Long-Term Outcome Up To 40 Years after Single Patch Repair of Complete Atrioventricular Septal Defect in Infancy or Childhood

Objectives Patients with repaired complete atrioventricular septal defect (CAVSD) represent an increasing portion of grown-ups with congenital heart disease. For repair of CAVSD, the single-patch technique has been employed first. This technique requires division of the bridging leaflets, thus, among other issues, long-term function of the atrioventricular valves is of particular concern. Methods Between 1978 and 2001, 100 consecutive patients with isolated CAVSD underwent single-patch repair in our institution. Hospital mortality was 11%. Primary endpoints were clinical status, atrioventricular valve function, and freedom from reoperation in long term. Follow-up was obtained contacting the patient and/or caregiver, and the referring cardiologist. Results Eighty-three patients were eligible for long-term follow-up (21.0 ± 8.7, mean ± standard deviation [21.5; 2.1–40.0, median; min–max] years after surgical repair). Actual long-term mortality was 3.4%. Quality of life (QoL; self- or caregiver-reported in patients with Down syndrome) was excellent or good in 81%, mild congestive heart failure was present in 16%, moderate in 3.6% as estimated by New York Heart Association classification. Echocardiography revealed normal systolic left ventricular function in all cases. Regurgitation of the right atrioventricular valve was mild in 48%, mild–moderate in 3.6%, and moderate in 1.2%. The left atrioventricular valve was mildly stenotic in 15% and mild to moderately stenotic in 2%; regurgitation was mild in 54%, mild to moderate in 13%, and moderate in 15% of patients. Freedom from left atrioventricular-valve-related reoperation was 95.3, 92.7, and 89.3% after 5, 10, and 30 years, respectively. Permanent pacemaker therapy, as an immediate result of CAVSD repair (n = 7) or as a result of late-onset sick sinus syndrome (n = 5), required up to six reoperations in single patients. Freedom from pacemaker-related reoperation was 91.4, 84.4, and 51.5% after 5, 10, and 30 years, respectively. Conclusion Up to 40 years after single-patch repair of CAVSD, clinical status and functional results are promising, particularly, in terms of atrioventricular valve function. Permanent pacemaker therapy results in a life-long need for surgical reinterventions.

Pacemaker therapy in the elderly and very elderly: comorbidity-burden vs age, as prognostic factors for excess of length of in-hospital stay, complications and mortality

Background The number of elderly patients undergoing pacemaker (PM) implantation is constantly growing. However, information on survival and prognostic factors of this particular patient group is scarce. Recent studies suggest that comorbidity burden may have an equal, if not greater, effect on length of in-hospital stay (LOS), complications and mortality, as age in a variety of clinical scenarios. Objective The objective of this study was to determine the survival of elderly and very elderly patients undergoing PM implantation, as well as to investigate the impact of comorbidities, as compared to age, on excess of length of in-hospital stay and mortality. Methods This is a retrospective observational study of a single centre. Patients that underwent (both elective and non-elective) PM implantation between June 2016 and December 2018 in our centre, were included for chart review. Elderly patients were defined as those with age 80–89 years, whereas very elderly patients were defined as those with ≥90 years of age. Excess in LOS was defined as an in-hospital stay >3 days. Results A total of 507 patients were included in the study with a mean age of 80.6 (±8.5) years. 255 elderly and 60 very elderly patients were included. Median follow-up time was 24 months. Baseline clinical characteristics are presented in Table 1. The mortality rate for elderly patients was 18.8% for the elderly and 36.7% for the very elderly (p=0.002). The presence of ≥2 comorbidities (defined in Table 1) resulted to be a significant predictor for the excess of LOS, whereas age did not significantly predict excess of LOS (HR: 7.1 (4.4–11.4), p<0.001); HR: 1.01 (0.9–1.1), p=0.56, respectively). Neither age, nor comorbidity burden predicted the appearance of device related complications. Both comorbidites and age predicted mortality. However, the association was stronger for the presence of comorbidites, than for age (HR: 1.9 (1.1–3.1), p=0.002 vs HR: 1.1 (1.1–1.2), p<0.001, respectively). Elderly patients with low comorbidity burden (<2 comorbidities) showed no significant differences with regards to LOS and mortality when compared to younger patients (2 (2–4) vs 3 (2–5) days, p=0.529 and 18.3% vs 17.4%, p=0.702; respectively). Conclusions Our study shows a good life expectancy of elderly and very elderly patients, that underwent PM implantation, with a survival rate that is comparable to the general population. Comorbidity burden, rather than age, significantly predicts excess of LOS and should therefore be the driving factor in the approach of patients undergoing new PM implantation. FUNDunding Acknowledgement Type of funding sources: None.

Previous pacemaker therapy was not associated with the risk of clinical events in patients with atrial fibrillation: the Fushimi AF Registry

Background Patients with atrial fibrillation (AF) occasionally require pacemaker implantation. Meanwhile, patients with implanted pacemaker are occasionally found to have subclinical AF and develop clinical AF. However, little is known about the clinical outcomes of AF patients with implanted pacemaker. Purpose We aimed to investigate the clinical outcomes in AF patients undergoing previous pacemaker therapy. Methods The Fushimi AF Registry is a community-based prospective survey of the AF patients in a city of Japan. Follow-up data including prescription status were available for 4,447 patients. After exclusion of patients with implantable cardioverter defibrillator and cardiac resynchronization therapy, we investigated 293 AF patients with pacemaker implantation at baseline. We performed propensity score-matching analysis to assess the impact of pacemaker therapy in AF patients. Results Of a total cohort, patients with pacemaker were more often female (51.2% vs. 39.7%; p<0.01) and older (78.0 vs. 73.3 years of age; p<0.01). Patients with pacemaker were more likely to have pre-existing heart failure (33.1% vs. 26.6%; p<0.01), valvular heart disease (22.9% vs. 16.8%; p<0.01), chronic kidney disease (48.8% vs. 34.7%; p<0.01), and history of performing direct current cardioversion (7.2% vs. 3.1%; p<0.01), compared with patients without pacemaker. Mean CHA2DS2-VASc score was higher in patients with pacemaker (3.80 vs. 3.34; p<0.01). Patients with pacemaker were more often prescribed oral anticoagulants (62.1% vs. 55.2%; p=0.02), verapamil (13.3% vs. 9.4%; p=0.03), and loop diuretics (30.7% vs. 21.8%; p<0.01). Using propensity score-matching, 291 patients with pacemaker and 291 without pacemaker were matched and baseline characteristics were comparable. The median follow-up period was 1,819 days. All-cause death occurred in 91 patients with pacemaker (6.0 /100 person-years) and 79 patients without pacemaker (5.9 /100 person-years), with a hazard ratio (HR) for patients with pacemaker of 1.01 (95% confidence interval [CI], 0.75 to 1.37; p=0.93). Furthermore, HR of cardiac death for patients with pacemaker was 1.00 (95% CI, 0.23 to 4.32; p=0.99), that of stroke or systemic embolism was 0.69 (95% CI, 0.44 to 1.07; p=0.10) and that of hospitalization for heart failure was 0.94 (95% CI, 0.65 to 1.37; p=0.76). Conclusion We identified that patients undergoing previous pacemaker therapy were not associated with the incidence of various adverse clinical events in Japanese AF patients. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, Takeda Pharmaceutical, and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development.

Misdiagnosis of bradyarrhythmias in clinical practice in Iraq

Background and objective: Bradyarrhythmias are one of the many causes of syncope, pre-syncope, and dizzy spells. Missing the diagnosis of bradyarrhythmias, an underlying etiology of those symptoms, may lead to serious complications and even mortality. This study aimed to set a standard case definition of bradyarrhythmias, which will improve patient survival. Methods: Patients presented with partial or total loss of consciousness, who were misdiagnosed as other non-arrhythmic etiologies and later diagnosed as bradyarrhythmia, were included in this study. Diagnosis of bradyarrhythmias was reached by either 12 leads electrocardiography, Holter monitor, or electrophysiological study. Results: A total of 150 patients who fulfilled the definition of missed diagnosis of bradyarrhythmias were included. A total of 100 males and 50 females were collected over 10 years. The pre arrhythmic over-diagnosis included transient ischemic attacks in 35 patients, vertebrobasilar insufficiency in 40 patients, vertigo in 30 patients, and other nonspecific diagnoses in 45 patients. The final diagnosis of bradyarrhythmias was reached by electrocardiogram only in 45, Holter recording in 75, and electrophysiological study in 30. All the diagnosed cases of bradyarrhythmias received permanent pacemaker therapy. Conclusion: Misdiagnosis of bradyarrhythmias in patients presenting with syncope is not uncommon in clinical practice in Iraq, which may have a bad impact on patients' morbidity and mortality. Understanding the causative factors for the missed diagnosis can help set up an educational program to minimize this problem. Keywords: Misdiagnosis; Bradyarrhythmia; Syncope; Dizzy spells.

The Short Term Influence of RV Pacing Burden on Numerous Echocardiographic and Spiroergometric Parameter In Patients With Preserved LVEF - The Mechanism of The Worsened Clinical Outcome Due To High RV Pacing Burden Remains Unclear.

Background: The cause of worsened clinical outcome due to high RV pacing burden remains unclear.Objective: To investigate the impact of RV pacing on several echocardiographic and spiroergometric parameter Methods: In 60 pacemaker patients with preserved LVEF serial echocardiographies and spiroergometries were performed over a time course of 12 months. Additionally in 50 patients retrospective echocardiographic analyses of the LV- and RV function were carried out up to 24 months after pacemaker implantation.Results: The patients were divided into two groups: The high RV pacing burden group (hRVP: ≥ 40%) and the low RV pacing group (lRVP <40%) according to the definitions in previous randomized MOST and DAVID trials. After a period of 12 month pacemaker therapy there could not revealed any changes LVEDD, LVESD, LVEF, E/A-ratio; E/E’-ratio and TAPSE independently of the RV pacing burden. Additionally, after 24 month long term follow-up there were no changes in LVEF and TAPSE in both groups. Accordingly to these echo data no relevant changes of peak exercise capacity, ventilatory anaerobic threshold and maximal oxygen consumption could be revealed independently of the RV pacing. Conclusions: In pacemaker patients with preserved LVEF the burden of RV pacing has no adverse influence, neither to several echocardiographic parameters nor to the clinical exercise capacity after a follow-up of 12 to 24 month. Therefore, the mechanism of the worsened clinical outcome due to high RV pacing burden in patients without a relevant structural heart disease remains unclear.

Pacemaker therapy in the elderly and very elderly: survival and prognostic factors

Funding Acknowledgements Type of funding sources: None. Background The number of elderly patients undergoing pacemaker (PM) implantation is constantly growing. However, information on survival and prognostic factors of this particular patient group is scarce. Objective The objective of this study was to determine the survival of elderly and very elderly patients undergoing PM implantation, as well as to investigate prognostic factors of mortality. Methods This is a retrospective observational study of a single centre. Patients ≥ 80 years of age, that underwent PM implantation between January 2017 and December 2018 in our centre, were included for chart review. Very elderly patients were defined as those with ≥ 90 years of age. Results A total of 269 patients were included in the study with a mean age of 85 (±4.1) years. 53 patients were ≥ 90 years of age. 52% of the patients were male. 24.5% of the elderly patients and 41.5% of the very elderly patients received a single chamber PM. Median follow-up time was 28 (14-30) months, with no significant differences between the two groups of patients. The mortality rate for elderly patients was 15.7% for the elderly and 32.1% for the very elderly (p = 0.002). Generating multivariate Cox regression models, the following parameters showed to be significant predictors of all-cause mortality: Age (1.37 (1.02-1.29), p = 0.005), chronic kidney disease (5.57 (2.47-12.56), p &lt; 0.001), COPD (3.74 (1.19-11.55), p = 0.023) and cancer (3.57 (1.02-12.51), p = 0.046). In the group of the very elderly only age (1.58 (1.10-2.27), p = 0.014) and cancer (3.76 (2.38-4.18), p = 0.003) significantly predicted mortality. Conclusions Our study shows a good life expectancy of elderly and very elderly patients, that underwent PM implantation, with a survival rate that is comparable to the general population. The primary prognostic factors were non-cardiological and co-morbidities, such as chronic kidney disease, cancer and COPD, had a stronger association with mortality than age.

Pacemaker Therapy in the Elderly and Very Elderly

Background: The number of elderly patients undergoing pacemaker (PM) implantation is constantly growing. However, information on survival and prognostic factors of this particular patient group is scarce. The objective of this study was to determine the survival of elderly and very elderly patients undergoing PM implantation, as well as to investigate prognostic factors of mortality. Methods: This is a retrospective observational study of a single center. Patients ≥ 80 years of age, that underwent PM implantation between January 2017 and December 2018 in our center, were included for chart review. Very elderly patients were defined as those with ≥ 90 years of age. Results: A total of 269 patients were included in the study with a mean age of 85 (±4.1) years. 53 patients were ≥ 90 years of age. 52% of the patients were male. 24.5% of the elderly patients and 41.5% of the very elderly patients received a single chamber PM. Median follow-up time was 28 (14-30) months, with no significant differences between the two groups of patients. The mortality rate for elderly patients was 15.7% for the elderly and 32.1% for the very elderly (p = 0.002). Generating multivariate Cox regression models, the following parameters showed to be significant predictors of all-cause mortality: Age (1.37 (1.02-1.29), p = 0.005), chronic kidney disease (5.57 (2.47-12.56), p<0.001), COPD (3.74 (1.19-11.55), p = 0.023) and cancer (3.57 (1.02-12.51), p = 0.046). In the group of the very elderly only age (1.58 (1.10-2.27), p = 0.014) and cancer (3.76 (2.38-4.18), p = 0.003) significantly predicted mortality. Conclusion: Our study shows a good life expectancy of elderly and very elderly patients that underwent PM implantation, with a survival rate that is comparable to the general population. The primary prognostic factors were non-cardiological and comorbidities, such as chronic kidney disease, cancer and COPD, had a stronger association with mortality than age.