Faculty Bibliography

Background: Prior studies demonstrate cardiac resynchronization therapy (CRT) with MultiPointTM Pacing (MPP) improves LV reverse remodeling and clinical response compared to biventricular (BiV) pacing. Objective: To assess the influence of MPP programming on CRT response. Methods: This multicenter, randomized study enrolled and followed 506 patients receiving CRT-D therapy (QuartetTM LV lead Model 1458Q with a Quadra Assura MPTM CRT-D, St. Jude Medical). Quadripolar BiV pacing was activated in all patients at implant. From 3 to 9 months post-implant, 232 patients continued to receive BiV pacing and 52 patients received MPP programmed with the widest LV electrode anatomical separation and shortest intraventricular timing delay (MPP-AS). Clinical outcomes included an assessment of CRT response measured by the Clinical Composite Score (e.g., NYHA, patient global assessment, HF event, and cardiovascular death) and freedom from a heart failure (HF) event or all-cause death. A HF event was defined as a hospitalization for HF >= 24 hours or a clinic or hospital visit for HF < 24 hours requiring administration of IV diuretics, inotropes, and/or vasodilators. Results: Baseline characteristics for the two cohorts were comparable. MPP-AS was associated with a significantly higher CRT response rate vs BiV (87% vs 72%, p=0.034). MPP-AS was associated with a reduction in HF event or death vs. BiV (1.9% vs 8.7%, p=0.100), which was numerically lower but did not achieve statistical significance. Conclusion: MPP-AS is associated with a significantly higher CRT response rate compared to quadripolar BiV pacing. In addition, optimal programming of MPP can reduce HF event or all-cause death. (Figure presented)

BACKGROUND: Studies have shown that Magnetic Resonance Imaging (MRI) conditional pacemakers experience no significant effect from MRI on device function, sensing, or pacing. More recently, similar safety outcomes were demonstrated with MRI conditional defibrillators (ICD), but the impact on ventricular arrhythmias has not been assessed. OBJECTIVE: To assess the effect of MR imaging on ICD sensing and treatment of ventricular tachyarrhythmias METHODS: The Evera MRI study was a world-wide trial of 156 patients implanted with an ICD designed to be MRI conditional. Device detected spontaneous and induced VT/VF episodes occurring prior to and following whole body MRI were evaluated by a blinded Episode Review Committee. Detection delay was computed as the sum of RR intervals of undersensed beats. A >/=5 second delay in detection due to undersensing was prospectively defined as clinically significant. RESULTS: Post-MRI, there were 22 polymorphic VT/VF episodes in 21 patients, with 16 of these patients having 17 VT/VF episodes prior to MRI. Therapy was successful for all episodes with no failures to treat or terminate arrhythmias. The mean detection delay due to undersensing pre- and post- MRI was 0.60 +/- 0.59 sec and 0.33 +/- 0.63 sec, respectively (p=0.17). The maximum detection delay was 2.19 seconds pre-MRI and 2.87 seconds post-MRI. Of the pre-MRI episodes, 14/17 (82%) had some detection delay vs. 11/22 (50%) in post-MRI episodes (p=0.03); no detection delay was clinically significant. CONCLUSION: Detection and treatment of VT/VF was excellent with no detection delays or significant impact of MRI observed. (Confirmatory Clinical Trial of the Evera MRI System for Conditionally-Safe MRI Access; ClinicalTrials.gov Identifier: NCT02117414).

Introduction: Transcatheter aortic valve replacement (TAVR) is becoming a widely accepted alternative treatment for patients with symptomatic aortic stenosis who are at high risk for surgical aortic valve replacement. A common complication of the procedure is the development of conduction defects requiring permanent pacemaker (PPM) implantation. It has been noted that in some patients, the conduction block is not permanent. Determine the incidence and predictors of resuming intrinsic conduction in patients that receive PPM implantation after TAVR. Methods: A retrospective chart review of patients undergoing TAVR at New York University Langone Medical Center was undertaken. Extracted data included patient demographics, pre-TAVR electrocardiogram, procedural, echocardiographic, catheterization, and device interrogation data. Evaluation of device interrogations done at one month follow-up or earlier to look for resumption of intrinsic conduction. Results: There were a total number of 451 patients who were status-post TAVR in our registry at NYU. Of the 451, 45 patients received a permanent pacemaker placement for complete heart block; 9.9% 45/451. The majority of patients were implanted within 48hrs post TAVR. Device follow-up information at 1 month or earlier was available for 33 of the 45 patients who received PPM. 5 patients who were recently implanted are still pending follow-up. 3 patients expired after implantation and 4 were lost to follow-up. Of the 33 patients, 14 (42%) patients had resumption of AV nodal conduction at 1 month follow-up. 19 patients (57%) remained dependent. Conclusions: 42% of patients who received a permanent pacemaker for complete heart block after TAVR had resumption of conduction. This suggests that many patients may not require long term PPM post TAVR. Patients that remained dependent had a higher incidence of preexisting RBBB and LAFB, however a lack thereof does not preclude an increased risk. These data suggest that waiting longer than 48 hours for resumption of AV nodal conduction would avoid unnecessary implantation in patients who develop complete heart block post TAVR

INTRODUCTION: The incidence of unscheduled encounters and problem occurrence between ICD implant and first in-person evaluation (IPE) recommended at 12 weeks is unknown. Automatic remote home monitoring (HM) may be useful in this potentially unstable period. METHODS AND RESULTS: ICD patients were randomized 2:1 to HM enabled post-implant (n = 908) or to conventional monitoring (CM; n = 431). Groups were compared between implant and prior to 1st scheduled IPE for IPE incidence, causes, and actionability (reprogramming, system revision, medication changes) and event detection time. HM and CM patients were similar (mean age 63yrs, 72% male, LVEF 29%, primary prevention 73%, DDD 57%). In the post-implant interval assessed (HM 100+/-21.3 days versus CM 101+/-20.8 days, p = 0.54), 85.4% (776/908) HM patients and 87.7% CM (378/431) patients had no cause for IPE (p = 0.31). When IPE occurred, actionability in HM (64/177 [36.2%]) was greater vs CM (15/62 [24.2%],p = 0.12). Actionable items were discovered sooner with HM (p = 0.025). Device reprogramming or lead revision was triggered following 53/177 (29.9%) IPEs in HM versus 9/62 (14.5%) in CM (p = 0.018). Arrhythmia detection was enhanced by HM: 276 atrial and ventricular episodes were detected in 135 follow-ups in contrast to CM (65 episodes at 17 IPEs). More silent arrhythmic episodes were discovered by HM (7.2% versus 1.5% (p = 0.15)). Since 27/42 (64.3%) IPEs driven by HM alerts were actionable, event notification was a valuable method for problem detection. Importantly, HM did not increase incidence of non-actionable IPEs (p = 0.72). CONCLUSION: Activation of automatic remote monitoring should be encouraged soon post-ICD implant