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Background: Remote monitoring (RM) is not routinely deployed in patients with low-energy devices, but there are limited efficacy and safety data in this population. In response to the COVID-19 pandemic, our institution enrolled all low-voltage devices onto RM to reduce clinic footfall. Purpose: To assess the efficacy and safety at 1 year of RM in patients with low-voltage devices. Methods: All patients implanted (Group 1) or with a scheduled follow-up (Group 2) with a pacemaker (PPM) or cardiac resynchronisation therapy pacemaker (CRTP), April to November 2020, were prospectively enrolled. Patients who were transferred to another centre were excluded. Group 1 had 1-month and 12-month virtual follow-up and Group 2 had 12-month virtual follow-up, with alerts or patient request triggering earlier review. The number, reason, outcome and time to remote or in-person clinic review were assessed. The 1-year mortality was assessed and compared with a historic cohort without RM between April and November 2018. Results: A total of 263 patients were enrolled (28% males, mean age 75 (SD 14) years; 63% Group 1 and 37% Group 2). This included 201 patients with PPM and 62 with CRTP. Overall, 390 scheduled remote reviews, 180 alerts and 173 clinic reviews took place. Per patient median (IQR) scheduled remote reviews, alerts and clinic reviews were: Group 1 1 (1–2), 2 (1–2.5), 1 (1–1.5), respectively; Group 2 1 (1–2), 1 (1–2), 1 (1–2), respectively. Overall, across both groups, 82 medical reviews were requested (median 1 [1–1] per patient), with 33% resulting in a change in clinical management, and 24 patients were referred to a specialist clinic. In Group 1, 17% had alerts before the 1-month review and 64% required early review (arrhythmia and heart failure management 50%, anticoagulation 12%, device reprogramming 12% and lead issue 22%). Between 1 and 12 months, 68% of patients had a remote or clinical review, median (IQR) 101 (31–364) days, and 51% required review outside the routine review (arrhythmia and heart failure management 27%, anticoagulation 6%, device reprogramming 32%, lead revision 1% and wound revision 2%). In Group 2, the median time to first follow-up was 141 (80–357.5) days, and 66% required clinical intervention prior to the 12-month review (arrhythmia and heart failure management 23%, anticoagulation 3%, device reprogramming 8%, lead revision 5%, generator change 21% and device upgrade 2%). Overall, 66% had a change in follow-up schedule. There was no significant difference in 12-month mortality overall when compared with a historical cohort without RM (deaths 6% (16/263) in the RM cohort and 6% (13/213) in the historical non-RM cohort (p=0.99). No device-related deaths were seen in the RM cohort. Conclusion: The use of RM was both efficacious and safe in patients with low-voltage devices at 1 year. In both de novo and routine follow-up cohorts, RM identified important findings in patients requiring intervention prior to routine review. This tailored strategy was not associated with a difference in mortality when compared with a local matched historical cohort without RM. ❑

Introduction: Chronic high burden of right ventricular (RV) pacing is well known to cause deleterious effects on the left ventricular (LV) systolic function. However, there is variation in this effect with LV systolic function being maintained in some patients and worsening in others. We investigated characteristics amongst a cohort of patients with RV pacing burden greater than 40% to establish any specific risk factors associated with this effect. Methods: We retrospectively examined records of 152 consecutive patients with RV pacing > 40% who underwent generator change (GC) or cardiac resynchronisation therapy (CRT) upgrade between July 2016 and July 2019 at Barts Heart Centre. All patients had LV assessment prior to initial pacing procedure and prior to GC or CRT upgrade with echocardiography. Case group included patients who underwent CRT upgrade (81 patients) with LV systolic dysfunction (ejection fraction EF ≤45%) and the controls were patients with preserved LV function who underwent only generator change (71 patients). Patients with underlying cardiomyopathies and complex congenital heart disease were excluded. Within the CRT upgrade group, factors affecting the development of LV systolic dysfunction were examined. Results: Baseline characteristics are presented in Table 1. Primary indication for pacing for both cohorts were similar with principal reason being complete heart block (72%). Median RV pacing % in both cohorts were high, 99% vs 100%. Median time between implant and upgrade or GC were similar (CRT upgrade 8 years vs GC 9 years). Male predominance was significantly higher (p=0.008) in the upgrade cohort compared to the GC cohort. Presence of low pre-implant LV ejection fraction (<55%), history of ischaemic heart disease, presence of atrial fibrillation and chronic kidney disease were more prevalent in upgrade cohort compared to GC cohort (p<0.04). Within the CRT upgrade cohort, the effect of paced QRS duration and age at implant were examined using Spearman’s correlation coefficient. There was an inverse correlation between paced QRS duration and LV systolic function prior to upgrade (r= -0.64; p<0.01). A negative correlation was also observed between age at implant and time to diagnosis of LV systolic dysfunction since implant (r= -0.36; p<0.01). There was no statistically significant association between RV lead position (apical vs septum) with paced QRS duration (p=0.58) and LV systolic function (p=0.89). Conclusion: Male gender, pre-implant LV ejection fraction (EF <55%), ischaemic heart disease, atrial fibrillation and chronic kidney disease may be associated with deterioration in LV function in patients who have a high burden of RV pacing. Wider paced QRS duration and age at implant may also be factors which influence development of pacing induced LV dysfunction. Further large prospective randomised studies are needed to determine aetiological factors in these patients. [Image Omitted]

In view of the history of prominent inflammatory symptoms-malaise, arthralgias, myalgias; symptoms suggestive of vessel involvement-abdominal aortic narrowing causing ischaemic pain; and the physical examination, a diagnosis of Takayasu's arteritis was considered. Recent published reports have shown that CT can be very useful in detecting Takayasu's arteritis because it shows such details as wall thickening and perivascular oedema, which cannot be detected by arteriography. 1- 3 CT is also useful as a non-invasive means of monitoring patients with Takayasu's arteritis who are undergoing treatment, to examine disease resolution or progression.

Introduction: Nonagenarians are under-represented in clinical trials of cardiac implantable electronic devices (CIEDs). Complete heart block (CHB) is a time-critical emergency and, particularly in elderly patients, the absence of test results or a comprehensive medical history can challenge operator decision-making, especially when permanent pacing is preferred. In patients over 90 years of age undergoing emergency CIED implant for CHB, we examined the prognostic value of data available from bedside examination and focussed echocardiogram alone. Methods: Data were extracted for the period 2016-2019. Bedside covariates were age, sex, previous cardiac surgery, atrial rhythm, LV systolic function, syncope at presentation, and QRS duration. Cox-proportional hazards regression examined associations with mortality (adjusted HR, 95% CI). Results: 232 patients were included (age 94.1 ± 3.3 years, 50.2% male, dual chamber device implanted: 71.9%, single chamber: 26.4%, CRT: 1.7%). Mortality was 13.8% at 90 days and 27.2% at 27.1 ± 16.7 months. The independent predictors of mortality were pre-procedural QRS duration >130 ms (HR 2.4 (1.4-4.1) p=0.001), age (HR 1.07 (1.02-1.15) p=0.004) and AF (HR 2.0 (1.1-3.6) p=0.02). Sex, syncope at presentation, LV function or previous cardiac surgery were not associated with patient mortality (all p>0.1). In 196 patients without AF, 84.7% were implanted with dual chamber pacemakers; this was associated with an adjusted survival benefit versus single chamber pacing (HR 0.38 (0.25-0.56) p<0.001) despite two atrial lead re-interventions in the dual chamber group. Conclusions: Nonagenarians undergoing emergency CIED implant have a reasonable prognosis. Data ascertained at the bedside can help predict survival; in the absence of AF, dual chamber pacing may confer a mortality benefit, however this association requires further investigation. [Image Omitted]

In response to COVID-19 at this tertiary cardiac centre, based on triaged risk, the number of patients on remote monitoring (RM) increased 1.75-fold, from 4,000 to 7,000 (55% of the total patient population). Pre-pandemic, this centre gave RM to high-voltage devices only. RM for all device patients aligns with NHS England guidance to reduce outpatient (OP) visits by 25%, increase patient-initiated follow-up (FU) and provide equitable, timely access to care. At this centre, the increase in RM led to a 2.4-fold increase in transmissions (3,600 per month), of which, on average, 50% are non-actionable. Total device clinic activity, face to face (F2F) plus RM, is 110% of 2019 levels and the 2022/2023 104% elective recovery target pushing lab utilisation is also stretching Cardiac Science (CS) resource. With a national shortage of CS and no capital funding for workforce, a strategy is vital to support demand and the change in practice to RM, whilst maintaining quality of care and staff wellbeing. The priorities to deliver this are recruitment, training, retention and optimisation of CS resource. To optimise CS time, this centre reviewed RM workflows and identified processes that are now performed by non-clinical staff. This includes checking in transmissions successfully received; contacting patients who have missed their scheduled transmission, and signposting and educating disconnected patients. New patient communication channels have also facilitated access to appropriate guidance. A proposed pilot sees a clinical support worker initiating RM post-implant; this would release 0.5 WTE CS, improve inpatient time to discharge and provide consistent patient education. Utilising a RM alert-driven FU model has been demonstrated as effective and efficient. Using this strategy with extended routine FU intervals for appropriate patients, we estimate routine OP attendance will reduce to 85%. This in turn reduces carbon emissions, reduces patient and transport cost, and increases capacity for urgent F2F review and specialist device clinics. Specialist device clinics provide individualised patient management, improve patient experience, promote retention of CS and better utilise available medical cover. Alert-driven FU relies on consistent connectivity so a robust process for minimising the number of disconnected patients is required first; the target to effectively control the risk is <5% disconnected. This centre has reduced disconnection rate from 17% to 10% (700 patients) with data cleaning, contacting disconnected patients and support from industry. Consistent 0.4 WTE clerical support is required to track patients and arrange F2F education for missed transmissions. Eligibility criteria have been created to ensure RM enrolment of appropriate patients. The next phase focuses on reducing inappropriate transmissions and non-actionable alerts to 20% by: targeting patients with a high volume of unscheduled transmissions; improving patient education; developing guidance on tailoring RM alerts; and reviewing false-positive alerts for each manufacturer. To ensure our approach is evidence-based, this centre is collaborating with industry on data dashboard solutions. Overall, these projects should release 11% (3.5 WTE) of current CS resource, which can then be used to plug the workforce gap for the expansion of RM and increase in elective activity. ❑

Abstract Aims In patients with heart failure and a pathologically prolonged PR interval, left ventricular (LV) filling can be improved by shortening atrioventricular delay using His-bundle pacing. His-bundle pacing delivers physiological ventricular activation and has been shown to improve acute haemodynamic function in this group of patients. In the HOPE-HF (His Optimized Pacing Evaluated for Heart Failure) trial, we are investigating whether these acute haemodynamic improvements translate into improvements in exercise capacity and heart failure symptoms. Methods and results This multicentre, double-blind, randomized, crossover study aims to randomize 160 patients with PR prolongation (≥200 ms), LV impairment (EF ≤ 40%), and either narrow QRS (≤140 ms) or right bundle branch block. All patients receive a cardiac device with leads positioned in the right atrium and the His bundle. Eligible patients also receive a defibrillator lead. Those not eligible for implantable cardioverter defibrillator have a backup pacing lead positioned in an LV branch of the coronary sinus. Patients are allocated in random order to 6 months of (i) haemodynamically optimized dual chamber His-bundle pacing and (ii) backup pacing only, using the non-His ventricular lead. The primary endpoint is change in exercise capacity assessed by peak oxygen uptake. Secondary endpoints include change in ejection fraction, quality of life scores, B-type natriuretic peptide, daily patient activity levels, and safety and feasibility assessments of His-bundle pacing. Conclusions Hope-HF aims to determine whether correcting PR prolongation in patients with heart failure and narrow QRS or right bundle branch block using haemodynamically optimized dual chamber His-bundle pacing improves exercise capacity and symptoms. We aim to complete recruitment by the end of 2018 and report in 2020.

Introduction: A greater biventricular pacing percentage (BiVp%) is associated with greater left ventricular reverse remodelling and reduction in all-cause mortality in patients with cardiac synchronisation therapy devices (CRT). A multi-disciplinary team (MDT) service was implemented at Barts Health NHS Trust to discuss patients with low BiVp%, to determine the cause, increase BiVp%, and provide a clear management plan to aid cardiac scientists when responding to remote monitoring alerts. Methods: This retrospective audit followed 121 patients who were referred to the low BiVp% service between June 2020 and July 2021. 106 patients were included in the analysis, of the excluded patients, 11 were deceased at 6 months, 3 had been transferred to another centre and one patient had left ventricular (LV) lead displacement. Baseline characteristics were collected at time of CRT implant and BiVp% and New York Heart Association (NYHA) functional class were collected at the time of MDT and 6-month post MDT. The outcome of the MDT was actioned and documented on patients’ electronic health records. Results: Of the 106 patients, 75% were male, mean age was 73 ± 10.6 years, mean LV ejection fraction (LVEF) at implant was 33 ± 11% and 57% were classed as NYHA II. The most common indication for implant was ischaemic heart disease (49%), and the most common QRS morphology was left bundle branch block (58%). The most common outcomes were to continue patient monitoring (35%) and lowering the alert threshold on remote monitoring (27%). In the remaining 40 patients, an active outcome was actioned, most commonly a referral to another cardiology service (19%). The other outcomes are summarised in Table 1. These 40 patients had a mean improvement in BiVp% of 6 ± 12% over a mean follow-up time of 5.9 ± 1.6 months post-MDT. An improvement of ≥1 NYHA class was seen in 16 patients (44%), no change in NYHA class was seen for 12 (33%) symptomatic patients (NYHA II-IV), no change in NYHA class was seen in 6 (16%) asymptomatic patients (NYHA I) and 2 patients showed a worsening of ≤1 NYHA class at a mean follow-up time of 5.9 ± 1.6 months post-MDT. Conclusion: This retrospective audit has demonstrated that in 38% of patients being discussed in a ‘low biventricular pacing MDT’, active changes were made to their clinical care. These patients had an improvement in biventricular pacing and around half had improved NYHA class over a short follow-up period. Changing alert threshold was a useful outcome for cardiac scientists when managing remote monitoring alerts. Future prospective studies should evaluate the outcomes over a longer follow-up duration. ❑ [Image Omitted]

Introduction: Cardiac resynchronisation therapy (CRT) has proven to improve left ventricular function, symptoms and quality of life in patients with symptomatic heart failure. Its effectiveness is largely dependent on the percentage of biventricular pacing (BiVp%). This can be reduced by a number of factors such as atrial and ventricular dysrhythmias and device programming. Barts Health NHS Trust has set up a service where patients with low BiVp% can be discussed with a cardiac scientist and a consultant cardiologist. Methods: Any patient with a BiVp% of ≤97 can be referred by cardiac physiologists from the device clinic. A pro forma was completed to include the patient’s past medical history, cause of the drop in BiVp%, patient symptoms, CRT device details and current medications (Figure 1). Any outstanding patients were discussed at a weekly meeting with an outcome documented and actioned. Results: Between June 2020 and July 2021, a total of 121 patients (76% male; age at referral 75 ± 10.6 years) were referred. Overall, 95 patients had a CRT-D (79%) and ischaemic heart disease was the most common underlying aetiology (63 patients, 53%). The mean BiVp% was 81 ± 10.7%, with the most common cause of reduced BiVp% being premature ventricular complexes (88 patients, 72%). A total of 50 patients (43%) were New York Heart Association class II at the time of referral, with shortness of breath being the most common symptom (62 patients, 52%). Conclusion: It is feasible to set-up an MDT-style service where patients with identified low biventricular pacing can be discussed and a clear outcome actioned to support cardiac scientists with the managements of this patient group. [Image Omitted]

Background: MultiPoint Pacing (MPP) CRT may improve electrical resynchronization of the left ventricle (LV). Optimization with SyncAV dynamically combines intrinsic atrioventricular (AV) conduction and pacing. Objective: To assess regions of fixed and functional conduction block in patients with LBBB and the impact of MPP & SyncAV, evaluated by electrocardiographic imaging (ECGi). Methods: Patients in sinus rhythm with LBBB, having CRT implantation (MPP CRT, quadripolar LV lead) underwent ECGi mapping; during intrinsic rhythm, nominal AV delay and optimized SyncAV (offset minimizing QRS duration) during biventricular (BiV), MultiPoint pacing (MPP) and LV only MPP (LVMPP). Activation times (AT) were calculated. Sites with conduction block were defined as difference in AT >50ms over 10mm. Results: ECGi was completed in 10 patients (80% male, mean age 66±16 years, 60% ischemic, LVEF 30±6%, QRSd 167±15ms). Latest activating LV segments during intrinsic rhythm were heterogenous: basal-anterior 20%, anterolateral 30%, lateral 10%, inferolateral 30%, inferior 10%. LV lead positions were concordant to the latest activating segment in 50%; adjacent 20% and remote (≥2 LV segments) 30%. Two or more lines of block of varying distribution were present in all cases. Leads were concordant with lines of block in 0%, adjacent 60% and remote 40%. Area of block was reduced by LVMPP SyncAV from intrinsic (p<0.05). MPP was superior to BiV by resolving (functional) block in 50% of cases Conclusion: Patterns of conduction block and latest activating segment were heterogenous. MPP vs BiV SyncAV reduced functional block in 50% of cases. Evaluation with ECGi mapping may be of value for complex CRT programming.

Aims: Cardiac perforations caused by pacemaker and implantable-cardioverter defibrillator (ICD) leads are serious events. Due in part to their infrequency, management options and outcomes are unclear. Methods: A single-centre retrospective study was conducted at a high-volume tertiary centre to identify patients in whom cardiac perforation occurred due to lead implantation or intervention. The search included all lead procedures spanning 3 years from 2016-2019. 6 months follow-up was assessed in all patients with perforation. Results: Of 4619 procedures 32 patients were diagnosed with lead related cardiac perforation (involving 33 leads), mean age 74±15 years, 20 (63%) female, mean left ventricular ejection fraction 51% (±11). 9 devices were implanted at other centres; therefore, the institutional rate of perforation was 0.5% (n=23 patients, 24 leads). 9 (39%) were identified acutely (<24 hours), median time to diagnosis was 32 (±49) days in sub-acute/chronic perforation. All but one leads were active fixation models; 25/32 (78%) had abnormal electrical parameters at device interrogation. 6/33 (18%) were ICD leads. 27/33 (82%) leads perforated the right ventricle (RV) in the apex or anterior apical region, 3 (9%) mid anterior RV and 2 (6%) lateral right atrium. Management was trans-venous in 31/32 (97%) patients with lead extraction or repositioning; pericardial drainage was required in 10/32 (31%), sternotomy with surgical repair was required in 1 (3%). 1 (3%) patient was deceased within 30 days, all other patients made a full recovery and were well at 6 months follow-up. Conclusion: Although infrequent (0.5%), perforation occurred predominantly in the RV apex. No clear patient factors were identified as risk factors. Trans-venous lead extraction was safe and effective with surgical intervention rarely required.