Johns1, Razeen Gopal1, Mehul Dhinoja1, Mark Earley , Simon Sporton , Richard Schilling

Cardiology, St Bartholomew's Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We hypothesised that improved ablation lesion quality with robotic navigation may improve outcome in patients who have previously failed manual ablation of persistent AF. Method: We retrospectively studied consecutive patients who underwent redo ablation of persistent AF or recurrent atrial tachycardia (post prior AF ablation) using either a manual or robotic approach. All cases were performed by a single operator experienced in both techniques. Results: Fifty-nine patients were identified (26 robotic, 33 manual). Patients were well matched for age (59 ± 8 and 61 ± 7) and gender (81% and 82% male), had a similar mean duration of AF (72 ± 48 and 59 ± 27 months, p=0.2) and had undergone a similar number of previous ablation procedures (1.9 ± 0.9 and 1.7 ± 1.1, p =NS). Seventy-three per cent of robotic and 59% of manual patients presented in an atrial tachycardia (p=0.4). No difference was seen between groups in total procedure time (robotic 217 ± 72 min; manual 212 ± 66 min; p=0.8) or fluoroscopy time (robotic 36 ± 16 min; manual 45 ± 21 min;p=0.2). Sinus rhythm was restored by ablation in 77% of robotic and 71% of manual cases (p=0.75). Lesion sets performed in robotic and manual cases included pulmonary vein re-isolation in 67% and 81% (p=0.3), linear ablation in 71% and 96% (p=0.3) and ablation of fractionated electrograms in 46% and 46%, respectively (p =NS). No major complications occurred in the robotic cohort. One tamponade occurred in the manual group. At 3 months, 68% of robotic and 82% of manual patients (p=0.2) described an improvement in symptoms, corresponding to 71% and 66%, respectively, being in sinus rhythm at follow-up with no

documented atrial arrhythmias (p=NS). Twenty-three per cent of robotic and 25% of manual patients were taking anti-arrhythmic drugs at 3-month follow-up (p =NS). Conclusions: These early data are the first to suggest that the Hansen robotic navigation system can safely achieve equivalent outcomes to manual in the redo ablation of persistent AF.

14-41 Abstract 15-24

Left atrial floor ablation during ablation of persistent atrial fibrillation predicts recurrence

Joseph de Bono1, McCready James1, Charlotte Pawlyn1, Martin Lowe , Edward Rowland , Oliver Segal , Anthony Chow1, Pier Lambiase1

Electrophysiology, The Heart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Many different strategies are used in the ablation of atrial fibrillation (AFib) which may include linear ablation on the left atrial (LA) floor. Markers of success and failure in ablation of persistent atrial fibrillation (AF) are not fully established. We performed a retrospective analysis to identify risk factors associated with recurrence of AF. Method: A retrospective review was performed of the initial ablation procedure in 165 patients with persistent AFib (mean age 60, mean duration of AFib 4 years (0.3-20), 80% male) and mean 18 months of follow-up post-ablation. All patients underwent pulmonary vein isolation with further ablation at the operator's discretion. Results: Only left atrial (LA) size and ablation on the floor of the LA during the index procedure predicted AF recurrence on multivariate analysis. Floor ablation had been performed in 65 patients (group 1) compared with 99 with no floor ablation (group 2). There was no difference between the groups in LA size (group 1, 46 ± 6 mm; group 2, 46 ± 7 mm, p=0.7), duration of AF (4.7 ±4.1 and 3.6 ± 3.7 years, p=0.9), procedural length (240 ± 60 and 240 ± 50 min, p = 0.9), ablation to an organised rhythm (23% and 25%, p=0.8) or other clinical factors between the two groups. However, ablation on the LA floor was associated with linear ablation elsewhere in the LA and a lower probability of freedom from recurrence (group 1, 25%; group 2, 44%, p=0.01). These differences persisted after multiple procedures

(freedom from AF group 1, 51%; group 2, 76%, p=0.01). Conclusion: Ablation on the floor of the left atrium during the initial ablation of persistent AFib is associated with long-term failure even after multiple procedures. This may reflect the greater complexity of the substrate requiring multiple linear lesion sets or that linear LA floor ablation may itself be pro-arrhythmic.

14-42 Abstract 15-23

The learning curve for atrial fibrillation ablation after >300 procedures: do results continue to improve late in experience?

Muzahir Tayebjee1, Razeen Gopal1, Richard Schilling2 1Cardiology, St Bartholomews Hospital, London, United Kingdom of Great Britain and Northern Ireland; 2Cardiology, St Bartholomews and London Bridge Hospitals, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We hypothesised that outcome following percutaneous AF ablation would continue to improve over time even after experience of a large number of procedures. Methods: Results of AF ablation were examined for a single operator (teaching centre) with experience of >900 AF ablations. Only cases where the operator performed the entire case were included. Procedures during Jan. to Dec. 2006 were compared to those between July 2008 and Aug. 2009. All patients had medically refractory symptomatic AF (>1 year); none had undergone AF ablation. Conscious sedation with three-dimensional mapping (CARTO/NavX) was used. All patients had wide area circumferential ablation to electrically isolate the pulmonary veins; the persistents also had atrial substrate modification. At 3 months symptoms, ECG and 7-day Holter were used to determine first-time success. Procedure numbers (non-solo cases) were used to determine overall increase in operator experience. Results: Cumulative AF ablations performed by

the single operator were 340 at the end of 2006 and 907 at the end of 2009. Study patient characteristics are shown in table. Within the paroxysmal AF cohort, there were significantly fewer patients requiring redo procedures or medical therapy to control their symptoms as operator experience increased. Procedure time was longer in 2008/ 2009. Conclusions: Even after experience of >300 cases, results of catheter ablation of AF continue to improve with continued procedural experience, suggesting that the technical learning curve for AF ablation is long.

14-43 Abstract 15-28

Additional ablation of complex fractionated atrial electrograms (CFAES) after pulmonary vein isolation (PVAI) in patients with atrial fibrillation: a meta-analysis

Weiju Li1, Bai Yongyi2, Tang Ribo1, Ma Changsheng1 1Anzhen hospital, Beijing, China; 2Fuwai hospital, Beijing, China

Background: The efficacy of additional complex fractionated atrial electrograms (CFAEs) ablation after pulmonary vein antrum isolation (PVAI) in patients with atrial fibrillation (AF) remains controversial. This meta-analysis was performed to assess the additional efficacy of CFAEs ablation after a single procedure without antiarrhythmic drugs. Methods: Four electronic databases were searched: MEDLINE, Cochrane Library, Embase, Google Scholar; articles regarding long-term outcomes of CFAEs ablation in patients with AF were reviewed; references in relevant studies were manually retrieved. Controlled cohort studies comparing the long-term efficacy of additional CFAEs ablation after PVAI with PVI alone were included. Primary endpoint was maintained of sinus rhythm (SR) without antiarrhythmic drugs. Results: Six controlled trials (total 526 patients with AF, 263 patients underwent PVAI plus CFAEs ablation, and 263 patients underwent PVAI alone) were included in the meta-analysis. In an overall pooled estimate, compared with PVAI alone, long-term rates of SR maintenance (relative risk [RR] 1.13, 95% confidence interval [CI] 0.97-1.31, P=0.107) were not increased by additional CFAEs ablation. Subgroup analysis demonstrated that additional CFAEs ablation increased rates of SR maintenance in non-paroxysmal AF (RR 1.28, 95% CI 1.00-1.64, P=0.048), whereas it had no effect on patients with paroxysmal AF (RR 1.02, 95% CI 0.90-1.16, P= 0.741). Conclusions: Adjuvant CFAEs ablation in addition to standard PVAI increase the rate of long-term SR maintenance in non-paroxysmal AF patients after a single procedure without antiarrhythmic drugs, whereas it does provide additional benefit to SR maintenance in paroxysmal AF patients.

14-44 Abstract 15-17

Is complete anatomical circumferential isolation essential for complete electrical pulmonary vein isolation? Assessment using NavX-Ensite system

Masahiro Esato1, Kida Yoshitomi2, Mani Hiroki1, Nishina Naoto , Kitajima Hiroki , Teramoto Kunihiro , Chun Yeonghwa1

Arrhythmia Care Center, Koseikai Takeda Hospital, Kyoto City, Japan; 2Department of Arrhythmia, Ijinkai Takeda General Hospital, Kyoto City, Japan

Background: Complete anatomical circumferential isolation combined with 3D mapping is widely used as an ablation strategy for pulmonary vein (PV) isolation. However, it is still unclear whether this method is essential for complete electrical PV isolation. Methods: Twenty consecutive patients with drug-refractory atrial fibrillation were enrolled. After registration of the 3D computed tomography image of the left atrium and PVs was done into NavX-Ensite system (NES), complete electrical PV isolation was performed based on the potentials from circular, multipolar electrode (Lasso) catheters placed within the left- and right-sided ipsilateral superior and inferior PVs antrum area (i.e., double Lasso technique) guided by fluoroscopy. NES was totally not used during the procedure and fluoroscopy was only used for ablation and Lasso catheter manipulation. After complete electrical PV isolation was succeeded, assessment of the discontinuity (gap) of the ablation lesions created by the NES was achieved. Results: Complete electrical PV isolation was succeeded in all patients. Discontinuity of the ablation lesions from the NES was 20% on average out of each circumference of ipsilateral superior and inferior PVs and also highly variable. No significant complications occurred. Conclusions: For complete electrical PV isolation, complete anatomical circumferential isolation using 3D mapping might not be essential.

14-45 Abstract 29-01

Provisional experience of high-intensity focused ultrasound for surgical epicardial ablation of AF: a non-randomised comparison to radiofrequency energy using the isolator bipolar ablation clamps

F C Goromonzi1, L Richmond1, V Baker1, R Hunter1, A Shipolini1, R Schilling1

JCardiac Research, Barts and the London NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Background: Concomitant surgical ablation (SA) of AF is increasingly common. Historically, the Cox-maze III

procedure has been proven to be effective at eliminating AF, although not widely adopted due to some complexities and technical challenges. We compared alternative techniques of epicardial high-intensity focused ultrasound (HIFU) to radiofrequency energy using isolator bipolar ablation clamps (IBAC). Methods: Patients undergoing HIFU underwent pulmonary vein isolation (PVI) alone; those in the IBAC group also underwent linear ablation between the left atrial appendage (LAA) and left superior pulmonary vein as well as LAA amputation. Three IBAC patients also had ganglionated plexuses mapping and monopolar ablation. Patients were followed up at 16± 1.3 months with a 12-lead ECG and 7-day Holter monitoring to establish any complication or recurrence of AF/atrial flutter or tachycardia. Results: Eighteen patients (ten men) aged 39 to 83 years. All patients had concomitant surgery coronary artery bypass graft surgery (CABG), valve replacement or valve repair. Prior duration of AF was 55 ± 9 months and 39% (7/18) had paroxysmal AF (PAF). Of 11 patients (two PAF), HIFU group, seven (64%, two PAF) remained free of AF. Of seven patients (five PAF), IBAC group, two (29%, all PAF) remained free from AF. Symptoms improved in all patients 5 in 11 (45%, three on AAD), completely asymptomatic in the HIFU group and four in seven (57%, all on AAD) in the IBAC group. There was one adverse event of heart block following coronary artery bypass surgery and aortic valve surgery requiring a permanent pacemaker (IBAC). Duration of AF correlated with AF recurrence after surgery. Conclusion: Provisional experience with HIFU shows that it achieves similar results to that obtained with IBAC despite the more extensive procedure associated with IBAC. Further research in larger patient groups are needed to confirm any significant difference in safety and efficacy between the techniques.

14-46 Abstract 07-08

Outcome of catheter ablation and predictors of recurrence of tachyarrhythmias in patients with secundum atrial septal defects

A B Gopalamurugan1, Girish Ganesha Babu1, Syed Ahsan1, Umesh Vivekananda , Vineet Wadehra , Pier Lambiase , Anthony Chow , Martin Lowe

The Heart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Catheter ablation of arrhythmias in patients with secundum atrial septal defect (ASD) is an established treatment. But its outcome, recurrence rate, and predictors of recurrence have not been reported before. Methods: Secundum ASD patients who underwent catheter ablation were analyzed. Patient demographics, echocardiographic

parameters, electrophysiologic study, and ablation details and follow-up details were obtained. Immediate procedural success was defined as trans-isthmus conduction block in cavotricuspid (CTI)-dependent atrial flutters, pulmonary veins isolation in atrial fibrillation, and non-inducibility at the end of the procedure for other tachycardias. Results: Twelve patients were studied: seven surgical closures, one percutaneous closure, and five awaiting percutaneous closure. Three in 12 (25%) had CTI-dependent flutter, 1 in 12(8.3%) had RA floor flutter, 4 in 12 (33.3%) had persistent atrial fibrillation, 2 in 12(16.6%) had ventricular tachycardia from the right ventricle, 1 in 12 (8.3%) had AVRT, and 1 in 12 had left atrial (LA) tachycardia. 3D mapping systems were used in all atrial arrhythmias, and ablation was performed with irrigated tip radiofrequency catheters in 7 of 12 (58.3%) patients. Immediate success was achieved in 11 of 12 (91.6%) patients, but one patient with LA tachycardia had prolongation of tachycardia cycle length and no termination. Mean follow-up was 15 months. Five in 12 (41%) had recurrence: three AFs (index ablations were for AF ablation), one was LA tachycardia (index ablation was for LA tachycardia), and one atypical atrial flutter (index ablation was for typical CTI flutter). Procedures that required left atrial ablation (AF and LA tachycardia) was found to be an independent predictor of recurrence (p=0.028). Conclusion: The immediate success rate for catheter ablation of tachyarrhythmias in patients with secundum ASDs was 91.6% overall. The recurrence rate was, however, 41%, reflecting the complexity of left atrial-based arrhythmias associated with this condition

14-47 Abstract 18-02

Radiofrequency parameters for robotic ablation may need to remain at conventional manual settings to deliver clinical improvements

settings in clinical ablation Methods: Percentage reduction in electrogram voltage was measured in seven pig atria, with robotic and manual ablation performed at identical RF settings. The pigs were killed and lesions correlated with ablation modality. Following this, 12 patients were randomised to manual or robotic ablation. Voltage reduction was measured for each RF delivery: 30 W 60 s in manual and 25 W 30 s in robotic ablation. Results: Robotic ablation in pig atria reduced signal amplitude to a greater degree than manual ablation 49±2.6% vs. 29±4.5%, p=0.0002. On inspection, a greater proportion of robotic lesions were transmural, but not associated with any perforation. In the clinical study, robotic ablation with reduced power settings showed no significant difference in signal attenuation compared with manual ablation 46±1.4% vs 50±5.1% signal reduction, p=0.32. Conclusions: With equivalent RF settings, robotic ablation is superior to manual as measured by signal attenuation. This advantage is lost with reduced power and duration of RF used for clinical robotic ablation. Manual RF settings may have to be used for robotic ablation to improve lesion quality and clinical outcomes.

Louisa Malcolme-Lawes1, Pipin Kojodjojo2, Zachary I

Whinnett2, Phang Boon Lim1, D Wyn Davies2, Nicholas S 14-48 Abstract 15-11

Peters1, Prapa Kanagaratnam2

Cardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland; Cardiac Electrophysiology, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Introduction: The Hansen robotic system was designed to improve catheter tip stability, lesion quality and clinical outcomes. Concerns over cardiac perforation from the rigid sheath and soft transmural lesions led to a recommendation to reduce radiofrequency (RF) power and time. We tested the hypothesis that robotic ablation is superior to manual in a pig model and then assessed the impact of reduced RF

Characterisation of fractionated electrograms critical for maintenance of AF: a randomised controlled trial of ablation strategies

Ross Hunter1, Ihab Diab1, Simon Sporton1, Mark Earley1, Richard Schilling1

1Cardiology, Barts and The London NHS Trust and QMUL, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We sought to determine the impact of targeting different complex fractionated electrogram (CFE) morphologies on AF cycle length (AFCL) in persistent AF.

Methods: After pulmonary vein isolation and linear lesions at the roof and mitral isthmus, CFE were targeted systematically throughout the left then right atrium, with the endpoint of ablation to sinus rhythm or abolition of all CFE prior to DC cardioversion. CFE were identified by visual inspection of 10-s bipolar electrograms and classified using the validated grading system shown in Table 1. Patients were randomised to targeting of CFE starting with either the most fractionated first (i.e. grades 1 to 5) in group 1 or the least fractionated first (i.e. grades 5 to 1) in group 2. Grade 5 (normal) electrograms were targeted at sites incorporated into linear lesions. The randomised strategy firstly controlled for any cumulative effect of ablation on AFCL and secondly allowed assessment of the order of ablation on success. Mean AFCL was determined manually over 30 cycles from bipolar electrograms recorded at the left and right atrial appendages before and after targeting each CFE. An increase in AFCL of >5 ms was regarded as significant. Results: Eight patients have been randomised (four to each group). Age was 63 ± 7 years. All had persistent AF of duration 60 ± 30 months. In total, 412 CFE were targeted, 33 ± 23 per patient in group 1 and 70 ± 30 in group 2 (p=0.11). Two patients were ablated to sinus rhythm in group 1 and one in group 2. AFCL increased after targeting 33.3% grade 1 CFE, 32.5% grade 2, 9.6% grade 3, 26.8% grade 4 and 2.7% grade 5 (p<0.01 for grades 1, 2 and 4 versus 5, 3 versus 5 not significant). There was no effect of CFE amplitude or the order of CFE targeted. Conclusion: Targeting CFE is not simply debulking the atria. Certain types of CFE are important in maintaining AF. Targeting these CFE may reduce unnecessary atrial destruction and help ablate to sinus rhythm.

Table 1 Classification of complex fractionated electrograms

Grade 1 Uninterrupted fractionated activity

(defined as segments >70 ms) for >70% of

recording, and uninterrupted segments >1 s

Grade 2 Interrupted fractionated activity >70%

of recording

Grade 3 Intermittent fractionated activity 30-70%

Grade 4 Discrete (<70 ms) complex electrogram

(>5 direction changes)

14-49 Abstract 18-23

Atrial fibrillation ablation with magnetic navigation: the impact of technological advances on the reduction of X-ray exposure

Pedro Adragao1, Diogo Cavaco1, Martha Bouzin1, Leonor Parreira , Pedro Carmo , Katya Reis-Santos , Susana Marcelino , David Cabrita , Miguel Abecasis Arrhythmia Unit, Hospital da Luz, Lisbon, Portugal

Percutaneous ablation is the treatment of choice for paroxysmal/persistent drug refractory atrial fibrillation. The exposure to ionizing radiation is a major drawback of percutaneous ablation. The magnetic navigation system, combined with electroanatomical mapping (CARTO), allows for the ablation of atrial fibrillation with a low exposure to X-ray from patients and personnel. Several improvements to the system or related with the catheters have appeared in the last 2 years. Goal: The goal of this study was to evaluate the exposure to X-ray in patients submitted to atrial fibrillation ablation, with the Magnetic Navigation System and its relation with introduced technological advances. Methods: Retrospective analysis of the duration of exposure to X-ray in patients submitted to pulmonary veins isolation in different moments in time: initial period, with 8-mm tip catheter (group A), after the introduction of the irrigated tip catheter (group B) and after increase in the magnetic field from 0.08 to 0.1 T (group C). The population consisted of 157 patients. Results: These results (see chart) show a reduction in X-ray exposure from groups A to B (p< 0.05, t test) and from B to C (p<0.05, t test). Conclusions: Technological advances in MNS allow nowadays the ablation of atrial fibrillation with very short X-ray exposure duration, lowering the risks associated with ionizing radiation.

N Exposure to X-ray (min, mean ± SD)

Group A 72 33.9±13.12

Group B 56 17.94±6.36

Group C 29 10.89±6.47

14-50 Abstract 15-14

Modulation of the renin-angiotensin-aldosterone system in patients undergoing catheter ablation of atrial fibrillation does not appear to affect outcome or the need for redo procedures

Muzahir Tayebjee1, Antonio Creta1, Stefan Moder1, Mehul Dhinoja , Mark Earley , Simon Sporton , Richard Schilling

Cardiology, St Bartholomews Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: We hypothesised that AF ablation would have a more profound effect on atrial remodelling than modulation of the renin-angiotensin-aldosterone system (RAAS), and therefore, drug therapy in combination with ablation will have little or no additive impact on the number of procedures required to restore sinus rhythm (SR). Methods: A retrospective study was conducted of all patients undergoing percutaneous catheter ablation for long-standing (>1 year) symptomatic paroxysmal (pulmonary vein isolation (PVI)) or persistent AF (PVI and substrate modification) using

radiofrequency ablation between November 2004 and December 2008 by analysis of medical records (table). Follow-up data were recorded at the final follow-up (>90 days after the last procedure). The predominant rhythm was recorded (i.e. SR, paroxysmal AF, persistent AF) on the basis of clinical history, 12-lead ECG and 7-day Holter recording. Results: Four hundred nineteen patients with AF were included (222 paroxysmal, 197 persistent AF). One hundred seventy-five underwent one procedure (41.8%), 166 had two (39.6%), 56 had three (13.4%), 14 had four (3.3%), seven had five (1.7%) and one had six (0.2%). Median follow-up from the first procedure was 253 (interquartile range 140-472)days. There were 142 patients on RAAS modulators and were older, more likely to suffer from hypertension, diabetes, coronary disease or left ventricular impairment (table). Sustained SR was achieved in 320 patients (76%). One hundred eighty-one patients had one or more risk factors for AF; out of these, 128 were on RAAS modulators. In this subgroup, sustained SR was maintained in 37 patients (70%) without RAAS modulators compared to 98 (76%) with RAAS modulators (p= 0.342). Treatment did not impact on the number of procedures required to reach the final endpoint (Table). Conclusion: Outcome following catheter ablation of AF appears to be similar in patients who are either on or off RAAS modulators. The role of RAAS modulation in the presence of risk factors needs to be clarified.

No RAAS modulator (n = 273) RAAS modulator (n = 142) P

Age (years) 56±10 60±10 0.005

Male (%) 197 (72%) 106 (75%) 0.550

Paroxysmal AF (%) 164 (60%) 58(38%) <0.001

Hypertension (%) 42 (15%) 106 (75%) <0.001

Diabetes (%) 2 (0.7%) 9 (6%) 0.001

Coronary disease (%) 8 (3%) 26 (18%) <0.001

Impaired LV 9 (3%) 38 (27%) <0.001

(EF<40%, %)

Antiarrhythmic at 80 (29%) 66 (46%) <0.001

discharge (%)a

More than one 158 (58%) 86 (60%) 0.569

procedure (%)

Persistent sinus rhythm 215 (79%) 104 (73%) 0.397

achievedb (%)

(RAAS renin-angiotensin-aldosterone system, AF atrial fibrillation, LV left ventricle, EF ejection fraction aThese include beta blockers, sotalol, rate-limiting calcium channel blockers, flecainide, propafenone and amiodarone This was determined by a combination of Holter recording and symptomatic assessment

14-51 Abstract 15-22

Left atrial wall stress distribution in patients

with AF and the relationship with electrophysiologic

abnormalities

Ross Hunter1, Yankai Liu2, Yiling Lu2, Wen Wang2, Richard Schilling1

1Cardiology, Barts and The London NHS Trust and QMUL, London, United Kingdom of Great Britain and Northern Ireland; 2School of Engineering and Materials Science, QMUL, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Left atrial (LA) wall stress may contribute to the abnormal atrial substrate which sustains AF. We hypothesize that peaks of LA wall stress correspond to sites of complex fractionated electrograms (CFE) in patients with persistent AF. Methods: LA CTs were segmented on CARTO (Biosense Webster, Diamond Bar, CA) and exported into Gambit (ANSYS Inc, Brookfield, WI). Finite element analysis (ABAQUS Inc, Pawtucket, RI) predicted stress distribution. The LA was assumed to be a 2-mm-thick linear elastic shell tapering to 1 mm in the pulmonary veins (PVs). Young's modulus was assumed to be 3 MPa and Poisson's ratio 0.45. A map of LA CFE was recorded prior to catheter ablation for AF, with electrograms graded using a validated classification system shown in Table 1. The LA was divided into 22 areas, with peak stress and grade of CFE compared in each. Results: Distribution of von Mises stress was calculated for a pressure change of 20 mmHg in seven patients with persistent AF. Areas were deemed high stress if the peak was >mean + 2 standard deviations for that patient. Consistently high stress areas were the PVs (75% of PVs), the ridge between left atrial appendage and PV (57%), inferior wall (71%), anterior wall (100%) and septum (57%). The association of high stress with highly fractionated electrograms (grades 1-2) was assessed by receiver operating characteristic (ROC) analysis. Areas with peak stress >0.0627 MPa had positive and negative predictive values of 72% and 55%, respectively, for predicting highly fractionated electrograms (significantly better than chance: area under ROC curve 0.697; p=0.0001). There was moderate correlation between peak stress and degree of electrogram fractionation (r=-0.32). Conclusions: The correlation demonstrated between high wall stress and CFE suggests of a causal relationship. Refinement of this model may allow ablation procedures to be customised by predicting and targeting regions of electrophysiological remodelling.

Table 1 Classification of complex fractionated electrograms

Grade 1 Uninterrupted fractionated activity (defined as

segments >70 ms) for >70% of recording and

uninterrupted >1 s

Grade 2 Interrupted fractionated activity >70%

of recording

Grade 3 Intermittent fractionated activity 30-70%

of recording

Grade 4 Discrete (<70 ms) complex electrograms

(>5 direction changes)

Grade 5 Discrete simple electrograms (<4 direction changes)

14-52 Abstract 18-11

Guided isolation of culprit pulmonary veins. Is it enough for ablation of paroxysmal atrial fibrillation?

Mario Oliveira1, Pedro Silva Cunha1, Nogueira Silva1, JoanaFeliciano1, Ana Lousinha1, Ninel Santos1, Sofia Santos1, Fernando Marques1, Rui Ferreira1

1Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal

The importance of pulmonary veins (PV) for the occurrence of atrial fibrillation (AF) heralded an era of catheter-based ablation therapy. However, finding the culprit PV is not always reliable. Empirical isolation of all PV became accepted as the cornerstone of paroxysmal AF (PAF) ablation. Aim: he aim of this study was to assess the outcome after isolation of culprit PV in patients (P)

undergoing PAF ablation. Methods: Thirty-three P (79% male, 50±10 years) with PAF refractory to antiarrhythmics (AA), no structural heart disease, were submitted to ablation guided by a circular mapping catheter, and Ensite NavX system, integrated with digital CT image, with >6 months of follow-up. PVs were defined as culprit if these originated ectopic activity inducing AF and were identified during the procedure in 12 P (group A). In 21 P (group B), ectopic activity was not observed or electrical cardioversion was performed after all PV isolation. In group A, 50% were submitted to isolation of all PV, and 50% underwent isolation of one to three culprit PVs. In group B, 52% were submitted to isolation of all PV and 48% underwent isolation of two to four PV due to difficult PV access (n = 2) or PV without discernible electrical activity (n=8). There were no differences between groups regarding age, AF duration, lone AF, LA size, or AA after ablation. P were evaluated at 4 weeks and every 4 months. Results: The duration of the procedure, the fluoroscopy time, and the duration of radiofrequency applications were similar for both groups (174±48 vs. 182±58 min, 29±8 vs. 28±9 min, 26±18 vs. 25±7 min, p=NS; group A and group B, respectively). Two P, in group B, had a cardiac tamponade. During 19±14 months, there were 25% recurrences in group A and 28.5% in group B (p=NS). In group A, 67% of all recurrences occurred in P with ablation of culprit PV, whereas in group B, 83% of the recurrences occurred in P with partial PV isolation (p =NS). Conclusion: In P with PAF, identification and isolation of culprit PV may achieve a good long-term outcome.

SATURDAY APRIL 17, 2010 9:00 pm-12:00 pm Chaired Poster Session C Part 1

Arrhythmia mechanisms 15-54 Abstract 01-04

Moderate gap junctional uncoupling with carbenoxolone slows conduction and increases vulnerability to ventricular arrhythmias—an optical mapping study

Fu Siong Ng1, Alexander R Lyon1, Iqbal T Shadi1, Eugene TY Chang1, Rasheda A Chowdhury1, Emmanuel Dupont1, Nicholas S Peters1

JCardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland

Background: It is uncertain whether moderate conduction slowing through gap junctional uncoupling on its own, in the absence of action potential or structural changes, is sufficient to be pro-arrhythmic. We used optical mapping: (1) to study the effects of carbenoxolone (CBX), a gap junction uncoupler, on conduction velocity and action potential duration and (2) to assess the effects of moderate conduction slowing and gap junctional uncoupling on arrhythmia vulnerability in structurally normal hearts. Methods: Rat hearts (n = 12) were perfused on a Langendorff apparatus, loaded with a voltage-sensitive dye (RH237) and perfused with an excitation-contraction uncoupler (10 ^M blebbistatin). Transmembrane voltage transients were recorded using a 256-photodiode array. Hearts were then perfused with 30 ^M CBX (n=6) or control (n=6) for 30 min and epicardial activation mapped every 2 min during ventricular pacing. Subsequently, hearts were subjected to programmed ventricular stimulation and assigned an inducibility quotient depending on ease of arrhythmia inducibility. Results: CBX slowed conduction velocity (conduction velocity index: baseline 100%, CBX 70±2%, P<0.01), with no change in control hearts after 30 min (baseline 100%, controls 98±3%, P=NS). CBX did not affect action potential duration (APD90: baseline 90 ± 3 ms, CBX 94 ±5 ms, P=NS). Inducibility of ventricular arrhythmias was increased in CBX hearts compared with control hearts (inducibility quotient: CBX 5.0±1.0, control 2.5±1.0, P<0.05). Conclusions: Gap junctional uncoupling with CBX produced a 30% reduction in conduction velocity without changes in action potential duration and resulted in increased arrhythmia vulnerability. These results suggest that moderate conduction slowing pro-

duced by gap junctional uncoupling in isolation, i.e. in the absence of changes in action potential duration or structural abnormalities, is sufficient to increase susceptibility to ventricular arrhythmias.

15-55 Abstract 02-02

Carbenoxolone limits increase in Connexin43 expression in ischaemic rat ventricular tissue

Eugene TY Chang1, Fu Siong Ng1, Rasheda A Chowdhury1, Linda Inuabasi1, Emmanuel Dupont1, Nicholas S Peters1 imperial College, London, United Kingdom of Great Britain and Northern Ireland

Background: Carbenoxolone (CBX) is a gap junction uncou-pler known to slow myocardial conduction velocity (CV). However, the molecular mechanisms by which CBX uncouples cardiomyocytes is unclear and may involve altering phosphorylation states of gap junctional protein Connexin43 (Cx43) or affecting quantities of Cx43. We aimed to study the effects of CBX on the level of Cx43 in (1) cultured HL-1 atrial myocytes and (2) Langendorff rat hearts subject to regional ischaemia. Methods: (1) HL-1 mouse atrial myocytes were

incubated with 0-400 |o.M CBX for up to 2 h and 1-h washout (n=3). (2) For whole heart Langendorff studies, four groups were carried out: Langendorff perfusion (control), 30 |o.M CBX perfusion, LAD ischaemia, LAD ischaemia+CBX (30 min each, n=3 per group). Samples were separated into membrane-bound (docked) and non-membranal (undocked) parts for Western blot analysis of Cx43. Results: CBX did not significantly alter Cx43 expression in HL-1 atrial myocytes (baseline 0.76±0.24, 400 ^M CBX 0.61 ± 0.07 for docked Cx43 after 1 h). In rat ventricular tissue, regional ischaemia significantly increased Cx43 expression in ischaemic tissue compared to control (from 0.55±0.04 to 1.30±0.12 for docked Cx43, p=0.046 vs control). CBX (30 pM) had no

significant effect on Cx43 quantity (0.76±0.24). However, when administered in the context of ischaemia, CBX attenuated increase in Cx43 (1.11 ± 0.13) not significantly different from control. These CBX concentrations have previously been shown to significantly decrease CV in both models. Conclusion: In atrial HL-1 cultured cells and rat ventricular myocardium, CBX administration of up to 2 h did not significantly affect Cx43 levels, suggesting that its short-term effect of CV slowing is mediated by other mechanisms. CBX did appear to attenuate increase in Cx43 seen in ischaemic tissue, implying that when given in the context of ischaemia, the mechanism of action may involve regulation of Cx43 levels.

Membrane-bound (docked) Cx43 expression levels

HL-1 Cells Rat Left Ventricular Myocardium

0.9, T *

15-56 Abstract withdrawn 15-57 Abstract 04-02

Feasibility of intraprocedural measurements of autonomic tone as an ablation endpoint

Louisa Malcolme-Lawes1, Phang Boon Lim1, Pipin Kojodjojo , Ross Hunter , Laura Richmond , Darrel Francis , Richard Schilling , Prapa Kanagaratnam

Cardiac Electrophysiology, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland; 2Cardiac Electrophysiology, Barts and the London Hospitals, London, United Kingdom of Great Britain and Northern Ireland; 3Cardiac Electrophysiology, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Heart rate variability (HRV) is a measure of autonomic tone and a potential tool for intra-procedural assessment of autonomic modification during AF ablation.

We hypothesized that HRV changes can be detected during ablation and are associated with clinical outcomes. Methods: Conventional 5-min recordings of HRV are rarely ectopy-free during ablation. We investigated shorter recording times and found that reducing from 5 min to 40 s did not change low-frequency (LF) and high-frequency (HF) HRV indices. We performed short segment recordings during paroxysmal AF ablation at baseline and post-ablation. A subgroup had recordings taken at each stage to identify any preferential sites for modification. Clinical outcome was assessed at 6 months. Results: The overall reduction in log LF and HF was 0.82 and 0.66, respectively (n=33, p<0.001). In seven patients undergoing left vein isolation first, log LF was 2.32, 2.15, 1.95, and 0.55 and log HF was 1.91, 1.47, 1.75, and 0.68 at baseline, following transeptal puncture, L CPVA and R CPVA, respectively, demonstrating significant change after R CPVA only (p<0.001). In seven patients undergoing right vein isolation first, log LF was 1.67, 1.82, 0.25, and 0.28 and log HF was 1.43, 1.55, 0.23, and 0.25 at baseline, following transeptal puncture, L CPVA and R CPVA, respectively, demonstrating significant change after R

CPVA only (p<0.001). Twenty-nine patients completed 6 months of follow-up; 18 had recurrence of AF and 11 did not. No statistically significant differences in LF and HF reduction were found between these two groups (0.77 and 0.59 vs 0.93 and 0.79, p=0.65 and 0.58, respectively). Conclusion: Intra-procedural measurement of HRV is feasible, and we demonstrate that right CPVA ablation preferentially reduces HRV. Canine studies suggest that right anterior GP is a "gateway" to the sinus node, and our study implies a similar functional network in humans. HRV reduces secondary to denervation of the right GP, and this appears not to be related to clinical outcome.

15-58 Abstract 04-03

Heart rate variability as work stress marker in a team of police officers

Federico Quadrini1, Ezio Vincenzo Santobuono1, Riccardo Memeo1, Lucia Nuzzi1, Davide De Santis1, Frida Nacci1, Stefano Favale

Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy

Introduction: Stress is usually defined as the experience of negative events or the perception of distress and negative affect that are associated with the inability to cope with them. Mental stress and occupational stressors were found to correlate with the autonomic nervous system activity assessed by heart rate variability (HRV). The aim of the study was to assess the difference of HRV time domain parameters among working day and subsequent 24 h at rest and to identify the correlation between mental stress, assessed by modified mental health Professional Stress Scale (PSS) test, and HRV in a team of police officers. Materials and methods: Twenty healthy police officers with at least 2 years of seniority were studied (17 men; 45±6 years). Structural heart diseases were excluded by clinical evaluation, 12-lead ECG, and 2D echocardiogram. Subsequently, they compiled PSS test and underwent 24-h Holter monitoring both on a working day and on a rest day. Time domain-based measures of HRV, particularly the standard deviation of all normal RR intervals over the entire 24-h electrocardiographic recording (SDNN), were analyzed. Moreover, study population was divided into two groups according to PSS score, above (HS) and below (LS) the median value (40). Results: Mean value of PSS test was 36±17 (median 40). HRV was not different among working day and rest day evaluation (127±28 vs.123±38 ms, respectively, p=0.44). No linear correlation was detected among value of PSS score and SDNN

(r =0.00, p=0.99 during working day; r = -0.13, p=0.58 during rest day). Figure shows that there was no difference among HS and LS groups according to SDNN value neither on working day (p=0.83) and nor on rest day (p=0.68). Conclusion: The study showed that SDNN was not different among working day and rest day in a team of police officers and that stress, assessed by PSS, did not correlate with HRV assessed by SDNN.

SDNN 130

120 110 100

LS group HS group

15-59 Abstract 04-04

Peculiarity of autonomic tone modulation in post-ablation patients

Andrey Ardashev1, Andrey Shavarov2, Eugeny Zhelyakov1, Maxim Rybachenko , Yuri Belenkov 83 City Clinical Hospital of FMBA, Moscow, Russian Federation; Burdenko Head Clinical Hospital, Moscow, Russian Federation; 3Lomonosov Moscow State University, Moscow, Russian Federation

Purpose: The purpose of this study was to estimate cardiac autonomic tone modulation between patients (pts) with occurrence of atypical atrial flutter (AFl) and pts with sinus rhythm (SR) after radiofrequency ablation (RFA) of atrial fibrillation (AFib) using traditional heart rate variability (HRV) and nonlinear dynamics techniques. Methods: One hundred and forty consecutive pts (111 men, mean age 54 ± 11 years) who underwent RFA for symptomatic paroxysmal (61%) and persistent (39%) AFib were studied. Occurrence of atypical AFl was documented in 41 pts (AFl group). Ninety-nine (71%) were still free of arrhythmias during 12 months of follow-up (SR group). Time and frequency domain HRV measurements were analyzed. Nonlinear dynamics characteristics we used as follows: information, correlation and fractal dimensions, entropy, and Lapunov's parameter. Results: Six hours after ablation, HF was significantly higher in AFl group pts compared with SR group pts (4.4±1.3 vs. 4.0±1.2, p= 0.04). Twenty-four hours after RFA, SDNN and LF were significantly higher in AFl group pts compared with SR group pts (3.4±0.6 vs. 3.2±0.5, p=0.04; 5.1±1.7 vs. 4.3± 1.3, p=0.04, respectively). Twenty-four hours after RFA, Lapunov's parameter was significantly lower in AFl group pts compared with SR group pts (4.23±0.73 vs. 4.75±0.50,

p=0.0005). There were no significant differences among other HRV measurements. Conclusion: There were significant differences between AFl and SR group pts in cardiac autonomic status in early post-ablation period.

15-60 Abstract 04-01

Heart rate turbulence after exercise was associated with heart rate recovery

Harun Kilic1, Ozlem Karakurt1, Munevver Sari1, Ramazan Akdemir1

Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey

Background: Frequent ventricular ectopy during recovery after exercise is a predictor of an increased risk of death. Heart rate recovery after exercise testing is a powerful and independent predictor of the risk of death. In the absence of normal vagal reactivation, heart rate recovery is attenuated. Therefore, attenuated vagal reactivation during recovery might be associated with ventricular ectopy that is not suppressed. The disappearance of HRT implies the loss of normal autonomic nervous regulation in favor of sympathetic system. We hypothesized that patients who had abnormal heart rate recovery must have abnormal heart rate turbulence after exercise. Method and results: Retrospectively, 1,550 patients with symptom-limited treadmill exercise testing were analyzed. Among 1,550 patients, 103 (6.6%) had ventricular ectopy during the recovery period of exercise. There was no correlation between HRT after exercise and HRR. Conclusion: HRR and HRT might show different aspects of autonomic nervous system.

15-61 Abstract 04-05

Characterization of the cardiac neural network during atrial fibrillation ablation

Christian Meyer1, Martin Martinek2, Josef Aichinger2, Hans-Joachim Nesser , Helmut Purerfellner

University of Duesseldorf, Duesseldorf, Germany; Elisabethinen Hospital, Linz, Austria

Background: The neural network formed by interconnecting neurons, axons, and autonomic ganglia residing in the heart has been demonstrated to be related with atrial fibrillation (AF). The aim of the present study was to investigate the anatomical and functional relationship of parasympathetic responses during AF catheter ablation. Methods: In 48 patients who underwent catheter ablation for AF, we prospectively investigated the relationship between autonom-ic responses, their anatomical localization, and local electro-

gram characteristics. Parasympathetic responses were defined as transient sinus arrest, AV block, or prolongation of R-R interval >50%. A sympathetic response was defined as shortening of the R-R interval >50% during radiofrequency delivery. Results: During pulmonary vein (PV) isolation with an energy limit of 30 W, an autonomic response was observed in six patients (12.5%), five patients with a parasympathetic and one with a sympathetic response. In two patients, parasympathetic responses were elicited in more than one site. The most common localization of the parasympathetic response was the posterior left super PV-atrial junction (n=4) being related with sinus arrest (n=4), AV block (n=3), as well as R-R interval prolongation (n=3). Post-procedural analysis demonstrated that these sites were associated with the presence of a pre-ablation high-amplitude fractionated endocardial electrogram in three patients which has been proposed to delineate parasympathetic innervations. The sympathetic response was elicited during ablation at the ridge of the left pulmonary veins and the left atrial appendage. Conclusion: Our findings suggest that neurons at the left superior pulmonary vein-atrial junction are involved in neural sinus node and AV node control and might release neurotransmitters during radiofrequency delivery in some patients during AF catheter ablation.

15-62 Abstract 14-01

The upper turnover site in the reentry circuit of common atrial flutter—three-dimensional mapping and entrainment study

Ichiro Watanabe1, Yasuo Okumura1, Masayoshi Kofune1, Sonoko Ashino , Kimie Ohkubo , Koichi Nagashima , Toshiko Nakai , Atsushi Hirayama

Division of Cardiology, Department of Medicine, Nihon University School ofMedicine, Tokyo, Japan

Background: The anterior boundary of the common atrial flutter (AFL) is the tricuspid annulus. But the posterior boundary of the AFL circuit and the exact upper turning point of the AFL circuit are still controversial. The aim of this study was to determine the location of the posterior boundary of the AFL circuit and the upper turning point of AFL circuit by 3D mapping and entrainment pacing. Methods: In 17 patients with counterclockwise AFL, high-density mapping of the upper right atrium (RA) and SVC orifice was conducted using CARTO or Ensite system. Entrainment pacing was performed around the superior vena cava (SVC)-RA junction. Results: In 12 of 17 patients, the wave front from the septal RA split into two waves; one wave front moved to superior direction to the SVC, while another wave front moved to lateral direction to the SV region. The upper-directed wave front crossed the

SVC-RA junction from anterior direction and conducted to the RA-free wall, while the lateral wave front conduction was blocked at the SV region. In the remaining five patients, the wave front pg the septal RA propagated toward the anterior portion of the SVC-RA junction, while no obvious wave front to lateral direction was noted. Entrainment pacing from the SVC-RA junction also

demonstrated that anterior boundary is on the circuit o, but the posterior boundary is not a circuit. Conclusions: Three-dimensional mapping and entrainment pacing demonstrated that the posterior boundary of the AFL circuit is located at the SV region and that upper turnover site of the AFL locates at the cranial and anterior portion of the SVC-RA junction.

Isochronal Map During AFL

Sudden cardiac death 15-63 Abstract 19-10

Empiric ATP in primary prevention: mixed effects foster mixed emotions

Kousik Krishnan1, Christine Davis1

JCardiac Electrophysiology, Rush University Medical Center, Chicago, United States of America

Inappropriate ICD discharges are psychologically traumatizing to device recipients and a significant cause of fear in patients at high risk of sudden cardiac arrest (SCA) being evaluated for ICD placement. The PAINFREE RX II trial

evaluated a strategy of empiric fast ventricular tachycardia (VT) zone programming with anti-tachycardia pacing as a means of reducing ICD shocks. Methods: One hundred eight patients implanted with ICDs between January 2006 and June 2008 for primary prevention of SCA had empiric ATP (burst, ramp, then shocks) programmed for rates between 170 and 200 bpm. The ventricular fibrillation zone was set for rates over 200 bpm with all shock therapies. Supraventricular tachycardia discriminators were programmed at nominal settings. Device interrogations in patients with ICD therapies were evaluated and classified as either appropriate (ventricular origin) or inappropriate (supraventricular, noise, or electromagnetic interference). Results: Of the 108 patients, 37 (34%) patients had therapies detected in the VT zone. Eighteen (16.7%)

patients had appropriate therapies for VT, 15 (13.9%) patients had inappropriate therapies arrhythmias that were either supraventricular or noise, and four (3.7%) patients had both appropriate and inappropriate therapies in the VT zone. Conclusions: Our data suggest that a significant number of patients (20.4%) implanted with ICDs for primary prevention will experience ventricular tachycardia. While programming empiric ATP for slower VT will successfully terminate these arrhythmias, there is also a high rate of inappropriate shocks for non-ventricular arrhythmias (13.9%). Further large-scale studies are needed to determine how best to decide which patients should have empiric ATP for slower VTs.

Empiric ATP in primary prevention: mixed effects foster mixed emotions

Number (%)

Appropriate VT therapy 18 (16.7%)

Inappropriate VT therapy 15 (13.9%)

Appropriate and inappropriate therapy 4 (3.7%)

15-64 Abstract 19-19

Incidence of sprint fidelis lead failure—our experience

Pedro Carmo1, Diogo Cavaco1, Sergia Rocha1, Joao Brito1, Pedro Sousa1, Katya Santos1, Francisco Morgado1, Pedro Adragao1

JHospital de Santa Cruz, Carnaxide, Portugal

Purpose: Sprint fidelis high-voltage lead wire is associated to an increased risk of fracture which can cause device failure and the deliver of repeated, jeopardizing shocks. Reports from Medtronic indicate an incidence of lead malfunction at 4 years of 7.2%. The aim of this study was to assess the actuarial survival of all sprint fidelis lead implanted in our center. Methods: We studied 134 sprint fidelis leads implanted at our centre between March 2005 and September 2007. Lead failure data were registry prospectively collected. Results: Between March 2005 and December 2009, ten sprint fidelis leads (7.5%) failed. The mean follow-up was 2.6± 1.3 years, and the mean time until fracture was 2.3 ±1.0 years. There is an increase in the hazard of failure with time, but that difference is not significant. Seven pts received inappropriate shock therapy as the primary manifestation of lead malfunction. None of these pts had the lead integrity alert (LIA) installed, and there was not an increase in impedance at the last routine consultation before fracture. The remaining three lead failures were detected due to LIA activation (two) and to an increased lead impendence at routine consultation (one). In a landmark analysis at 2 years of follow-up, our incidence of failure (4/127=3.1%) was significantly higher than the Medtronic

reports (221/19878 = 1.1%, odds ratio=6.4; 95%CI 2.914.0). Conclusions: The incidence of sprint fidelis failure in our population is higher than in Medtronic reports. Fractures were most of the time unexpectedly exposing pts to an elevated risk of inadequate therapies.

15-65 Abstract 19-08

Extended follow-up of a cohort of patients with implantable cardioverter defibrillators

Nestor Galizio1, José L Gonzalez1, Lucas Valtuille1, Luis Medesani1, Marcelo Ramirez1, Federico Robles1, Ramón Raña , Sebastian Schanz

Electrophysiology Division, Favaloro Foundation - University Hospital, Buenos Aires, Argentina

Purpose: In a previous report, we found some predictors of appropriate shocks (AS) and death in 188 pts with first-implanted ICD during a follow-up of 16 months. We hypothesized that by extending the follow-up, we could find more data about the incidence and predictors of AS and death. Methods: From January 2004 to October 2009, the same cohort of 188 pts was followed prospectively (26.2 months, IQR 14.537.3 months). Secondary prevention (SP) or primary prevention (PP) pts with SCD-HeFT or MADIT II criteria were included. Event-free survival was analyzed with Kaplan-Meier curves and Cox regression analysis. Results: Baseline characteristics: age 59 ± 13 years (79% male), NYHA classes III—IV 36%, serum creatinine 1.2 mg/dl, mean QRS 131 ms, and left ventricular ejection fraction (LVEF) 24%. PP pts (n = 111— 59%) showed higher incidence of NYHA classes III-IV (36% vs 16.3%, p=0.008), wider QRS (141 vs 129 ms, p=0.01), and lower LVEF (24% vs 32.3%, p=0.0005) compared to SP pts (n=77-41%). Incidence of AS was 16.6% in PP vs 40% in SP (RR 3.3, p=0.0003). There was no difference between time to first AS between both groups. Survival free of ICD AS was 77% in PP and 47% in SP (p=0.0064). By multivariate analysis, only previous VT/VF predicted ICD AS (RR 2.49). Thirty-two pts died (17%). No differences were found between PP and SP in death-free survival (25% vs 23%, p=0.7). Mean time to death was 15.3 months in PP and 24.3 months in SP (p=0.03). Death-free survival in NYHA IMV pts was 48.1% and 66.8% in NYHA I-II pts (p=0.008). Multivariate Cox regression analysis revealed NYHA classes III-IV (RR 2.1) and LVEF <20% (RR 2.3) to be independent predictors of death (p=0.0007). Conclusions: In our study population, an extended follow-up period led to a higher incidence of events. Multivariate analysis showed previous VT/VF as an independent predictor of AS. LVEF<20% was found to be an independent predictor of death in addition to the previously reported NYHA classes III-IV.

15-66 Abstract 19-07

Exercise test provoked ventricular tachycardia is a strong prognostic sign for sudden death in asymptomatic patients with arrhythmogenic right ventricle

Andras Janosi1, Hajnalka Vago2, Marta Hubay3 Ill.Internal Department Cardiology, Szent Janos Korhaz, Budapest, Hungary; 2Semmelweis University Cardiology Center, Budapest, Hungary; 3Institute of Legal Medicine, Semmelweis University, Budapest, Hungary

Limited data are available about natural history of asymptomatic patients (pts) with arrhythmogenic right ventricle cardiomyopathy (ARVC) who have a ventricular tachycardia (VT) during exercise test (ExT). A 25-year-old female patient was treated with osteosynthesis because of ankle injury. Cardiology consultation was performed because of an abnormal ECG. Physical examination was normal. ECG showed a normal sinus rhythm, left axis deviation, negative T-waves in leads II, III, aVF and V2-V6.. Chest X-ray and laboratory findings were normal. Echocardiography showed normal ejection fraction (EF) along with inferior akinesis and dilated right ventricle (RV). Bicycle ExT revealed a good exercise tolerability (9 MET), and after sporadic ventricular extrasystoles (VE), VT developed lasting for 3 min, which spontaneously stopped after aborting the test and performing abdominal strain. MRI study was performed, which has shown normal left ventricular size, wall motion and EF, and depressed RV function (EF 31.6%) enlarged right ventricular end-systolic and diastolic volumes, hypo-akinetic regions without aneurysm and bulging. No contrast enhancement was seen in the thin RV wall. According to abnormal ECG and MRI findings, ARVC was diagnosed. No ICD implantation was indicated because the patient was asymptomatic, and no sudden cardiac death occurred in the family. Three months later, the patient was found dead. At autopsy, the RV chamber was markedly enlarged, with multiple translucent areas of fatty accumulation accompanied with extended myocyte loss. There was a characteristic triangle dysplasia: the inflow, outflow tracts and apical areas. The coronaries were free of atherosclerosis. Mallory's phosphotungstic acid-hematoxilin stain demonstrated the presence of fibrosis within the scattered myocardium. Conclusion: Malignant ventricular arrhythmia provoked by ExT in an asymptomatic patient with negative family history should be an indication for ICD implantation.

15-67 Abstract 19-15

Prevalence of j point elevation in the survivors of ventricular fibrillation and their first-degree relatives

Laurence M Nunn1, Justine Bhar-Amato1, Syed Ahsan1, Vineet Wadhera1, Martin D Lowe1, Perry M Elliott1, William J McKenna1, Pier D Lambiase1 JHeart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: J point elevation (JPE) or early repolarisation is known to have significantly higher prevalence in survivors of idiopathic ventricular fibrillation (IVF) than in matched healthy controls. Prevalence in families of IVF survivors is unknown. The purpose of this study was to examine prevalence of JPE amongst VF survivors and their first-degree relatives screened in a specialist clinic. Method: ECGs recorded during admission of 22 VF survivors and clinic assessment of 23 first-degree relatives were evaluated. Survivors with coronary artery disease or structurally abnormal hearts were excluded from analysis. Established definition of JPE of at least 0.1 mV from baseline present in two or more of the inferior (II, III and aVF) or lateral (1, aVL, V4-6) leads was used. Data were compared to age- and sex-matched normal controls. Results: Brugada syndrome (BrS) was diagnosed in five survivors (type 1 Ajmaline response, all gene-negative) and long QT syndrome (LQTS) in four survivors (three tested gene-positive). The remaining 13 had IVF. Six of idiopathic group and five of channelop-athy group had JPE (50% overall incidence, mean age 45.3 years, 73% male). JPE is present in 30% of first-degree relatives (mean age 45.7 years, 57% female) vs. 9% of matched controls (p<0.05). The most commonly recorded in inferior leads amongst relatives and lateral leads amongst survivors are present in an average of four leads in both groups. Clinical screening established diagnosis of BrS in one relative, LQTS in two relatives and confirmed five unaffected by diagnosis established in the family. Signal-averaged ECG was negative for late potentials in 80% of survivors and 100% of relatives with JPE. Conclusions: There is a higher prevalence of infero-lateral JPE amongst survivors and first-degree relatives of IVF and VF secondary to channelopathy. This suggests that an inherited early repolarisation abnormality may be the primary cause or important disease-modifying factor

promoting ventricular arrhythmia in cases of VF in the absence of coronary artery or structural heart disease.

15-68 Abstract 01-01

Medical emergencies and sudden cardiac deaths (SCD) at days (n = 34) of zero geomagnetic activity (GMA), 2002-2007

Stoupel Elyiahu1, Elchin Babayev2, Evgeny Abramson3, Jaqueline Sulkes3

1Cardiology Division, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tiqwa, Israel; Astrophysics, Azerbaijan National Academy of Sciences, Baku, Azerbaijan; Menaging Data Center, Rabin Medical Center, Petah Tiqwa, Israel

Recent studies show for many medical-biological parameters inverse links with GMA. The aim of this study was to study the dynamics of medical events not only at extremely low GMA levels but also at zero geomagnetic conditions, namely to check the number of medical events and specific death number trends at days of—daily zero—GMA. Patients and methods: Daily data came from Grand Baku Area (Azerbaijan, 3.0 million population) in accordance to the WHO standards for the period 01 December 2002-31 December 2007. About

1,567,576 emergency calls and 46,350 deaths, 10,054 cerebral strokes (CVA), 7,817 AMI, and 1,608 SCD were analyzed. In addition to cardiology data, trauma (n = 54,654) and infections (n = 18,838) were also included in the study on 1,837 consecutive days. According to daily GMA indices, K=0 were at 34 days and K>0 at 1,823 days. Daily cosmic ray activity (CRA) was studied as a parameter antagonistic to solar and GMA. CRA was presented by neutron activity on the Earth's surface in imp/min. Space weather data used were from the US, Russian and Finland space science centers. Results: All emergencies (n = 1,567,576, p<0.0001) and all deaths (n=46,350, p=0.0076) were revealed at days of zero level of GMA. Absolutely more (+5.0%) deaths from acute myocardial infarction (AMI), cerebral stroke (CS, +14.28%), sudden cardiac death (SCD, +17.08%), and trauma (+4.0%) were registered at geomagnetical zero days. Only for CS (n = 10,054)) and SCD (n = 1,615), a strong trend level was achieved. For MACE (AMI, CVA, SCD), the difference was p=0.058. The neutron activity on the Earth's surface was higher (p<0.0001) at days of "0" GMA. For achieving the statistical significance for CS and SCD, such days' number must be approximately three times higher (99-100). Conclusion: On days of zero GMA and high CRA neutron activity, the number of cardiovascular emergencies and deaths show a trend to rise compared to days with higher GMA. Between compared pathologies, SCD- and CVA-related deaths are the most prominent ones.

Session C Part 2 Techniques and tools 15-69 Abstract 05-10

Ventriculo-atrial index: a simple tool to differentiate atrioventricular nodal reentrant tachycardia and orthodromic reciprocating tachycardia utilizing a concealed septal accessory pathway

Mohammed Abdelhamid1, Hussein Shaalan1, Lamia Allam1, Said Khaled1

Cardiology, Ainshams University, Cairo, Egypt

Background: Distinguishing atrioventricular nodal reentrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT) utilizing a concealed septal accessory pathway (Sept-AP) may be problematic due to the presence of concentric atrial activation sequence in both. We studied the use of ventriculo-atrial (VA) interval (VAI) and index (VA index), measured during right ventricular (RV) pacing at apical and basal sites, to differentiate between them. Methods: Sixty patients were included (33 had AVNRT and 27 had ORT utilizing a concealed Sept-AP as follows: 15 right posteroseptal, 9 anteroseptal, and 3 left posteroseptal AP). RV pacing was performed during sinus rhythm at two sites: RV apex and RV base (below tricuspid ring towards the septum) at appropriate cycle length (CL, shorter than basic CL and longer than Wenkebach point of AV node or point of VA block of AP). VAI (interval from stimulus artifact to a stable atrial reference located at high right atrium) was measured at each site and VA index was calculated (VAI at the apex minus VAI at the base). Results: During apical RV pacing, significantly shorter VAIs were noted in the AVNRT group compared to the ORT group (132.4±34 vs 161.4±17 ms, p<0.05). During basal RV pacing, significantly longer VAIs were noted in the AVNRT group compared to the ORT group (161.5±28 vs 132.1 ± 15 ms, p<0.05). The VA index was always negative in the AVNRT group, while it was always positive in the ORT group (-29.1±11 vs 28.4±5 ms, respectively, p<0.01). After ablation of the Sept-AP, the VAI measured at the base increased significantly (179.3±4 ms post-ablation vs 132.1 ± 5 ms pre-ablation, p<0.01), turning the VA index to become negative (28.4±5 ms pre-ablation vs -18.2±3 ms postablation, p<0.01). Conclusions: A positive VA index can easily and accurately differentiate between ORT utilizing a

concealed septal-AP and AVNRT. A negative VA index after ablation of Septal-AP can prove the success of ablation.

15-70 Abstract 07-01

Influence of ischemia and coronary reperfusion on rpeak-rend interval and QT index in ST segment elevation myocardial infarction patients

Sana Ouali1, Lobna Laaroussi1, Slim Kacem1, Rim Gribaa1, Sami Hammas1, Sahbi Fradi1, Elyes Neffeti1, Fahmi Remedi1, Essia Boughzela1 Cardiology, Sahloul Hospital, Sousse, Tunisia

Introduction: TpTe and QT index were investigated in control healthy subjects and before and after primary percutaneous coronary intervention (pPCI) in patients with ST segment elevation myocardial infarction (STEMI). The present study investigated whether several ECG markers of ventricular repolarization are influenced by ischemia and coronary reperfusion. Methods: The study population included 60 patients with STEMI treated with pPCI (56 men; mean age, 56.8± 12 years) and 62 healthy control subjects (60 men; mean age, 53.8±11 years). A 12-lead ECG was recorded for each control subject (group A) and before (group B) and after (group C) pPCI in STEMI patients. QT and Tpeak-Tend intervals were measured in leads with limited ST segment deviation in STEM patients and in the lead showing the longest QT in control subjects. Tp-e/QT ratio and heart rate (HR)-corrected QT intervals (Bazett, Fridericia and Framingham, corrected QT) were also calculated in each patient. The primary end point was hospital mortality and ventricular arrhythmias. Results: In patients with acute STEMI either in pre- or post-pPCI, the Tp-e interval and Tp-e/QT ratio were significantly increased as compared to normal controls (P < 0.0001). Tp-e and Tp-e/QT decreased after pPCI (Tp-e interval=92.2±15.7 vs 87.9±13.7 ms, P=0.091; Tp-e/QT=0.25 vs 0.24, P=0.04). HR-corrected QT intervals prolonged after pPCI, but there was no statistically significant difference. A prolonged post PCI Tp-e was associated with increased hospital mortality and ventricular arrhythmias (106.7±15 vs 85.6±11.8 ms, P < 0.0001). Conclusion: The Tp-e/QT ratio is significantly greater in the patients at risk for arrhythmic event such acute myocardial infarction patients, suggesting the amplification of dispersion of repolarization. Tp-e interval and Tp-e/QT ratio decreased after coronary reperfusion. In patients with STEMI undergoing pPCI, post-PCI Tp-e predicted hospital mortality and ventricular arrhythmias.

15-71 Abstract 07-02

Application of new task force criteria for diagnosis of arrhythmogenic right ventricular dysplasia/ cardiomyopathy

Moniek GPJ Cox1, Jasper J van der Smagt2, Maartje Noorman3, Ans C Wiesfeld4, J Peter van Tintelen5, Douwe E Atsma6, Paul GA Volders7, Arthur AM Wilde8, Richard NW Hauer9

1Cardiology, UMC Utrecht + Interuniversity Cardiology Institute of the Netherlands, Utrecht, Netherlands; 2Medical Genetics, UMC Utrecht, Utrecht, Netherlands; Medical Physiology, UMC Utrecht + Interuniversity Cardiology Institute of the Netherlands, Utrecht, Netherlands; 4Cardiol-ogy, UMC Groningen, University of Groningen, Groningen, Netherlands; 5Medical Genetics, UMC Groningen, University of Groningen, Groningen, Netherlands; 6Cardiology, UMC Leiden, Leiden, Netherlands; 7Cardiology, Maastricht University Medical Center, Maastricht, Netherlands; 8Cardiology, Academic Medical Center, Amsterdam, Netherlands; Cardiology, UMC Utrecht, Utrecht, Netherlands

Background: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Diagnostic Task Force criteria (TFC) proposed in 1994 are highly specific but lack sensitivity. A new international Task Force will publish modified criteria to improve diagnostic yield. Aim: The aim of this study was the comparison of diagnosis by 1994 TFC versus the newly proposed criteria in three patient groups. Methods: In new TFC, scoring by major and minor criteria is maintained. Structural abnormalities are quantified and TFC highly specific for ARVD/ C upgraded to major (see table). Also, new criteria are added: terminal activation duration of QRS>55 ms, VT with LBBB morphology and superior axis plus genetic criteria. Three groups were studied: (1) 105 patients with proven ARVD/C according to 1994 TFC (ARVD/C pts), (2) 89 of their family members (Fam) and (3) 39 patients with probable ARVD/C (i.e. three points by 1994 TFC; TFC3 pts). ECGs were scored while off drugs. All pts and Fam were screened for pathogenic mutations in desmo-somal genes. Results: Three ARVD/C pts did not meet the new sharpened criteria on structural abnormalities and thereby did not fulfill new TFC. In 62 of 105 proven ARVD/C patients, mutations were found, 58 in the gene encoding Plakophilin2 (PKP2), three in Desmoglein2, two

in Desmocollin2 and one in Desmoplakin. Three patients had bigenic involvement. Ten additional relatives (11%) fulfilled new TFC: nine (90%) were females and all carried PKP2 mutations. No relatives lost diagnosis by application of new TFC. Of probable ARVD/C patients, 25 (64%) fulfilled new TFC: 8 (40%) females and 14 (56%) carrying pathogenic mutations. Conclusions: In this first study applying new TFC to patients suspected of ARVD/C, 64% of probable ARVD/C patients and 11% of family members were additionally diagnosed. Especially ECG criteria and pathogenic mutations contributed to new diagnosis. Newly proposed TFC have a major impact in increasing diagnostic yield of ARVD/C.

ARVD/C Family TFC3

patients members patients

(n = 105) (n=89) (n=39)

Age (years ± SD) 48±12 44±17 48±12

Male, n (%) 81 (77) 34 (38) 21 (54)

Diagnosis according to

1994 TFC n (%) 105 (100) 22 (25) 0

new TFC, n (%) 102 (97) 32 (36) 25 (64)

Main contributors to diagnosis in new TFC

n (%) n (%) n (%)

Major criteriaa

First-degree relative with n.a. 74 (83) n.a.

ARVD/Cb

Pathogenic mutation 62 (59) 59 (66) 16 (41)

Negative T-waves in V1-3b 70 (67) 15 (17) 17 (44)

LBBB VT with superior 45 (43) 2(2) 14 (36)

Minor criterion

Terminal activation duration 56 (53) 25 (28) 16 (41)

of QRS>55 msc

aMajor criterion = 2 points, minor criterion = 1point bMinor in 1994 TFC, upgraded to major in new TFC cMeasured from nadir of S wave to end of all depolarization

15-72 Abstract 05-01

Prevalence and spectrum of abnormal electrocardiograms in patients with an isolated congenital left ventricular aneurysm or diverticulum

Marc-Alexander Ohlow1, Bernward Lauer1, Christoph Geller2

department of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany; 2Invasive Electrophysiology, Zentralklinik Bad Berka, Bad Berka, Germany

Aims: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac anomalies and can be associated with ECG abnormalities and rhythm disturbances. We sought to investigate the prevalence and the spectrum of ECG abnormalities in such patients. Methods: We assessed 125 patients with isolated LVA or LVD for the prevalence of ECG abnormalities and compared the findings to an age- and gender-matched control group. The 12-lead ECG patterns were evaluated according to commonly used criteria and were classified into three subgroups (distinct, mildly, and minor). Results: Fifty-four of the 125 patients (43.2%) had normal and 71 (56.8%) had abnormal ECGs. Mean age was 66 years. Forty-nine (39.2%) were male. Distinct abnormal ECG patterns were more prevalent in patients with LVD (38.2% versus 15.8%, p=0.04) and apical location of the anomaly (36.6% versus 16.6%, p=0.02). Older age (>66 years) was associated with a trend for a higher prevalence of abnormal ECG pattern (33% versus 18%, p=0.06), whereas gender had no influence (32% versus 16%, p=0.14). This study also shows that the sensitivity, specificity, positive, and negative predictive value of a 12-lead electrocardiogram for the diagnosis of LVA or LVD is low. Conclusions: This large single-center study suggests that the prevalence of abnormal ECG patterns in patients with isolated LVA or LVD is as high as 56.8%. However, ECG is not specific and sensitive to be used as a screening tool in such patients.

15-73 Abstract 04-07

extracted, and Lyapunov exponent expressing local divergence and correlation dimension expressing degrees of freedom were calculated and correlated with age. For calculation, an embedding dimension of 30 was used. Results: There was no gender difference of Lyapunov exponents and correlation dimension of the RR intervals. Correlations are seen in the figure. Conclusion: Both Lyapunov exponent and correlation dimension are positively correlated with age.

äo 3b 40 ä) 60 70 SB at age [y]

Age dependence of nonlinear dynamics in heart rate variability

Morten Skou Nielsen1, Fan Wang1, Esben Vedel-Larsen2, Charlotte E Larroude2, Niels-Henrik Holstein-Rathlou3, Jens Christian Jakobsen , Prof. Jorgen K Kanters

Laboratory of Experimental Cardiology, University of Copenhagen, Copenhagen N, Denmark; Dept. of Cardiology, Gentofte University Hospital, Copenhagen, Denmark; 3Dept. of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark

Objective: The objective of this study was to examine how nonlinear dynamics characteristics change with age. Methods: Holter recordings were obtained from a total of 68 healthy individuals aged from all decades from 20 to 80 years (43 women and 25 men). RR interval series were

15-74 Abstract 01-06

Wavelet analysis of atrial depolarization patterns in young athletes of rowing

Vasilios Vassilikos1, Dr. George Dakos1, Ioanna Chouvarda2, Lilian Mantziari1, Panagiotis Kalpidis1, Stelios Paraskevaidis1, George Stavropoulos , Nikolaos Maglaveras , Ioannis Styliadis1

11st Cardiology Dept, Aristotle University of Thessaloniki, Thessaloniki, Greece; Medical Informatics Laboratory, Aristotle University of Thessaloniki, Thessaloniki, Greece

The aim of this study was to investigate the atrial depolarization patterns in young athletes of rowing using P-wave wavelet analysis. Methods: Group A consisted of 14 athletes (13 men, mean age 24 ± 4 years) of the national

rowing team, while group B consisted of 50 patients (27 men, mean age 54 ± 10 years) with history of paroxysmal atrial fibrillation (PAF) and without organic heart disease. Control group C consisted of 50 normals (19 men, mean age 56 ± 9 years). The P-wave was analyzed during sinus rhythm using the Morlet wavelet and wavelet parameters expressing the mean and max energy of P-wave were calculated in the three orthogonal leads (X, Y, Z) and in the vector magnitude (VM) in three frequency bands (first, 200160 Hz; second, 150-100 Hz; and third, 90-50 Hz). Results: Group A subjects had lower heart rate compared to groups B and C patients (55 ± 12 vs 75 ± 7, p<0.001 and 77 ± 9, p< 0.001, respectively). In addition, they demonstrated lower mean and max in the first and second frequency bands at all axes and at the VM compared to groups B and C patients, while group C subjects showed lower mean in all frequency bands at X- and Z-axes compared to group B patients. P-wave duration at Z-axis (PdurZ) was significantly longer in group B compared to groups A and C patients (87.3 ± 13 vs 76.2 ± 9.4, p=0.004 and 71.5 ± 15, p<0.001, respectively). Multivariate analysis revealed PdurZ and mean energy in the second frequency band at Z-axis as significant and independent predictors ofPAF occurrence, holding Sn92% and 75%, Sp74% and 76%, respectively, for the discrimination between group A, group B, and group B, group C patients. Conclusion: It seems that young rowers demonstrate particular atrial depolarization patterns that are possibly due to increased vagal activity. Nevertheless, the parameters that can distinguish PAF patients from young athletes and normals remain the same.

15-75 Abstract 05-11

Diagnostic and prognostic value of the electrophysiological study in patients with non-documented palpitations

Ermengol Valles1, Victor Bazan1, Debora Cian1, Laura Portillo1, Miguel Guijo1, Desire Ruiz1, Jordi Bruguera1, Julio Marti1

1Cardiology, Hospital del Mar, Barcelona, Spain

Introduction: Documentation of the arrhythmia helps in predicting the tachycardia mechanism in patients presenting with palpitations, thus guiding the management. Documentation of the arrhythmia is not always feasible, generally due to self-termination. In these situations, the diagnostic value of electrophysiologic study (EPS) is of concern. Otherwise, we do not know the long-term prognosis of patients with undocumented palpitations. Methods: One hundred and seventy-two patients (132 women) with normal basal ECG and undocumented palpitations suggesting supraventricular tachycardia underwent EPS. Results: Symptoms were long in duration (>5 min) in 56%. Sudden termination was present in

65% and neck palpitations in 36%. EPS was abnormal in 86 patients: 43 atrioventricular nodal reentrant tachycardias (AVNRT), 9 orthodromic reentrant tachycardias (ORT), and 34 atrial tachycardia/fibrillations (AT/AF). Long duration episodes (p<0.001), sudden termination (p<0.001), and neck palpitations (p=0.01) were clinical predictors of arrhythmia induction and were also predictors of AVNRT (p<0.001). Patients were followed for 53±36 months. Patients with AVNRT or ORT underwent ablation and remained symptomfree at follow-up. Among patients with negative EPS, 92% remained symptom-free compared to 32% in the group with AT/AF (p<0.001). Kaplan-Meier analysis showed recurrence among those patients with diminished left ventricle ejection fraction (LVEF; p<0.0001), <50 years (p<0.0001), or AT/AF (p<0.0001). Age>50 years and diminished LVEF were independent predictors for recurrences in the multivariate analysis. Conclusions: Fifty percent of patients with undocumented palpitations have abnormal EPS. Certain clinical characteristics are helpful in predicting tachycardia inducibility and can help in selecting patients for study. Most of the patients with negative EPS results remain symptomfree at long-term follow-up. AT/AF induction, age>50 years, and diminished LVEF are predictors of recurrences.

15-76 Abstract 07-04

Prognostic value of restitution slope and other monophasic action potential characteristics during long-term follow-up in patients with ischemic and dilated cardiomyopathy

Marc Dorenkamp1, Andreas Morguet2, Christian Sticherling3, Steffen Behrens , Markus Zabel

Dept. of Cardiology and Pneumology, Georg-August-University of Gottingen, Heart Center, Gottingen, Germany;

Dept. of Cardiology and Pulmology, Charité—Universitats-medizin Berlin, Campus Benjamin Franklin, Berlin, Germany; 3Division of Cardiology, University Hospital Basel, Basel, Switzerland; 4Dept. of Cardiology, Vivantes HumboldtKlinikum, Berlin, Germany

Background: Steep action potential duration (APD) restitution has been proposed as a risk marker for malignant ventricular arrhythmias. We aimed to determine the long-term prognostic value of APD restitution and additional action potential (AP) characteristics in patients with ischemic (ICM) and dilated cardiomyopathy (DCM). Methods: Endocardial monophonic APs were recorded at two right ventricular sites in patients with ICM (n=32) and DCM (n=42) undergoing programmed ventricular stimulation (PVS). Left ventricular ejection fraction was 32 ± 7% and 28 ± 9%, respectively. APD and effective refractory period (ERP) were measured at baseline stimulation (S1) and upon introduction of one to three extrastimuli (S2-S4).

Restitution curves were created for each extrastimulus by plotting APD at 90% repolarization as a function of the preceding diastolic interval. Slopes were determined from linear fits of 40-ms diastolic interval segments. Results: Nineteen (59%) of ICM patients and four (10%) of DCM patients were subsequently treated with an implantable cardioverter-defibrillator (ICD). Inducible ventricular arrhythmias were found in 22 of74 patients (30%). Patients with ICM and DCM did not differ in APD restitution slope maximum (slope S2, 1.5 ± 0.7 vs. 1.4 ± 0.5; S3, 1.3 ± 0.3 vs. 1.5 ± 0.5; S4, 1.3 ± 0.5 vs. 1.3 ± 0.6; all ns) or in ERP/APD ratios (ratio S1,0.99 ± 0.09 vs. 0.97 ± 0.09; S2,0.97 ±0.13 vs. 0.96 ± 0.08; S3, 0.95 ± 0.13 vs. 0.92 ± 0.11; all ns). After a mean follow-up of 6.1 ± 3.0 years, 19 patients had died (26%) and ten (14%) had received an appropriate ICD shock. The combined end-point of mortality and and/or ICD shock was not predicted by APD restitution slope > 1, ERP/APD ratios, or APD itself. Positive PVS was predictive of outcome (p= 0.006). Conclusion: The maximum slope of ventricular APD restitution, APD, and ERP/APD ratios do not predict mortality in patients with impaired left ventricular function due to ICM or DCM.

15-77 Abstract 08-01

Sedation effects on electrophysiologic intervals

different from historical controls (Table 1). Sedated patients were older (53 vs. 45). There were no statistically significant differences between AH, HV, His duration, Wenckebach cycle length, and SACT. Conclusions: EP conduction intervals do not change in a clinically relevant manner during moderate intravenous sedation with morphine and midazolam.

Interval

Moderate sedation (ms)

Historical controls (ms)

P value

Mean ±2SD N Mean ±2SD N

23 3-43 336 27 9-45 61 <0.01

93 39-147 334 90 54-126 81 0.34

44 24-64 341 43 31-55 96 0.35

PA AH HV

His duration 19 11-27 184 19 13-25 88 1.00

Wenckebach 374 192-556 345 386 270-502 168 0.12

CSNRT 342 20-664 168 230 -60-520 245 <0.01

SACT 94 48-140 207 92 37-147 176 0.44

15-78 Abstract 04-08

Increased beat-to-beat repolarization variability during exercise is suppressed by beta-receptor blockade

John Fisher1, Mark Metzl1, Farbod Raiszadeh1, Marc Ostreicher1, Inna Nelipovich1

1Cardiology, Montefiore/Albert Einstein College ofMedicine, Bronx, NY, United States ofAmerica

Christina Abrahamsson1, CorinaDota1, Bo Skallefell1, Leif Carlsson1, Nils Edvardsson2, Göran Duker1 1AstraZeneca R&D Mölndal, Mölndal, Sweden; 2Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden

Introduction: Previously electrophysiologic (EP) studies (EPS) were done in the "non-sedated, post-absorptive state". "Normal" EP intervals came from EPS done under these conditions. Since the 1990s, we have done EPS with moderate intravenous sedation with midazolam and morphine (patients "asleep" but with protective reflexes intact and arousable with stimulation). The effect of such sedation on EP intervals has been unknown. We now report the effects of moderate sedation on routine EP intervals. Methods: From a computerized database of 4,216 patients, with exclusions described below, we measured the usual EP intervals. PA, AH, HV, His duration, Wenckebach cycle length, corrected sinus node recovery time (CSNRT), and sinoatrial conduction time (SACT) in 345 "normal" studies were compared with historical conduction intervals, defined by our laboratory among others, in the pre-sedation era. Exclusions for analysis of specific intervals were patients with known conduction abnormalities patients on medications affecting the conduction system. Results: Differences in PA interval and CSNRT obtained during EP studies under intravenous sedation were statistically

Background: Patients with congenital long QT syndrome (LQTS) benefit from treatment with beta-blockers. The mechanism of the protective effect against the development of torsades de pointes (TdP) has not been elucidated, and no electrophysiological effects of the treatment have been demonstrated. Therefore, the effect of propranolol on beat-to-beat repolarization (QT interval) variability, a tentative risk marker for TdP, was investigated in healthy subjects in the present study. Method: The repolarization variability, assessed with a new method which measures the beat-to-beat temporal variability of the T-wave down slope, deltaT50, was continuously monitored in eight healthy subjects (age 22-27 years, four men) during rest, deep breathing (0.1 Hz, DB), standing (ST), rest on the ergometer bicycle (RoB), and ergometer bicycling aiming at a heart rate (HR) of 100 bpm (BE). The protocol was repeated after infusion of 0.2 mg/kg propranolol. Results and conclusion: The increase in deltaT50 induced by the exercise was abolished after treatment with propranolol. As propranolol did not influence the heart rate, the protective effect of beta-receptor blockade against TdP may hypothet-

ically be attributed to preserved repolarization stability during sympathetic activation.

Telemedicine and remote monitoring 15-79 Abstract 22-04

Centralized daily wireless remote home monitoring in a prospective, multicenter study: effort and effect on the clinical management of patients with devices

T Vogtmann1, A Marek1, S Stiller2, V Kühlkamp3, S Löscher4, J Schaarschmidt1, S Kespohl5, G Baumann1

1CC 13, CCM, Cardiology and Angiology, Chanté Universitätsmedizin Berlin, Berlin, Germany; 2Cardiology, University Ulm, Ulm, Germany; Herzzentrum Bodensee, Konstanz, Germany; 4Cardiology, Hospital St Georg, Leipzig, Germany; 5Biotronik, Berlin, Germany

Introduction: Fully automatic daily transmitted event/status reports of device patients of nine satellite clinics were centrally analyzed in the Home Monitoring Center (MoniC) of Charité, Universitätsmedizin Berlin. For the first time, the prospective multicenter study collected structured data about coverage of Home Monitoring days, patient compliance, and effort to restore data transmission after a discontinuation. Methods: One hundred twenty-one patients (59 ICD, 62 PM) were monitored over 391± 156 days. The incoming data from the device were screened for clinical relevance by a specially trained nurse. In the case of a discontinuation of transmission of more than 1 week, she contacted the patient and offered telephonic technical support, if required. Results: Eighty-nine percent of all 47.343 monitored patient-days were covered by event/ status reports. In only 11% of all pts, the days covered was <75%. There were 170 gaps in transmission of >1 week (median 1, range 0-9). Sixty-seven percent of all pts had at

60 HR-bpm

40 20 0

least one transmission gap, with one third of them occurring within the first 2 weeks after Home Monitoring activation. Ninety percent of user errors, counting for 46% of all gaps, could be solved by telephone support, with a time effort of 140 s per workday on 100 monitored patient-days. In 32% of gaps, the pt was absent from his home; in 21 of 170, the reason remained unclear after a call. Ninety-seven percent of all patients remained in the study without terminating the Home Monitoring prematurely. Conclusion: Fully automatic, wireless Home Monitoring covers nearly 90% of all monitored days. For nearly 90% of pts, an event/status report was received on >75% of monitored days. Majority of HM transmission gaps occur within the first 2 weeks after hospital discharge. A scheduled telephone check/ support shortly after discharge might improve this. Telephone technical support is highly effective while solving 90% of user errors and is with an averaged daily time effort of 2 min per 100 monitored patient-days.

15-80 Abstract 05-04

Latitude vs. Carelink: there is a difference

Kousik Krishnan1, Jeanine Murphy1, Courtney Schuten1

Cardiac Electrophysiology, Rush University Medical Center, Chicago, United States of America

Introduction: Remote monitoring systems aim to decrease the amount of time needed to perform ICD evaluations and provide device clinics with increased efficiency. The Latitude TM (Boston Scientific Corp.) and Carelink TM (Medtronic Corp.) remote monitoring systems are used most frequently. There are no published comparisons of the two systems by experienced users performing the same

ddtuTÜO, *

ms 1,5

11 i 11

Rest DD ST Roß BE Rest DB ST Roß BE □ DeltaT50 Baseline! ■ Relia ESO Propranolol □ HR Baseline ■ HR Propranolol

tasks in both systems. Methods: We compared the amount of time it took two certified Cardiac Device Specialist (CCDS) RNs to complete nine (total 18) remote downloads. One nurse used the Latitude system, while the other nurse used Carelink. Both nurses have over 9 months of experience with their respective systems. The two nurses evaluated a matched distribution of device types (single-chamber, dual-chamber, and cardiac resynchronization therapy defibrillators). Time was measured from opening web site patient data to time the report was sent to a printer. The mean times were compared using a one-tailed, homoscedastic t test. Results: Both nurses evaluated two cardiac resynchronization therapy defibrillators, two dual-chamber defibrillators, and five single-chamber defibrilla-tors. The mean time for the Latitude report download was 70 s versus 116 s for the Carelink report (p=0.0005). Conclusion: The results of our study suggest that the download time for an experienced CCDS nurse is significantly different between the Latitude and Carelink systems. Although time difference per patient is small, the resources of clinics that follow a large number of device patients may be impacted negatively if Carelink is the dominant follow-up system. This may influence devices chosen for implantation as busy electrophysiology practices transition from in person device evaluations to remote evaluations.

15-81 Abstract 05-03

Latitude expertise: a short climb to the summit

Kousik Krishnan1, Courtney Schuten1, Julie Saunders1, Jeanine Murphy

Cardiac Electrophysiology, Rush University Medical Center, Chicago, United States of America

Introduction: Recent advances in ICD monitoring have allowed a large population of patients to be followed remotely. While this new technology has been welcomed in some clinics, others may be hesitant to adopt these systems due to concerns related to technologic barriers and inefficiency of less experienced staff members. Methods: We compared Latitude TM (Boston Scientific Corp.) remote evaluations performed by three nurses in our device clinic. Two nurses (novices) were new to the system, and one nurse (expert), a certified Cardiac Device Specialist (CCDS), had over 1 year of experience with the system. Each nurse performed 15 downloads. Timing was recorded independently for remote follow-up data download and data entry into an EMR (Paceart TM, Medtronic, Minneapolis, MN). These two times were added to calculate a total time. Times required for the first ten download and the last five download of the novice nurses were compared to those of the expert nurse. A one-tailed, homoscedastic t test was

used to compare mean times. Results: The mean data download times for the first ten patients were 94 and 76 s for novices and expert, respectively (p=0.017). The mean times for the final five downloads were 76 and 70 s for the novices and expert (p=0.273). The mean time for the EMR data entry for the first ten downloads was 247 and 98 s for novices and expert, respectively (p=0.004). The mean time for the final five downloads was 209 and 146 s for the novices and expert (p=0.123). The mean time for the total evaluation time for the first ten downloads was 342 and 161 s for the novices and expert, respectively (p=0.004). The mean time for the final five downloads was 286 and 216 s for the novices and expert (p=0.11). Conclusions: The Latitude Remote Monitoring System has a very rapid learning curve. After ten patient evaluations, novice Latitude users can complete a full device evaluation almost as quickly as a CCDS.

15-82 Abstract 05-05

Practical benefits of a telemedicine supervision of heart rhythm disturbance

Songuel Secer1, Tanja Feige1, Britta Graefe1, Otto Wagner1, Jan Gummert2, Heinrich Koertke1 1Insitut fur angewandte Telemedizin, Herz

Backgrounds: In 50% of symptomatic heart rhythm, disturbances are diagnostically not clarified. This problem cannot be identified by long-term ECG. Telemedicine is an important component in the care of patients with heart rhythm disturbances. Fifty percent of cases show an asymptomatic course and 50% shows a symptomatic course. With telemedicine, a better antiarrhythmic therapy can initiate early under safety of anticoagulation. Methods: Patients get necessary telemedical equipment in the form of a mobile single-channel ECG (Holterphone) to record the heart rhythm disturbances. The patients receive the instruction in the use of the equipment through the practicing physician or the institute for applied tele-medicine (IFAT). All patients have to observe their regular care by a family doctor at home. The ECGs should be transmitted every week by telephone or by acoustic coupler. Considering data security and medical confidentiality, patient data were collected and interpreted 24/7. Results: From 2004 to 2005, 850 patients were treated by telemedicine. The first 322 patients (66.1% male, 33.9% female; mean age+SD male 62.13 + 14.8 years, female 60.46 + 15.6 years) were analyzed. From this observation time, five patients (1.55%) died. Over 2,138 ECGs were transmitted. Of the ECGs, 12.6% (270 ECGs) had an intermittent atrial fibrillation (AF), 5.4% (116 ECGs) present a permanent AF, 1.3% (28 ECGs) had a persistent

AF, and 79.4% (1697 ECGs) had a sinus rhythm. Because of the bad quality, 1.2% (27 ECGs) could not be analyzed. Bradyarrhythmia absoluta were identified in 6% (812 ECGs) and tachyarrthmia absoluta in 8% (818 ECGs). Seventy-six patients (28.1%) with intermittent AF were symptomatic; the rest were asymptomatic. Conclusion: The results of these examinations show that an intermittent AF could be discovered in 270 ECGs (12.6%). Twenty-five percent of patients were asymptomatic. The results show that the number of treatment has increased. To reduce the complication, oral anticoagulation is necessary.

15-83 Abstract 05-06

Remote monitoring and prevention of clinical events with the Biotronik home monitoring system

Matteo Lori1, Gino Lolli1, Nicola Bottom1, Fabio Quartieri1, Marco Parravicini2, Carlo Menozzi1

1Cardiology, ASMN, Reggio Emilia, Italy; 2Biotronik-SEDA, Milan, Italy

Introduction: The latest technological development in implantable devices has allowed, with the remote monitoring systems, the remote transmission of a remarkable volume of clinically relevant device-related and physiologic data. Goals: The goal of this study was a retrospective evaluation of using the Biotronik Home Monitoring (HM) system in our centre in order to

establish its reliability in the monitoring of the main parameters of patients with implantable devices, as well as its possible impact on the clinical management of these patients. Methodology: Twenty-seven ICDs and two PMs have being monitored with the HM system. From the organisational point of view, two individuals are responsible for the remote monitoring of these patients: one nurse of the EP lab, appointed to periodically check the condition of the patients in monitoring, and one EP physician, appointed to evaluate the received notification messages. The devices were checked, as usual, through both scheduled and non-scheduled outpatient FUs. Results: During a period of about 4 years, a close correlation between the data achieved through nonremote FU and those derived from the remote FU has been identified. Absent notifications or false notifications, as regards stimulation and shock impedances, battery charge and arrhythmic episodes, were not observed. Moreover, remote monitoring has made it possible to anticipate and then to prevent some clinical events in as many patients, leading us to a valuable early detection system. Conclusions: The Biotronik HM system has demonstrated to be reliable to the point that it can replace the outpatient FUs of the implantable devices, giving the possibility to extend up to 12 months the interval between the outpatient FUs, enabling in this way a possible reduction in human resources. Moreover, this system has shown that it is remarkably capable of supplying, in a very timely manner, useful information to prevent more serious clinical events.

SATURDAY APRIL 17, 2010, 2:00 pm-5:00 pm Chaired Poster Session D Part 1

Catheter ablation of tachyarrhythmias 16-84 Abstract 18-01

Method for predicting lesion size shortly after onset of RF energy delivery

Ding Sheng He1, Micheal Bosnos2, Guillen Jose2, Frank I Marcus2

Bard, Lowell, United States of America; University of Arizona, Tucson, United States of America

Predicting lesion size is critical to the success of RF-based catheter ablation. Multifactors influence lesion size, such as tissue-electrode contact force, ablation energy level, cooling factors, i.e., blood flow rate, tissue perfusion, and RF energy delivery duration. There is no currently available technology to accurately predict lesion size within seconds of onset of RF energy delivery. Methods: In vitro experiments were performed with a 7-F quadruple catheter with a 4-mm distal electrode, which was placed on fresh bovine myocardium immersed in circulating blood and oriented perpendicular to the surface under a weight of 15 g. Unipolar pulsed RF energy (300 kHz) was applied to the electrode for 500 ms on pulse cycle followed by a 500-ms off period. Impedance (Z) and phase angle (O), 300-kHz RF current (I), voltage (V), and power (P) were recorded during the RF on-phase. Electrode temperature (Te) was recorded during the entire cycle time. Changes in several biophysical parameters of cardiac tissue within 5-15 s of the onset of RF delivery were evaluated to predict lesion formation at 120 s. Changes in Z, O, and the resulting resistance (R) and capacitance (C), P, and Te during RF ablation were analyzed. Stepwise multiple linear regression analysis was conducted with a full model which included: percent changes of impedance with 300-kHz unipolar, 5- and 800-kHz bipolar RF R, O, and C. Results: At 5 s, the predicted value of the lesion volume was very close to the actual measured value in gross pathology. When using the combination of R, peak P, Z, time to peak P, and 300-kHz unipolar Z to correlate lesion size, r value was 71% at 5 s. Conclusions: Parameters relating to tissue change, i.e., changes of Z and O as well as P, can predict lesion size in vitro in the first few seconds from the onset of RF delivery. A

combination of these parameters provides better correlation with lesion formation than a single parameter.

16-85 Abstract 07-09

Catheter ablation of tachyarrhythmias in patients with d-transposition of great arteries: outcome, recurrence rate and predictors of recurrence

A B Gopalamurugan1, Umesh Vivekananda1, Girish Ganesha Babu1, Syed Ahsan1, Pier Lambiase1, Anthony Chow1, Martin Lowe1

The Heart Hospital, London, United Kingdom of Great Britain and Northern Ireland

Introduction: Patients with d-transposition of great arteries (d-TGA) have a high incidence of atrial arrhythmias that may be treated with catheter ablation. However, recurrence rate and predictors of successful ablation have not been reported before. Methods: Patients with d-TGA who underwent catheter ablation in our centre were analysed. Patient demographics, echocardiographic parameters, electrophysiological study and ablation details and follow-up details were obtained. Immediate success was defined as ablation resulting in sinus rhythm and non-inducibility of tachyarrhythmias at the end of the procedure. Results: Thirteen patients were studied: 9 in 13 (69%) had isolated d-TGA. Four in 13 (31%) had associated anomalies: one tricuspid atresia, one double inlet and double outlet left ventricle, one VSD and one coarctation of aorta. Twelve in 13 (92%) had corrective surgery: eight Mustard, two Senning, one arterial switch and one Fontan operation. Eight in 13 (61%) had cavotricuspid isthmus-dependent atrial flutters, 2 in 13 pulmonary venous atrial tachycardias, one macro reentrant tachycardia around a posterolateral scar in the systemic venous atrium, one AVNRT(Arterial switch) and one AVRT due to a left lateral pathway. Ablation was performed with irrigated tip radiofre-quency (RFA) catheters in 11 in 13 (84.6%). Mean procedure time was 214.4 min, and mean screening time was 31 min with a mean radiation dose of 1,264 cGy cm . Immediate success was achieved in 11 patients (84.6%). Mean follow-up was 21 months. Seven (53.85%) had recurrence, and mean recurrence time was 13 months (range 4-26). There were no independent predictors of arrhythmia recurrence, albeit female sex (p = 0.07) and presence of arrhythmias other than CTI-dependent flutter (p=0.07) showed a trend towards recurrence. Conclusion: In patients with d-TGA, the

immediate success rate of catheter ablation of tachyar-rhythmias was 84.6%, but there was a high recurrence rate of 53.85%. No independent predictors of recurrence were identified. Studies with large numbers may address this issue further.

16-86 Abstract 13-01

Impact of coronary sinus anatomy on the outcome of accessory pathway radiofrequency ablation

Rasha Abbass1, Samir Wafa1, Mervat Abou El Maaty1, Hussein Shaalan , Ahmed Tamara Ain Shams University, Cairo, Egypt

Background: The cardiac venous system assumes importance especially in posteroseptal accessory pathways (Aps) due to their known association with coronary venous anomalies like coronary sinus (CS) diverticula. Successful catheter ablation is almost always achieved by RF energy delivery at the neck of the diverticulum. Hence, early recognition of such anatomical variations is important to reduce procedure times and failure rates. Aim of the work: This work was conducted to study the coronary venous anatomy and anomalies in Aps and whether these findings are indicative of successful ablation sites. Methods and results: The morphologic features of the coronary venous system was studied with retrograde CS venography in100 pts (49% with left-sided Aps, 27% with posteroseptal Aps, 20% with anteroseptal/ midseptal Aps, and 4% with right free wall Aps). CS cannulation was successfully achieved in 88% of the pts. The study reported CS abnormalities in 41% of pts. CS anomalies included: diverticuli (39%), funnel-like shape of the terminal CS (11%), subthebesian pouch (11%), aneurysm (11%), narrowing of CS segment (11%), acute angulation of CS (5.56%), hypoplastic CS (5.56%), and bulbous enlargement of the CS (5.56%). The Aps in pts with CS abnormalities were located mainly in the left free wall (24%) and posteroseptal area (11%). Among Aps with an angiographically normal CS, successful ablation site was related to a venous branch in15% (11% located in lt free wall Aps and 4% in lt posteroseptal area). Among Aps with CS anomalies, successful ablation site was related to a CS anomaly in 50% (22% in lt free wall Aps and 28% in lt posteroseptal area). Conclusions: Posteroseptal Aps are often related to CS abnormalities. Left-sided Aps have a close anatomic relation between AP localization and venous branches.

CS venography should be an important adjunct in ablation of posteroseptal and left-sided Aps, especially if initial attempts at ablation from the endocardial aspect have not been met with success.

16-87 Abstract 15-35

Patients with different number of triggering ectopic foci: is there still a reason for ostial pulmonary vein isolation?

Evgeny Mikhaylov1, Sergey Gureev1, Dmitry Lebedev1 Electrophysiology and Cardiac Pacing, Almazov Federal Heart, Blood and Endocrinology Centre, Saint-Petersburg, Russian Federation

Purpose: The purpose of this study was to perform retrospective analysis of paroxysmal atrial fibrillation ablation (PAF) efficacy using ostial PV ablation (OPVA) or circumferential PV isolation (CPVI) in patients with different numbers of atrial triggering foci. Methods: Thirty-six patients with PAF were included. Twelve-lead Holter monitoring was performed in all patients without antiarrhythmic drugs. Holter data were processed and early P on T premature contractions were analyzed with T-wave subtraction. Then, the ectopic P-waves were classified as one of the following types: LSPV, LIPV, RSPV, RIPV, CS ostium, SVC, IVC, and non-differentiated. OPVA was carried out in 15 patients (52±7 years old); CPVI was performed in 21 patients (54±6). Comorbidity, PAF history, and left atrial dimension were comparable in two groups. Results: In OPVA group 4, different foci were revealed in one patient, three types in six patients, two types in five patients, and one type in two patients. Among group of CPVI, four types of triggering foci were revealed in two patients, three types in six patients, two types in ten patients, and one type in three patients. Follow-up period was 20±5 (18-36)months in group of OPVA and 16±6 (5-22)months in group of CPVI. Linear correlation was revealed between number of ectopic foci and number of patients with recurrence of PAF after OPVA. Success rate of 100% was revealed in patients with one type and 80% in patients with two types. In CPVI group, there was no such correlation, but two patients with one to two types undergo redo procedure due to new atrial tachycardias. Conclusion: CPVI was more effective, but in patients with only one or two triggering sites, OPVA resulted in 80-100% success rates. In patients with one to two ectopic sites and CPVI procedure, a second procedure was required due to new atrial tachycardias.

16-88 Abstract 28-01

A new 3D mapping system for catheter ablation of ventricular tachycardias

Lucia De Luca1, Ermenegildo De Ruvo1, Luigi Sciarra1, Lorenzo Zuccaro1, Marco Rebecchi1, Antonella Sette1, Chiara Lanzillo1, Ernesto Lioy1, Leonardo Calo1 1Cardiologia, Policlinico Casilino, Roma, Italy

Introduction: Three-dimensional reconstruction of heart chambers is critical for radiofrequency catheter ablation (RFCA) of complex arrhythmias, such as ventricular tachycardias (VTs). The new Carto3 mapping system allows a new volumetric 3D reconstruction of the cardiac chambers: the fast anatomical mapping (FAM). The FAM shell of right ventricle (RV) and left ventricle (LV) could guide electroanatomical mapping (EAM) during VT procedures. There are no available data regarding the application of this new mapping system to guide ventricular arrhythmias ablation. Methods: Twenty patients (63±16 mean age, 16 men) were referred to our lab for RFCA of VTs with ECG morphology suggesting a ventricular outflow tract origin. During FAM, volume data were recorded continuously based on the position of the location sensor embedded in the mapping catheter. FAM (resolution 14) and EAM, both in a stable mode, were performed to guide RFCA. Results: In 13 patients, the origin of the tachycardia was in the RV outflow tract (three anteroseptal, seven posteroseptal, two anterolateral, and one posterolateral) and in seven patients in the LV outflow tract (four anteroseptal, one posteroseptal, and two anterolateral). A total of 30 maps (20 RV) were obtained using FAM and EAM (mean points number 60±45 for RV, 61 ±50 for LV). Mean procedure and fluoroscopy time were 96±23 and 28± 12 min, respectively. The mean anatomical and activation mapping time was 16 ±5 min. Acute success of target arrhythmia RFCA was 100%. Conclusion: The new Carto3 FAM provides a simple and fast real-time cardiac reconstruction of ventricular anatomy. Carto3 is a useful tool to guide RFCA of complex ventricular arrhythmias with a high success rate.

16-89 Abstract 18-17

Ablation of ventricular arrhythmias in right ventricular dysplasia: arrhythmia-free survival after endo-epicardial substrate-based mapping and ablation

Luigi Di Biase1, Pasquale Santangeli2, Atul Verma3, Prasant Mohanty , J. David Burkhardt , Javier E. Sanchez , Antonio Dello Russo2, Claudio Tondo4, Andrea Natale1

1Texas Cardiac Arrhythmia Institute at St David;s Medical Center, Austin, United States of America; Electrophysiol-ogy, Catholic University, Rome, Italy; Electrophysiology, Southlake Hospital, Toronto, Canada; 4Electrophysiology, San Camillo Hospital, Rome, Italy

Introduction: In patients with arrhythmogenic right ventricular dysplasia (ARVD), freedom from ventricular arrhythmias (VAs) after endocardial ablation (abl) is limited at the long-term follow-up. We compared the long-term freedom from recurrent VAs by using endocardial substrate-based abl. versus endo-epicardial substrate-based abl. Methods: Forty-two patients with ARVD undergoing abl. of VAs have been included. All patients had an ICD. Conventional and 3D mapping were utilized to identify the area of "scar". Clinical VAs were induced with pacing maneuvers or administration of isoproterenol. In all cases abl. was performed with a 3.5-mm open irrigated catheter. In the first 23 patients, abl. was performed only endocardially (group 1), while the remaining 19 underwent endo-epicardial abl. after either failed endocardial abl. (ten patients) or at the time of the first procedure (nine patients) (group 2). Results: At the 3-year follow-up, freedom from VAs or ICD shocks/ATP was 52% (12/23) in group 1 and 84% (16/19) in group 2 (figure). Out of the three patients reporting VA ablation failure in group 2, one pt had an ICD shock 2 weeks after the procedure, one had a VT treated with ATP at 6 months of follow-up, and one had an ICD shock after 1 year when discontinuing antiarrhythmic drugs (AADs). In addition, group 2 patients were more likely to have discontinued AADs (21% in group 1 versus 68% in

group 2, p<0.001). Conclusions: At the long-term follow-up, VAs in patients with ARVD when compared to endocardial endo-epicardial abl. achieves higher freedom from recurrent abl.

16-90 Abstract 18-19

Catheter ablation of ventricular arrhythmias with the remote magnetic navigation system and the 3.5-mm open irrigated magnetic catheter: results from a large single-center series

Luigi Di Biase1, Pasquale Santangeli2, Vladimir Astudillo1, Sanghamitra Mohanty , Javier E. Sanchez , Rodney Horton , Prasant Mohanty , J. David Burkhardt , Andrea Natale1

ITexas Cardiac Arrhythmia Institute at St David's Medical Center, Austin, United States of America; 2Electrophysiology, Catholic University, Rome, Italy

Introduction: Remote magnetic navigation (RMN) has been reported as a feasible and safe mapping and ablation system for the treatment of ventricular arrhythmias (VAs). However, the success rate has been limited with the 4- and 8-mm catheter tip. We report the results in a consecutive large series of patients undergoing radiofrequency (RF) catheter ablation of VAs using the RMN with the 3.5-mm magnetic irrigated tip catheter (OIC). Methods: Seventy-one patients with history of VAs were included in the study. In all cases, an OIC was utilized for mapping and ablation. Post-ablation pacing maneuvers and isoproterenol were utilized to verify the inducibility of the VAs. Results: Mapping and RF catheter ablation was performed in all 71 patients with ventricular arrhythmia (VA). LV was accessed through antegrade approach in 49 (69%) patients and by retrograde approach in 22 (31%). During EP study, clinical VAs were documented in 13 (19%) patients (average cycle length 357±158 ms), while premature ventricular contractions (PVC) were present in 58 (81%). Ischemic cardiomyopathy was present in 16 (23%), non-ischemic in 9 (12%), and in 46 (65%) patients, no

structural heart disease was present. Endocardial mapping was performed in all patients while both endo-epi mapping in 27 (38%) patients. In 20 (28%) patients, VA originated form RV, while in 51 (72%) patients, the origin was clustered in LV (left coronary cusp 13%, aorto-mitral continuity 4%, CS 8%, LV apex 4%, septum 17%, and lateral free wall 12%, anterior wall 8%, inferior wall 2%, mitral valve annulus 4%). The average procedure time was 3.6±1.5 h, and the fluoroscopy time was 32.05±18 min. During the procedures, crossover to manual ablation was required in eight patients (11%). At 6.6± 3.7 months of follow-up, 59 (83%) did not experience any clinical VAs. Conclusions: This large series of consecutive demonstrates that catheter ablation utilizing the RMN with the magnetic OIC is effective for the treatment of VAs.

16-91 Abstract 18-10

Catheter ablation of scar-related ventricular tachycardia in patients with electrical storm using remote magnetic catheter navigation

Arash Arya1, Christopher Piorkowski1, Charlotte Eitel1, Andreas Bollmann , Thomas Gaspar , Philipp Sommer , Ruzbeh Zaker Shahrak , Ulrike Wetzel , Gerhard Hindricks

Heart Center University of Leipzig, Leipzig, Germany

Introduction: A remote magnetic navigation system (MNS) has been used for ablation of ventricular arrhythmias. However, irrigated tip catheter has not been evaluated in a large series of patients. This study intended to evaluate acute and long-term efficiency of the newly available irrigated tip magnetic catheter for radiofrequency ablation of scar-related ventricular tachycardia (VT) in patients with ischemic heart disease. Methods: Between January 2008 and October 2009, a total of 30 consecutive patients with ischemic heart disease (26 men, age, 70.1 ±8.7 years; left ventricular ejection

fraction, 30%±9%) and electrical storm due to monomorphic VT underwent radiofrequency ablation using a remote MNS and a magnetic irrigated tip catheter. Results: Acute success was defined as non-inducibility of any monomorphic VT during programmed right and left ventricular stimulation and was obtained in 24 (80%) patients. A total of one to six VT (mean 2.3±1.2, 394±108 ms, 210-660 ms) were inducible during each procedure. The duration of radiofrequency energy application was 41.2±23.3 min, with total procedure and fluoroscopy times of 158±47 and 9.8±5.3 min, respectively. No acute complications were observed during the procedures. During a mean follow-up of 7.8 months, 22 patients (71%) were in sinus rhythm, have no recurrence of VT, and received no ICD therapy. Conclusions: Irrigated ablation of scar-related ventricular tachycardia using remote MNS is an effective modality for the management of monomorphic VT in patients with ischemic cardiomyopathy with minimal radiation exposure.

16-92 Abstract 17-04

Ablation of ventricular tachycardias using an intracardiac ultrasound guided 3D map

Armin Luik1, Matthias Merkel1, Tobias Riexinger1, Claus Schmitt1

1IV Medizinische Klinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany

Background: Catheter ablation of ventricular tachycardias (VT) is still challenging. The use of 3D mapping systems can

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help understand the underlying mechanisms and can therefore improve the success of the ablation procedure. Nevertheless, the steerability of the ablation catheter in the left ventricle (LV) can be challenging even if the retrograde and transseptal approaches were combined. The aim of this study was to evaluate weather a 3D mapping system with integrated intracardiac ultrasound can improve VT mapping and ablation. Methods: Five consecutive patients (P) with recurrent VTs underwent catheter ablation. In a first step, an intracardiac ultrasound catheter (ICE; SoundStar®, Biosense Webster) was introduced in the right atrium (RA). This catheter can be visualized in the 3D mapping system (CartoSound®, Biosense Webster) and enables the construction of a 3D LV model (Fig. 1). On top of this model, additional maps, such as voltage or activation maps, can be performed. Procedural endpoint: Non-inducibility of all VTs. Results: Patient data: Five P (age 60 ±9 years, 0 women) were ablated due to recurrent VTs (four times ischemic, one time dilatative cardiomyopathy). In all P, the ultrasound-guided 3D map was completed successfully (five to eight slices horizontally and vertically). A total of eight VTs could be induced, mapped, and ablated (eight voltage and six activation maps). In all P, VTs were not inducible after ablation. Total procedure time was 186±44 min, fluoro duration was 26±8 min, and fluoro dose was 73 ± 51 Gy cm2. Conclusion: The construction of a 3D LV map from the RA using an intracardiac ultrasound catheter is feasible and safe. It enables anatomical information before starting the ablation procedure. Additional maps can be performed on top of the 3D sound map. Altogether, this may improve the understanding of the underlying mechanism and may improve ablation success rates.

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16-93 Abstract 13-02

Wolff-Parkinson-White syndrome in children

and adolescents—clinical presentation, type of tachycardia,

course and treatment choice in different age

Svetlana Tadic1, Miodrag Grujic2, Rudolf Papic3, Jelena Marinkovic4

IPediatric department, Clinical hospital centre Zemun-Beograd, BELGRADE, Serbia and Montenegro; 2Institute for Cardiovascular Disease, Clinical Center of Serbia, Belgrade, Serbia and Montenegro; 3Department of Cardiology, Mothers and Childs Health Institute, belgrade, Serbia and Montenegro; 4Medical School, Univesity of Belgrade, Belgrade, Serbia and Montenegro

Wolff-Parkinson-White syndrome is the commonest cause of paroxysmal tachycardia in children and adolescents. There are several types of tachycardia: orthodromic reciprocating tachycardia (ORT), antidromic reciprocating tachycardia (ART), atrial flutter (Aft) and atrial fibrillation (AF). Purpose: The purpose of this study was to investigate the clinical presentation, type of tachycardia, course and best treatment in different age groups. Method: A group of 130 children, M/F=78:52, with first tachycardia at first day until 21 years, mean 8.6±6.3 years, were divided into four groups: group I, from first day-12 months; group II, 15 years; group III, 6-12 years; and group IV, 13-21 years. All of them had ECG during tachycardia and in sinus rhythm, echocardiographic and 51 intracardiac electrophys-iological investigation (EPI). They were followed up 217 years, mean 5.4±3.2 years. Results: In group I, 12 of 22 had heart failure (55.5%), in group II 4 of 18 (22%), in group II 2 of 39 (5.1%) and in group IV 1 of 51 (2%, p<0.01). Syncope occurred in 15 of 51 (29.4%) in group IV and in 2 of 39 (5.1%) in group III (p<0.001). Type of tachycardia were: in group I, ORT in 20 of 22 (90.9%) and in two newborn atrial flutter; in group II, all 18 had ORT; in group III, ORT in 36 of 39 (93.7%) and ART in three (6.3%); and group IV, ORT in 27 of 51 (47.4%), ART in 11 of 51 (19.3%), and A19 of 51 (33.3%, p<0.01). Atrial fibrillation was the first tachycardia in 3 of 130 (2.3%) children. During follow-up, group I, tachycardia recurred in 5 of 22 (27%), in 12 of 18 in group II (66.6%), in 3 of 39 in group III (92.3%), and in 47 of 51 in group IV (92.1%, p<0.01). Conclusion: Clinical characteristics of WPW syndrome are: in infants, heart failure, ORT, and good prognosis; in the school years group, the onset of syncope, ART, and recurring of tachycardia; and in teenage group, syncope, atrial fibrillation, and risk of VF and sudden death. The best therapeutic option is medical treatment before 6 years, but in teenage radiofrequency catheter ablation.

16-94 Abstract 05-02

The impact on operator-incurred radiation of coronary sinus catheter implantation through inferio-vena cava approaches using steerable catheter

Yan Yao1, Nabei Halik1, Long Yang1, Lihui Zheng1, Wensheng Chen1, Wen Huang1, Shu Zhang1 Arrhythmia Center, Fuwai Heart Hospital of Peking Union Medical College - Chinese Academy of Medical Sciences, Beijing, China

Background: While the ablation volume has been increased greatly in busy centers, the potential radiation damages on procedure performers should be considered. This study was aimed at assessing the impact on operator-incurred radiation by way of inferio-vena cava with the steerable catheter in coronary sinus (CS) catheter implantation. Methods: One hundred and sixty-four patients who underwent catheter ablation were divided into two groups. IVC group (n=82): CS catheter was placed through the femoral vein and inferio-vena cava with a steerable catheter. SVC group: CS catheter was placed through the jugular vein with a non-steerable catheter (n=82). The coronary sinus catheters were placed by three fixed operators. The exposure time of each patient and the number of operator-incurred radiation during operation were collected. Results: CS catheters were positioned successfully in 80 patients of IVC group A and in all patients of the SVC group, whereas the two failed (after 5 min operation) patients of the IVC group also failed in the following attempt by the way of jugular vein with non-steerable catheter. While there was no significant difference in the exposure time between the IVC group and the SVC group (105 ± 12 vs 108 ± 19 s, P=0.925), the average dosage of operator-incurred radiation for each procedure was significantly lower in the IVC group (0.30 ± 0.04 vs 1.49 ± 0.27 nGy, P=0.001) due to the low radiation per second (0.25±10-2 vs 1.38 ± 10-2|o.Gy/s). No cardiac or vascular complication was observed in both groups. Conclusions: The steerable catheter through femoral vein may significantly decrease the radiation dosage on the operator during the coronary sinus catheter implantation.

Catheter ablation of atrial flutter

16-95 Abstract 14-04

Non-fluoroscopic ablation of typical atrial flutter

Armin Luik1, Merkel Matthias1, Riexinger Tobias1, Claus Schmitt1

IV. Medizinische Klinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany

Introduction: Three-dimensional mapping systems can help ablate complex arrhythmias. On the other hand, the computer-based visualization of the ablation catheter can reduce fluoroscopic exposure. In addition to the ablation catheter, the new electroanatomical mapping system Carto3® is now able to display all used catheters. Each intracardiac ECG of these catheters can be recorded. The aim ofthis study was to evaluate if this system enables performing an ablation procedure without the use of fluoroscopy. Methods: This is a case report of a patient with CCW atrial flutter. First, the Carto3® system was initialized and the NaviStar® ablation catheter was introduced. With the first detection of atrial signals, a fast anatomical map "FAM" was started. This map enables a continuous recording of the anatomical information. A complete RA map was performed. Special structures as the TK annulus and the His bundle were marked with 3D points. For stimulation maneuver, two steerable ten-polar diagnostic catheters were introduced. The catheters were placed without fluoroscopy. One catheter was placed in the CS and the other at the RA free wall, and the ablation of the cavotricuspid isthmus (CTI) was started. Procedural endpoint was a bidirectional isthmus block. Results: The ablation was completed successfully without the use of fluoroscopy. Time to complete map was 20 min, total procedure time was 51 min, 11 RF ablations, and total ablation time was 762 s. Total fluoro duration was 0 min and fluoro dose was 0 cG cm2. Conclusions: The new Carto3® system is able to visualize all used catheters. This enables the ablation of selected right atrial tachycardias without the use of fluoroscopy.

16-96 Abstract 18-03

Catheter ablation of atypical atrial flutter resulting from previous cardiac surgery

Jose L Gonzalez1, Prof. Nestor Galizio1, Marcelo Ramirez1, Luis Medesani1, Ramon Raña1, Federico Robles1, Alejandro Palazzo1, Felix Albano1

IElectrophysiology Division, Favaloro Foundation-University Hospital, Buenos Aires, Argentina

Background: Atypical atrial flutters are facilitated by scars resulting from previous cardiac surgery. Objective: The objective of this study was to describe the results of radiofrequency ablation (RFA) of atypical atrial flutters, related to scars from previous cardiac surgery, with radio-scopic technique (RT) or 3D electroanatomic mapping (3D-EAM). Methods: Between May 2003 and August 2009, 27 pts (47 ±13 years, 11 men) with atypical atrial flutters were analyzed. Previous cardiac surgery included: congenital heart disease in 17 pts (atrial septal defect 14 pts, Fontan 2 pts, Fallot 1 pt), valvular disease in five pts, heart transplant in four pts, and septal myomectomy in one pt. RFA with RT was performed in 21 pts (group A) and with 3D-EAM in 11 pts (group B). Five pts underwent two procedures of RFA. Results: Circuit localization: right atrial lateral wall in 24 pts, left atrium in two pts, and right inter-atrial septum in one pt. Overall RFA success was 75%, 66.6% in group A and 91% in group B. During a follow-up of 20 ± 21 months, five pts had recurrences (35%) in group A and two pts (20%) in group B. Conclusions: In our study population of pts with prior cardiac surgery, atypical atrial flutters catheter ablation was successful in 75% of the pts. The most frequent circuit was found around the scar of the right atrial lateral wall. 3D-EAM showed higher success rate and lower recurrence incidence.

16-97 Abstract 14-07

Atrial flutter following radiofrequency and high-intensity focused ultrasound left atrial ablative procedures

Ahmed El-Damaty1, Josee Michaud1, Ratika Parkash1, Magdy Basta1, Chris Gray1, Martin Gardner1, John Sapp1 1Cardiology, QEII Health Science Centre, Dalhousie University, Halifax, Canada

Introduction: Iatrogenic atrial tachyarrhythmias have increased with the widespread application of LA ablative procedures to treat AF. We report similar electrophysiologic findings in two patients with post-ablation flutter: one had

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undergone catheter ablation (PV isolation) and another underwent surgical ablation using high-intensity focused ultrasound (HIFU) with the intention of posterior left atrial isolation. Methods: N/A. Results: Case 1: A 67-year-old man with palpitations 18 months after CABG and HIFU en bloc posterior LA isolation was found to be in atypical atrial flutter. At EP study, entrainment mapping was highly suggestive of inferior exit from the previous ablation line between the two inferior pulmonary veins. Activation mapping of the left atrium revealed the inferior exit and left superior entrance site, both of which were successfully ablated, isolating the posterior LA. Case 2: A 62-year-old

man with syncope and atypical atrial flutter 8 months after catheter ablation for atrial fibrillation (wide area pulmonary vein isolation). Activation and entrainment mapping revealed an anterior entry and a posterior exit from an otherwise isolated left-sided pulmonary venous antrum across two conduction gaps with local delayed conduction. Both gaps were ablated successfully. Conclusions: Both surgical and catheter-based linear ablation techniques for AF may create the substrate for reentrant atrial flutter with slow conduction at entry and exit sites from otherwise isolated segments. These may be amenable to catheter ablation.

16-98 Abstract 18-05

First experience of percutaneous radiofrequency ablation for atrial flutter and atrial fibrillation in a patient with Heart-Mate II left ventricular assist device

Philippe Maury1, Clément Delmas1, Charlotte Trouillet1, Alexandre Duparc , Pierre Mondoly , Anne Rollin , Jerome Roncalli , Michel Galinier , Camille Dembrun

University Hospital Rangueil, Toulouse, France

Background: Because of potential severe hemodynamical alterations in the presence of electromagnetic interferences,

percutaneous RF ablation in the presence of Heart-Mate II left ventricular assist device has never been performed in humans. Methods: A 61-year-old man was referred for RF ablation of recurring atrial arrhythmias. He previously underwent implantation of a non-pulsatile axial flow Heart-Mate II left ventricular assist device for post-ischemic end-stage heart failure. Poorly tolerated typical or atypical atrial flutter and atrial fibrillation recurred despite chronic amiodarone therapy. Results: The ablation procedure was conducted under fluoroscopy (use of magnetic non-fluoroscopic navigation system being impossible due to the magnetic field generated by the device). Segmental ostial pulmonary vein disconnection was per-

formed using an externally irrigated RF catheter, while additional linear RF was delivered (atrial roof, mitral isthmus, cavotricuspid isthmus). RF delivery never altered the blood pressure curve, and no harmful effect was noted

at this time or after the procedure. Post-procedure transtho-racic echocardiography did not reveal visible interatrial shunt. No recurrent atrial arrhythmia happened over a follow-up of 9 months.

Session D Part 2

Causes and underlying conditions of atrial fibrillation (7 posters)

16-99 Abstract 14-06

Atrial-fibrillation associated kcne1 polymorphism: role of serine 38 for IKs constitution

Zenawit Girmatsion1, Peter Biliczki1, Ina Takac2, Jürgen Bereiter-Hahn3, Stefan H. Hohnloser1, Joachim R. Ehrlich1

'Div. of Cardiology, J. W. Goethe-University, Frankfurt, Germany; Inst. of Cardiovascular Physiology, J. W. Goethe-University, Frankfurt, Germany; Biology Center, J.W. Goethe-University, Frankfurt, Germany

Introduction: The KCNE1 single nucleotide polymorphism S38G is associated with atrial fibrillation. Previous work found that KCNE1 38G impaired KCNQ1 membrane localization and reduced IKs. The underlying mechanism is unknown. We hypothesized that serine at position 38 and positively charged amino acids (AA) in

the N-terminus play a role in membrane anchoring of KCNE1 and subsequent a-subunit membrane targeting. Methods: We designed KCNE1 constructs with N-terminal mutations disrupting positive residues or modulating AA 38 (A). Patch-clamp, confocal microscopy and protein biochemistry were used. Results: All constructs expressed and effective co-immunoprecipitation proved interaction with the KCNQ1 a-subunit. IKs density resulting from co-expression of KCNQ1 (B) with 38S was greater compared to expression with KCNE1 38G (after +50 mV: 47±11 vs. 13±2 pA/pF, P<0.05) and the mutated constructs (Â1-38, 15±3; linker, 18±6; 38S-3xA, 17±1; 38G-3xA, 10±2 pA/pF, P<0.05 vs. 38S for each). Cell fractionation (C) consistently showed a greater amount of KCNQ1 protein at the plasma membrane with 38S (1.4±0.3 arbitrary units [a.u.]) than with the other constructs (38G, 0.9±0.1; Â1-38, 0.8±0.1; linker, 0.7±0.1; 38S-3xA, 0.7±0.1; 38G-3xA, 0.7±0.1 a.u.). Confocal images supported these findings indicating impaired membrane localization of KCNQ1 with all mutants. Conclusions: The results of our study indicate that serine 38 and positively charged N-terminal AA are important for reconstitution of IKs and suggest a role of KCNE1 membrane anchoring in the physiological basis of KCNQ1 membrane targeting.

16-100 Abstract 15-02

P-wave duration and dispersion in patients with rheumatic mitral stenosis

Sana Ouali1, Lobna Laaroussi1, Sami Hammas1, Rim Gribaa , Slim Kacem , Sahbi Fradi , Elyess Neffeti , Fahmi Remedi , Essia Boughzela Cardiology, Sahloul Hospital, Sousse, Tunisia

Background: Patients with mitral stenosis have prolonged P-wave duration and increased P-wave dispersion (PWD). The aim of the study was to investigate the acute effect of percutaneous mitral dilation on P-wave duration and P-wave dispersion. Methods: Thirty-eight rheumatic mitral stenosis patients in sinus rhythm were included. A 12-lead electrocardiogram was recorded for each subject before and after percutaneous mitral dilation. The difference between maximum and minimum

P-wave duration was calculated and defined as PWD. An echocardiographic examination was also performed for each subject. Results: After percutaneous mitral dilation, mean mitral gradient, and pulmonary artery systolic pressure (PASP) were significantly decreased (mitral gradient = 12.4±4.5 vs 5.28±2.2 mmHg, p<0.0001; PASP=45.7± 15.43 vs 35±6.9 mmHg, p=0,004) and mitral valve area (MVA) was increased (1.1 ±0.3 vs 2 ± 0.3 cm2). There were significant decreases in Pmax and Pmin (Pmax, 118±9.8 vs 105±1.3 ms, p = 0.001; Pmin, 93 ± 12 vs 85± 11 ms, p=0.035). PWD was higher in patients before percutaneous mitral dilation, but there was no statistically significant difference between the two groups (PWD, 25±8 vs 20±7 ms, p=0.068). In addition, P-wave duration and PWD were positively correlated with age, mean mitral gradient, mitral valve area, left atrium area, and a history of paroxysmal atrial fibrillation. Conclusion: P-wave duration and PWD decrease progressively after percutaneous mitral dilation indicating a decrease risk for atrial fibrillation

16-101 Abstract 03-01

Association of the KCNE1 38GG genotype with CETP TaqI B1B1 condition in women with atrial fibrillation

Antonio Galati1, Michele Accogli1, Antonio De Lorenzis1, Francesca Galati2, Serafina Massari2 IDivision of Cardiology, "Card. G. Panico" Hospital, Tricase, Italy; 2Department of Biological and Environmental Science and Technologies, University of Salento, Lecce, Italy

Background: Atrial fibrillation (AF) is the most common type of complex arrhythmia found in everyday clinical practice. Genetic factors may underline this arrhythmia. We performed a case-control study to investigate the possible association between atrial fibrillation and the G38S polymorphism of the KCNE1 gene encoding the a-subunit of I (Ks) potassium channel. Methods: To this purpose, a group of case patients and control subjects have been genotyped the KCNE1 G38S polymorphism by means of PCR-RFLP. In both groups, the presence of the TaqIB genotype for CETP gene was previously determined. Results: Our preliminary data showed an increase of the 38GG genotype of the KCNE1 gene in atrial fibrillation patients with the CETP B1B1 genotype than the control (10% vs 3%, p< 0.05). The frequency is further increased in B1B1 women (14% vs 2%, p<0.01) rather than in men (4.4% vs 4.0%, NS). Conclusions: Therefore, we suggest that the presence of B1B1 genotype in women could enhance the shortening

of the atrial effective refractory period in patients carrying the KCNE1 38GG genotype and so increase susceptibility to atrial arrhythmias.

16-102 Abstract 15-20

The relationship of paroxysmal and persistent lone atrial fibrillation with endothelial function and markers of chronic inflammation

Marija Polovina1, Tatjana Potpara1, Vojislav Giga1, Miodrag Grujic1, Miodrag Ostojic1

ICardiology, Institute for Cardiovascular Diseases, Clinical Center of Serbia, Belgrade, Serbia and Montenegro

AIM: The aim of the study was to evaluate the influences of arrhythmia type (parox. or persist.) on chronic inflammation (C-reactive protein, CRP) and endothelial function (brachial artery flow-mediated dilation, FMD) in pts with lone atrial fibrillation (AF). Methods: We compared FMD and CRP values among three groups: Gr.1 persist. (>7 days) AF (n = 24, age 39.2±3.8 years, 12 men), Gr.2 parox. AF (self-terminating paroxysms lasting <48 h, n = 22, age 43.2±4.9 years, 10 men), and Gr.3 controls in sinus rhythm (n = 23, age 41.2±5.1 years, 14 men). FMD% and FMD time course (time to the max. FMD) were determined with ultrasonic brachial artery diameter measurements every 10 s and 0-120 s after cuff release. To accommodate for beat-to-beat flow variation due to cycle length differences in AF, diameters taken from five consecutive cycles were averaged for each measurement, and this protocol was applied in all participants. FMD was assessed during AF in both patient groups, and CRP was measured on the day of the vascular study. Results: There were significant differences among the three groups regarding FMD% (Gr.1, 3.0±0.8 vs Gr.2, 5.6±0.7 vs Gr.3, 7.2±1.9%; p<0.001), FMD time course (Gr.1, 67.5±12.9 vs Gr.2, 55.0±8.5 vs Gr.3, 51.7±10.3 s;p <0.001), and CRP levels (Gr.1, 2.2±0.8 vs Gr.2, 1.2±0.2 vs Gr.3, 1.0±0.4 mg/L; p<0.001). Both AF groups had lower FMD% compared with the controls, but only pts with persist. AF had slower FMD time course (p=0.001) and higher CRP levels (p<0.001). Comparison of the two AF groups revealed that pts with persist. AF had lower FMD% (p=0.001), slower FMD time course (p=0.016), and higher CRP levels (p<0.001). In the multivariate analysis, persist. AF was a multivariate predictor of FMD% (b=-2.6, p< 0.001), FMD time course (b = 12.9, p=0.003), and CRP levels (b =01.1, p<0.001). Conclusions: Patients with persist. lone AF have slower and impaired endothelium-dependent dilation and higher CRP levels compared with

subjects in sinus rhythm or with parox. AF. Persist. AF regeneration, and a decrease in inflammation. Future

might be related to increased cardiovascular risk.

16-103 Abstract 15-07

Circumferential pericardial reconstruction with an extracellular matrix: a novel approach to reduce the risk of postoperative atrial fibrillation in coronary artery bypass surgery patients

Thomas Deering1, Douglas Boyd2, William Johnson3, Parvez Sultan4, Robert Matheny5

1Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, United States of America; Cardiac Surgery, University of California Davis Medical Center, Davis, United States of America; Cardiac Surgery, Mobile Infirmary Medical Center, Mobile, United States ofAmerica; 4Cardiac Surgery, Trinity Medical Center, Birmingham, United States of America; 5Cardiac Surgery, CorMatrix, Atlanta, United States of America

directions: Given the highly positive initial findings, a prospective, multicenter randomized trial is now in progress to test further the hypothesis that this novel and innovative approach can reduce the rate of p-op AF.

16-104 Abstract 15-06

Purpose: This study was initiated to evaluate the efficacy of circumferential pericardial reconstruction, using an extracellular matrix (ECM) capable of promoting de novo pericardial tissue growth, in reducing the risk of postoperative (p-op) atrial fibrillation (AF). Methods: A retrospective comparison of the incidence of p-op AF rates was performed between 111 patients (pts) who underwent circumferential pericardial reconstruction with the ECM and a control group of 111 pts who did not undergo pericardial reconstruction following isolated coronary bypass surgery (CABG). Results: P-op AF occurred in 43 of 111 control patients (38.74 ± 9.71%), but only 20 of 111 treated patients (18.02 ± 8.43%). This constitutes a relative risk reduction of 53.8% and an absolute risk reduction of 20.7% (p=0.0003). A multivariate, logistic regression analysis of underlying clinical features, the presence or absence of prior revascularization, the study site, and the pharmacologic treatment choices demonstrated that the only two factors influencing the development of p-op AF were age (odds ratio of 1.071, p<0.001) and the use of the ECM (odds ratio of 3.369, p=0.0024). Conclusions: (1) Use of an extracellular ECM, capable of promoting de novo pericardial tissue growth, is associated with a highly statistically significant reduction in the incidence of p-op AF in this retrospective analysis. (2) Pt age and the use of the ECM were the only variables, assessed by a multivar-iate, logistic regression analysis, associated with a reduction in p-op AF. (3) The mechanism(s) potentially responsible for this benefit remain speculative at present but possibly include a decrease in atrial stretch, pericardial repair or

Does central sleep apnea influence the onset of tachycardiomyopathy in persistent/permanent atrial fibrillation patients?

Maria Vittoria Matassini1, Michela Brambatti1, Marco Marchesini1, Stefano De Luca2, Giuseppe Pupita1, Alessandro Capucci1

1Clinica di Cardiologia, Universita Politecnica delle Marche, Ancona, Italy; U.O. Pneumologia, Ospedale di Osimo, Osimo, Italy

AIM: Sleep-disordered breathing (SDB) is common in heart failure, with central sleep apnea (CSA) being the most prevalent type of apnea in these patients. The aim of the study was to assess the impact of CSA in the unexplored setting of tachycardia-induced cardiomyopathy (TIC). CSA could promote the onset and the evolution of TIC through the nocturnal apnea-related anatomic and neurohumoral alterations. Methods and results: Fourteen consecutive patients (nine men, five women; age, 65.2± 12.1 years) with persistent/permanent atrial fibrillation (AF) were investigated with clinical evaluation, echocardiography, nocturnal cardiorespiratory monitoring, and 24-h electrocar-diography (ECG) recording with HRV analysis. The patients fell into two groups: group A (n=7) is composed of AF patients and group B (n=7) consisted of AF patients with TIC. On 24-h ECG recording, in group B, we found persistent and high heart rate both at night (8 pm to 8 am) and in the daytime (8 am to 8 pm) compared with group A (p<0.05); moreover, the physiologic nocturnal dipping of

heart rate was lacking (p=0.023). The HRV analysis showed that the LF/HF ratio was reduced (p<0.037) in group B compared with group A only during sleep time. On nocturnal cardiorespiratory monitoring, 57% of group B patients had CSA. In group A, both CSA (28%) and obstructive sleep apnea (OSAS, 44%) were present. We considered that the interference of the specific SDB on the cardiac activity by HRV: LF/HF ratio (mean, 1.24) is very reduced in CSA patients during the night compared with the patients without CSA (p=0.014). Conclusions: Patients with AF and TIC had a high prevalence of CSA, nocturnal high heart rate, and low LF/HF ratio. The diagnosis of CSA could negatively influence prognosis through an alteration of the sympathovagal balance. The sympathetic activation, evidenced by the low LF/HF ratio, provokes high heart rates that are considered a main factor responsible for the pathogenesis of TIC.

16-105 Abstract 15-21

Short- and long-term mortality after acute coronary syndrome in patients with and without atrial fibrillation

Dritan Poci1, Marianne Hartford2, Thomas Karlsson2, Nils Edvardsson2, Kenneth Caidahl3

department of Cardiology, University Hospital Orebro, Orebro, Sweden; 2Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden; 3Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

Atrial fibrillation (AF) is associated with an increased morbidity and mortality even after acute myocardial infarction. We hypothesized that the CHADS2 score which is developed to assess the stroke risk in patients with atrial fibrillation could be used as a risk assessment tool for mortality in patients with acute coronary syndromes (ACS) irrespective of the presence or absence of AF. Methods: Consecutive patients with ACS admitted to the coronary care unit between September 1995 and March 2001 were prospectively followed until death or to the end of follow-up on January 1, 2007. The CHADS2 scores at baseline were retrospectively calculated from the database collected

at admission. Results: Of a total of 2,335 patients with ACS, 442 (71±8 years, 142 women) had AF. Follow-up period was 72±5 months. The mean CHADS2 score was 1.6±1.4 versus 1.0±1.1 in patients with and without AF (p<0.0001). The early mortality (<30 days) was 13.8% for patients with AF and 5.2% for those without AF (p< 0.0001). The all-cause mortality at 10 years showed a strong association with CHADS2 scores in both groups, although stronger in patients without AF [hazard ratio (HR) per unit increase in the six-graded CHADS2 score 1.53 (1.42-1.64), p<0.0001, vs 1.28 (1.16-1.43), p<0.0001, after adjustment for potential confounders]. The all-cause mortality at 10 years was 63.6% and 36.3%, respectively, in patients with and without AF (p<0.0001). Conclusion: In patients with ACS, the CHADS2 score was useful in assessing the risk for subsequent short- and long-term mortality both in patients with and without AF. A consistent use of the CHADS2 score on admission for ACS might help optimize the treatment of risk factors which could, in turn, mitigate subsequent risk of death.

16-105B Abstract 15-29

Gender-specific differences in symptom burden

and management of atrial fibrillation in the AFNET:

data from a large prospective clinical registry

Andrea Gerth1, Michael Nabauer1, Tobias Limbourg2, Michael Oeff3, Ursula Ravens4, Thomas Meinertz5, Günter Breithardt6, Gerhard Steinbeck1

Medical Department I, University Hospital Munich, Campus Grosshadern, Munich, Germany; Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen am Rhein, Germany; Brandenburg Municipal Hospital, Brandenburg, Germany; 4Medizinische Fakultaet Carl Gustav Carus der TU Dresden, Dresden, Germany; 5Universitaeres Herzzentrum Hamburg gGmbH, Hamburg, Germany; 6University Hospital Muenster, Muenster, Germany

Gender differences in cardiovascular diseases are increasingly recognized, but large-scale studies on gender-specific differences in atrial fibrillation are missing. Methods: Patients with AF were enrolled from Feb 2004 until March 2006 in the Central Registry of the German Competence NETwork on

Atrial Fibrillation (AFNET). Results: Nine thousand five hundred seventy-six patients were included in the registry, 60.9% male; mean age of women was higher by 5.4 years (71.7± 10.0 years; men, 66.3±11.2 years,p<0.0001). Women more frequently presented with paroxysmal AF than men (32.3% vs. 29.4%, p<0.01). AF was classified as persistent more frequently in men (21.0% vs. 18.0%, p<0.001). Female gender was associated with a more severe symptomatic status; symptoms associated with AF most prominently were palpitations (48.5% in women vs. 36.2% in men) and dyspnea (50.0% vs. 40.6%, p<0.001), but also chest pain (20.3% vs. 17.3%) and dizziness (31.2% vs. 20.0%, p< 0.001). Only 16.1% of women were asymptomatic compared to 26.5% of men (p<0.001). Heart rate during AF was higher in women than in men (87 vs. 84 bpm, p<0.0001) and was predictive of symptoms. Despite higher symptom burden, women less frequently received interventions or AA drug therapy for rhythm control at the time of presentation (electrical cardioversion, 11.3% in women vs. 14.3% in men; catheter ablation, 4.7% vs. 6.4%; amiodarone, 7.1% vs. 11.0%, p<0.001). Even after correction for baseline differences including type of AF, female gender was associated with a lower probability to receive interventions or AA drugs to restore or maintain sinus rhythm. At 12 months of follow-up, symptom control was more successful in men, with 39.0% of initially symptomatic men being free of symptoms as comparedto only 26.1% of women (p<0.001). Conclusions: Women in AF have a higher heart rate and more frequently report symptoms. Despite a higher symptom burden, women are less likely to receive specific treatment to restore and maintain sinus rhythm.

Cardioversion of atrial fibrillation

16-106 Abstract 15-04

Different atrial contractile recovery after successful cardioversion in lone and hypertensive patients with atrial fibrillation may imply a different pathogenetic mechanism

Marchesini Marco1, Matassini Maria Vittoria1, Brambatti Michela , Francioni Matteo , Franchini Sara , Bartoli Beatrice2, Capucci Alessandro1

1Clinica di Cardiologia, Université Politecnica delle Marche, Ancona, Italy; 2Scienze Statistiche, Université di Bologna, Bologna, Italy

Background: Lone AF has a prevalence of up to 15% in the AF population. Patients (pts) are young and clinically similar to the hypertensive of comparable age, but the mechanisms leading to AF may be different. Our purpose was to evaluate the atrial contractile behavior after successful cardioversion (CV) in lone (L) and hypertensive (Hy) AF pts through a standard and TDI echo evaluation. Methods: Fourteen consecutive pts with paroxysmal/persistent AF and age <65 years, without any evidence of cardiopulmonary disease, were divided into two groups according to the presence of hypertension or absence of any heart disease (L=6; Hy=8). At echo, we excluded a hypertensive cardiomyopathy (intraventricular septum > 14 mm, E/A < 1). Echo parameters were recorded at AF (T0), 24 h after CV (T1), and 1 month later (T2). We assessed mean peak velocities (MPV) of contraction of atria, divided into segments (1-5) left atrium (LA, 6-8), right atrium from the apical four-chamber view, and (9-13) LA from the apical two-chamber view. Results: AF duration, prophylactic therapy, and recurrence at T2 did not differ in the two groups. As expected, there was a different consumption of ARBs (L=0%; Hy=75%) and HMG-CoA reductase inhibitors (L=0%; Hy=50%). The standard echo exam showed a substantial equality of dimensional and functional parameters. TDI did not show any difference in the sum of all segmental MPV (MPVs) at T0-T1. However, it was significantly greater in L at T2 compared to Hy (L=68.8 cm/s; Hy=49.4 cm/s, p=0.02). The same was for sum of only LA MPV (L=52.8 cm/s; Hy=39.9 cm/s, p=0.02). Calculating the variation of MPVs from T1 to T2, there emerged a statistic difference (p=0.03) with a greater variation in L (L = 22.8 cm/s; Hy=0.5 cm/s). Finally, atrial wave (F, P) duration was longer in L at T0, T2 (T0: L=78 ms; Hy = 24.3 ms, p=0.02; T2: L = 117 ms; Hy=83.3 ms, p=0.02). Conclusions: L had a good and rapid mechanical recovery, whereas Hy showed a persistent mechanical dysfunction prolonged at 1 month after CV. The atrial electrical remodeling on the opposite was prevalent in L.

16-107 Abstract 15-32

Impact of inflammation markers on recurrence of atrial fibrillation after successful cardioversion

SvetlanaGrigoryan1, Karlen Adamyan1, Lusine Hazarapetyan1 of Arrhythmia, National Institute of Health, Yerevan, Armenia

Background: Atrial fibrillation (AF) is the most frequent arrhythmia found in clinical practice. AF is associated with atrial structural changes that may have an inflammatory basis. In the last years, we have suggested a mechanistic link between inflammatory processes and the development of AF. Classical markers of inflammation, C-reactive protein (CRP), and pro-inflammation agent interleukin-6 (IL-6) were found elevated in patients with AF. However, inconsistent results have been published with regard to the role of these markers in predicting sinus rhythm maintenance after successful cardioversion. In this study, we aimed to assess the association between inflammation markers and recurrence of AF. Methods: Fifty-six patients (mean age 63.6±7.3) with non-rheumatic AF after successful cardioversion where enrolled in this study. After the enrollment, the echocardiography examination and 24-h ambulatory Holter monitoring ECG were registered

in each patient. Blood samples were tested on the serum level of CRP and IL-6. The follow-up time lasted 32 weeks. After that, all patients were divided into two groups according to the primary end-point. The first group of patients had less than five episodes of AF recurrence and the second group with more than five episodes of AF recurrence. Prophylactic drug therapy with amiodarone (200-300 mg daily dosage) to prevent early recurrence of AF was administered to all 56 patients. Results: The obtained results have shown that the basis data of hs-CRP and of IL-6 levels in the second group vs the first group of patients were significantly increased (0.62±0.52 mg/dL and 32±21 pg/ml vs 0.48±0.11 mg/do, p<0.01 and 22.1 ± 8.9 pg/ml, p<0.05 accordingly). Conclusion: There is the link between inflammation and recurrence of AF after successful cardioversion.

16-108 Abstract 14-02

Outpatient electrical cardioversion of atrial fibrillation analysis of shock-related arrhythmias

Giovanni Morani1, Mariantonietta Cicoira1, Daniela Lanza , Laura Pozzani , Carlo Angheben , Gabriele Zanotto1, Corrado Vassanelli1

1Divisone Clinicizzata Di Cardiologia, University Of Verona, Verona, Italy; 2Ospedale S Maria del Carmine, U.O. Cardiologia, Rovereto TN, Italy

Background: Outpatient electrical cardioversion (EC) of atrial fibrillation (AF) is currently the standard of care. Shock-related arrhythmias, even if uncommon, may be particularly deleterious in this setting. Preoperative identification of high-risk patients may be very useful. Methods: A retrospective analysis was made of 543 consecutive elective EC procedures in 457 outpatients over an 8-year period in a university cardiological institute. The protocol included adequate anticoagulation, intravenous anesthesia, DC shock, and direct observation after shock to detect procedure-related complications. No patients were excluded due to severity of pathology or comorbidities. Clinical characteristics, energy delivered, medications, arrhythmic phenomena, predictors of success, and complications were analyzed. Results: Of 543 ECs performed, 88.2% restored sinus rhythm, which persisted at discharge in 83.2%. No anesthesia-related complications were detected. No ventricular arrhythmic events were detected. Use of a biphasic cardioverter was the only predictor of success (p=0.0001). The bradyarrhythmic complication rate was 1.5%. Serious bradyarrhythmic phenomena were observed immediately after shock in eight cases: in six cases, the bradyarrhythmia resolved, whereas two patients underwent pacemaker implantation. Atrial flutter was present in five of eight procedures in patients who developed complications vs 44 of 535 patients who had no complications (p<0.0005), and prosthetic heart valves in four of eight complicated vs 40 of 535 uncomplicated cases (p=0.0044). The combination of atrial flutter and prosthetic heart valve was found in four of eight complicated vs 11 of 535 uncomplicated cases (p<0.0005). Conclusion: The major finding of this study is that shock-related arrhythmias are essentially bradyarrhythmias. Atrial flutter and previous cardiac surgery identify a subgroup of patients at high risk of post-shock bradyarrhythmic complications.

16-109 Abstract 15-16

Clinical improvement of patients undergoing DC cardioversion—symptom reduction measured with the new short, validated, AF-specific questionnaire AF6

Nils Edvardsson1, Marie Härden2, Britta Nyström2, Ann Bengtson , Jennie Medin

Sahlgrenska Academy, Göteborg, Sweden; Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden; Astrazeneca R&D, Mölndal, Sweden

Introduction: There are, as yet, few instruments to assess symptoms in AF based on patient language. AF6 is an AF-specific instrument designed to be short, easy to understand, and easy to complete. The AF6 recently underwent formal psychometric validation. Methods: One hundred eleven patients completed AF6 before and 12±3 days after elective DC cardioversion (DC). Their mean age was 67± 12 years, and 80% were men. The AF6 contains six items referring to (1) breathing difficulties at rest; (2) breathing difficulties upon exertion; (3) limitation in day-to-day life due to atrial fibrillation; (4) feeling of discomfort due to atrial fibrillation; (5) tiredness due to atrial fibrillation; and (6) worry/anxiety due to atrial fibrillation. Results: The total score decreased from 18±12.4 to 13±11.6 (p<0.0001). Patients in sinus rhythm (SR) at 12±3 days (n=56) improved their score most, 22.2±13.6 to 12.0±12.0 (p< 0.0001). The corresponding figures for patients in AF at 12±3 days (n=55) were from 13.7±9.3 to 14.1±11.2 (N.S.). The highest scoring items were consistently items

2 and 5, followed by items 3, 4, 6, and 1. For all patients, the score in item 1 improved (I) in 23 and worsened (W) in 20, while the rest were unchanged (N.S.). The corresponding figures for the other items were: item 2: I 52, W 27 (p=0.002); item 3: I4 9, W 28 (p=0.0091); item 4: I 45, W 27 (p = 0.0031); item 5: I 64, W 26 (p<0.0001); and item 6: I 37; W 26 (p = 0.08). For patients in SR at 12±3 days, improvement was seen in all but one item; item 1: I 14, W 6 (N.S.); item 2: I 31, W 10 (p<0.0001); item 3: I 36, W 6 (p<0.0001); item 4: I 29, W 9 (p<0.0001); item 5: I 39, W 7 (p<0.0001); and item 6: I 24, W 11 (p=0.014). None of the items improved in patients in AF at 12±3 days. Conclusions: The reduction of AF-related symptoms after DC was highly statistically significant in patients maintaining SR at 12±

3 days as opposed to no change in patients who were in AF. The data show that the AF6 was responsive to changes in the AF-specific symptom burden after DC.

16-110 Abstract 14-03

Management of atrial fibrillation in elderly patients in China: a prospective, multicenter study

Dong-Ling Liu1, Chang-Sheng Ma1, Xiao-Hui Liu1, Jianzeng Dong1, Xin Du1, Jun-Ping Kang1, Ri-Bo Tang1, Man Ning1

department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing, China

Introduction: This study aimed at exploring the clinical characteristics and current therapy of AF in a variety of hospitals in the Chinese elderly patients. Methods: From January 2009 to June 2009, patients >65 years old who had documented AF would be included in the study, and patients

with valvular disease would be excluded. Database from seven tertiary hospitals and two non-tertiary hospitals in China were used. Results: In total, 372 patients (204 men, 168 women), with a mean age 73 ± 4, were enrolled. Among the 372 patients, 53.3% had chronic AF, 43.7% had paroxysmal AF, and 66.9% were 65 to 74 years old. Two hundred fifty-six patients (68.8%) had hypertension, 66 (17.7%) had diabetes, 46 (12.3%) had coronary artery disease, and 39 (10.4%) had congestive heart failure (HF). Previous stroke occurred in 77 of 372 patients (20%) with atrial fibrillation and TIA in 12 patients (3.2%). New onset stroke occurred in 3 of 154 patients with atrial fibrillation and TIA in one patient when followed up at 6 months. Of the three patients with new onset stroke, one had taken warfarin. CHADS2 score of >2,1, and 0 were presented in 140 (37.2%), 131 (35.2%), and 60 (16.1%)

patients. The prevalence of the patients on warfarin was 60%, 46.5%, and 6.8% in the patients with CHADS2 score of >2,1, and 0, respectively. Overall, 186 patients (50%) had warfarin. One hundred twenty-seven patients (34.1%) had aspirin, and 44 patients (11.8%) did not receive any antithrombotic treatment. Two hundred eight patients (55.3%) used medicine rate control, of which beta-receptor blockers were administered in 153 (73.5%) patients. Sixty-five (17.4%) used rhythm control, and 99 (26.6%) did not receive any antiarrhythmic treatment. Patients of age 75 years or older in high risk (chads2 >2) who had taken warfarin are more than patients of age 65-74 years (51.6% vs 47.8%). Conclusions: According to the guideline, most of the patients in this study received antithrombotic therapy combined with rate control or rhythm control.