NHJ abstract 2016

Vo l u m e 2 5 Supplement 2 N o v e m b e r 2 01 6 ISSN 1569-643X

Abstracts

Netherlands Heart Journal Supplements Journal of the Netherlands Society of Cardiology

Abstracts of the Scientific Autumn Congress of the Netherlands Society of Cardiology 2016

De abstracts zijn ook digitaal beschikbaar via www.cardiologie.nl/nhj

3 and 4 November 2016, Papendal, Arnhem

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PREFACE

Autumn Congress of the Netherlands ­Society of Cardiology 3 and 4 November 2016, Papendal, Arnhem

Dear reader, We are pleased to present here the abstracts of the Scientific Autumn Meeting of the Netherlands Society of Cardiology which will be held on 3 and 4 November 2016 in Papendal, Arnhem.

We hope that you will enjoy reading the abstracts.

On behalf of the Chief Editorial Board Prof. Dr. E.E. van der Wall

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Abstracts

SESSION I CARDIOVASCULAR IMAGING

NORMATIVE VALUES MEASURED WITH 3D AND 2D ECHOCARDIOGRAPHY IN A HEALTHY DUTCH POPULATION

Keywords: 3D echocardiography; normal values; reference values

R.W.J. van Grootel; A.E. van den Bosch; M.E. Menting; J.S. McGhie; J.W. Roos-Hesselink (Erasmus Medical Center, Rotterdam) r.vangrootel@erasmusmc.nl

Figures. Four figures showing the LV and RV volumes measured with 3D echocardiography, specified per age and gender.

ABSTRACT Purpose: To obtain 1) echocardiographic chamber measurements in healthy volunteers aged 20 to 72 years to propose normative values and 2) determine influences of anthropomorphic factors on these measurements.

Methods: A cohort of 155 prospectively recruited healthy subjects, aged 20-72 years (at least 28 subjects per age decade, equally distributed for sex) underwent physical examiniation and 2D- and 3D-echocardiography. Both ventricles and atria were assessed and volumes were calculated.

Results: 147 subjects were included (age 44±14 years, 50% female). Feasibility for 3D values were 82.3% and 66.0% for LV and RV respectively. Values found with 2D and 3D were consistently higher than current guidelines recommend (See figure). 3D volumes were higher than 2D volumes. Gender dependency was seen in all BSA corrected volumes, but age had little influence on volumes or ejection fractions. Blood pressure was an independent predictor for RV volumes, even after correction for gender and age.

Conclusion: This study provides 2D and 3D echocardiographic reference ranges for both the LV and RV, bases on a healthy Dutch population measured with TomTec. BSA indexed volumes remain gender-dependent, age did not influence ventricular volumes and a rise in blood pressure was independently associated increased RV volumes, suggesting that adequate blood pressure management could have protective qualities. The higher volumes found may be indicative for the Dutch people used in this study.

RUBIDIUM-82 POSITRON EMISSION TOMOGRAPHY MEASUREMENTS OF MYOCARDIAL BLOOD FLOW IN PATIENTS WITH CORONARY ARTERY BYPASS GRAFTS

FIRST-PASS ADENOSINE MR IMPROVES PRE-TEST LIKELIHOOD IN 641 PATIENTS WITH STABLE CHEST PAIN

B.J.H.G. van Gageldonk; A.T.L Fiolet; A. Mosterd; I.E.M. Bank; J.M.H. de Klerk; A.M. Scholtens (Meander Medical Center, Amersfoort) babsvangageldonk@gmail.com

D. Rijlaarsdam-Hermsen; D. Kuijpers; P.R.M. van Dijkman; R.T. van Domburg; J.W. Deckers ( Erasmus Medical Center, Rotterdam) dorinerijlaarsdam@gmail.com

ABSTRACT

ABSTRACT

Purpose: Rubidium-82 Positron Emission Tomography (Rb-82 PET) is a reliable technique to detect ischemia: global myocardial stress flow in native coronary arteries (cut-off 2.0mL/g/min) is strongly related to clinical outcome.

It has been suggested that grafted coronary arteries have different myocardial stress flow, due to differences in blood-to-vessel wall interactions and diameter in arterial and venous grafts compared to native coronary arteries. Rb-82 PET Myocardial stress flow has not been validated for grafted coronaries. We investigated Rb-82 PET global myocardial stress flow in CABG patients.

Purpose: The diagnostic yield of conventional coronary angiography (CCA) is low. Two-thirds of diagnostic CCAs in patients with stable chest pain are not followed by a revascularisation. The purpose of this study is to assess whether coronary artery calcium scoring (CACS) followed by first-pass adenosine MR is able to improve the diagnostic yield of CCA.

Methods: A retrospective analysis of all Rb-82 PET scans (n=2819) performed in our institution between February 2014 and May 2016 identified 295 scans in post-CABG patients, who were divided based on Global Myocardial stress flow ((<1.8mL/g/min; low (n=106), 1.8-2.0mL/g/min; borderline-low (n=39), >2.0mL/g/min; normal (n=150)).

Left ventricular ejection fraction (LVEF), myocardial blood flow and summed difference scores (SDS, indicating extent of ischemia) were compared across groups. Patients were followed for coronary revascularizations and acute coronary syndromes (ACS).

Results: Rb-82 PET measurements in the ‘borderline-low’ and ‘low’ group were similar in terms of SDS (6.1±5.4 vs 4.2±4.4, p=0.100) and both resting LVEF (50.8±15.5 vs 55.3±13.6, p=0.203) and stress LVEF (51.2±15.5 vs 57.3±14.0, p=0.067) The ‘normal’ group had lower SDS (2.4±3.5) and higher LVEF (62.1±11.5 and 64.5±11.6).

There was a significant difference across groups in patients free of ACS and/or revascularization during follow-up (71.4% versus 79.5% versus 88.1% p=0.003).

Conclusion: Established Rb-82 PET myocardial blood flow velocity cut-off values provide useful (prognostic) information in CABG patients as well.

Keywords: Rb-82 Positron Emission Tomography; Coronary Artery Bypass Graft; myocardial blood flow

Methods: From December 2004 to May 2011 consecutive new patients with stable chest pain and CACS >0 referred for first-pass adenosine MR were enrolled. Pre-test likelihood was assessed according to the ACC/ AHA guidelines on exercise testing. Pre-test probability scores were compared with ROC analysis. Patients with a perfusion defect were examined by CCA. Outcome was obstructive CAD defined as ≥ 70% diameter stenosis in ≥ 1 vessel on CCA. Results: In total, 641 patients were included ( mean age 61.7 year, 50% men) of whom 12.8% had low, 72.0% intermediate and 15.1% high pre-test likelihood of CAD. Ischemia was present on adenosine MR in 13.6%. Of the patients with high pre-test likelihood 64.9% showed no ischemia, whereas of the patients with low pre-test likelihood 3.6% showed ischemia. In most patients (90,5%) in whom an ischemic first-pass adenosine MR was performed, a positive diagnostic CCA was found. CACS and first-pass adenosine MR in addition to pretest likelihood improves the diagnostic yield of CCA to 90,5% (c-index improved from 0.64 to 0.70; p<0.01).

Conclusion: ACS combined with first-pass adenosine MR provide important incremental value over pre-test likelihood, and increases the diagnostic yield of CCA to 90,5%.

Keywords: coronary angiography; adenosine MR; calcium score

Figure 1. Kaplan-Meier curve which shows the event-free survival for the total population divided into the three groups according to the global myocardial stress flow.

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Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Abstracts

SESSION I CARDIOVASCULAR IMAGING (continued)

CARDIAC INVOLVEMENT IN ANKYLOSING SPONDYLITIS: INSIGHTS FROM CARDIO­ VASCULAR MAGNETIC RESONANCE IMAGING

COMPREHENSIVE CARDIAC CT VERSUS FUNCTIONAL TESTING IN SUSPECTED CORONARY ARTERY DISEASE: THE MULTICENTRE, RANDOMIZED CRESCENT II TRIAL

P.S. Biesbroek; S.C. Heslinga; T.C. Konings; I.E. van der Horst-Bruinsma; M.B.M. Hofman; P.M. van de Ven; O. Kamp; V.P. van Halm; M.J.L. Peters; Y.M. Smulders; A.C. van Rossum; M.T. Nurmohamed; R. Nijveldt (VU Medical Center, Amsterdam) p.biesbroek@vumc.nl

M.M. Lubbers; A. Coenen; M. Kofflard; M. Kock; M. van Gent; E.J. van den Bos; L. van Woerkens; S. Kooij; T. Galema; P. Musters; T. Bruning; A. Niezen; B. Kietselaer; M. Das; S. Altintas; A. Moelker; M. Hunink; K. Nieman (Erasmus Medical Center, Rotterdam) m.m.lubbers@erasmusmc.nl

ABSTRACT Purpose: To determine the presence and extent of cardiac involvement in patients with ankylosing spondylitis (AS) using cardiovascular magnetic resonance (CMR).

Methods: Patients with AS were screened by transthoracic echocardiography (TTE) for study participation. Fifteen consecutive AS patients with an abnormal TTE, including cardiac abnormalities, valvular disease, or aortic root dilatation, were prospectively included.

CMR protocol included cine imaging for left ventricular (LV) function, late gadolinium enhancement (LGE) for focal fibrosis, and T1 mapping for quantification of the extracellular volume (ECV) (e.g. marker of diffuse interstitial fibrosis). LV dysfunction was defined as a LV ejection fraction (LVEF) below 55%.

Results: Sixty-three patients were screened by TTE when the predefined number of 15 participants was reached, of which one was excluded. In the 14 included AS patients with a complete CMR exam (mean age 62 years, 93% male, and mean disease duration 21 years), LV diastolic dysfunction was the most common finding on TTE (69%), followed by aortic root dilatation (19%), right ventricular (RV) dilatation (6%), and RV dysfunction (6%). CMR revealed focal hyperenhancement in three patients (21%), all with a particular pattern of enhancement (Figure 1). LVEF was impaired in five patients (36%), and was significantly lower in patients with hyperenhancement (47 ± 8% versus 56 ± 5%, p=0.03). Myocardial ECV was strongly correlated with CRP concentration (Pearson’s correlation = 0.83, p<0.01) and ESR level (Spearman’s rank correlation = 0.69, p<0.01).

Conclusion: The findings of this first CMR study in AS suggest the presence of cardiac involvement.

CMR with cine imaging and LGE identified global LV dysfunction and focal areas of hyperenhancement, while T1 mapping with ECV quantification could discriminate patients with various degrees of disease activity.

ABSTRACT

Keywords: Ankylosing Spondylitis; Cardiovascular Magnetic Resonance; Cardiac Involve­ment; Late Gadolinium Enhancement; T1 Mapping

Keywords: clinical trials; stable angina; diagnostic testing; CT calcium scan; coronary CT angiography; CT Myocardial perfusion imaging; functional testing

Figure 1. Hyperenhancement was found on the late gadolinium enhancement images in three patients.

All three had a particular pattern of enhancement, with mid-wall to subepicardial hyperenhancement, localized in the basal inferior and inferolateral LV walls (arrows). A) A 70-year old male, diagnosed with Ankylosing Spondylitis (AS) since 24 years B) A 74-year old male, diagnosed with AS since 16 years C) A 65-year old male diagnosed with AS since 42 years.

Figure. Downstream testing. Proportion of patients requiring further non-invasive and/or invasive testing after cardiac CT and a baseline functional test.

THE AGATSTON SCORE OF THE DESCENDING AORTA IS AN INDEPENDENT PREDICTOR OF FUTURE CORONARY ARTERY DISEASE ON TOP OF CORONARY AGATSTON SCORE IN A LOW-RISK POPULATION

COGNITION AND STRUCTURAL BRAIN DAMAGE IN ADULTS WITH TETRALOGY OF FALLOT

E.A.M.P. Dudink; F.E.C.M. Peeters; S. Altintas; L.I.B. Heckman; RJ Haest; J.A. Kragten; J.E. Wildberger; B.L.J.H. Kietselaer; B. Weijs; H.J.G.M. Crijns (Maastricht University Medical Center, Maastricht) elton.dudink@mumc.nl ABSTRACT Purpose: We assessed the ability of the Agatston score of the descending aorta in a coronary artery calcium scan (CCS) to predict future significant coronary artery disease (CAD) in a low-risk population.

Methods: 320 patients, referred for cardiac CT as work-up for pulmonary vein isolation (n=99) or cardiac screening (n=221), were included. All were free of cardiovascular disease at baseline. Two observers determined the Agatston score of the aorta between the end of the aortic arch and the diaphragm on standard CCS images.

Results: 13 patients (4.1%) developed CAD (ACS (n=4), PCI/CABG (n=5), significant CAD on CAG (n=8)) during follow-up of 67±12 months. Baseline characteristics of patients who developed CAD were equal to those of patients who did not, except for age (61.9±6.8 vs 55.2±10.1 years, p=0.02). The Agatston score of both the coronary arteries and the descending aorta were higher in patients who developed CAD (range 0-1295 (median 0) vs 0–761 (median 0); 0–5675 (median 0) vs 0–1421 (median 0)). Age adjusted Coxregression showed that both the coronary Agatston score (HR per 100 units 1.37 (1.17– 1.60); p<0.001) and the descending aortic Agatston score (HR per 100 units 1.05 (1.01– 1.09); p=0.01) were predictors of future CAD. 45 patients had no coronary calcification but did show aortic calcification, which was associated with a high incidence of CAD (6.7%).

Conclusion: Freely available information on calcification of the descending aorta should be included in the standard analysis of CCS since it predicts future CAD in a low-risk population.

Keywords: cardiac CT; aorta calcification; prognosis

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Purpose: Cardiac CT has the potential to improve the diagnostic workup of patients with angina pectoris. Adding myocardial CT perfusion imaging to cardiac CT provides an opportunity for combined evaluation of coronary anatomy and functional significance of coronary stenosis and can be an important gatekeeper for invasive angiography. In this randomized trial we assessed the effectiveness, efficiency and safety of a tiered cardiac CT protocol in comparison to functional testing.

Methods: Between July 2013 and November 2015 266 patients with stable angina, were prospectively randomized between cardiac CT and functional testing. The tiered cardiac CT protocol included a calciumscan, followed by CT-angiography if the Agatston calciumscore was>0. Patients with a significant stenosis on CT-angiography continued to CT-perfusion imaging.

Results: By six months, the rate of negative invasive coronary angiograms, was lower for the cardiac CT group, in comparison to the functional testing group (2% vs. 7%,p=0.035) and the the number of performed invasive angiograms with a class-I revascularization indication, was 88% after CT, compared to 50% in the functional-testing group(p=0.017). The median duration until the final diagnosis was 0 (0;0) days by CT and 0 (0;17) by functional-testing (p<0.001). Overall, 13% of patients randomized to CT underwent another test after the baseline test, compared to 37% in the functional-testing group (p<0.001)(Figure1).

Invasive angiography was similarly frequent after CT and functional-testing (13% vs 14%) (p=0.860). The observed MACE rate was comparable (3% vs 3%, p=1.000).

Conclusion: For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing.

M.A. Sluman; E. Richard; L. van Wanrooij; J.W. van Dalen; B.J. Bouma; M. Groenink; C.B.L.M. Majoie; B.A. Schmand; B.J.M. Mulder (Academic Medical Center Amsterdam, Amsterdam) m.a.sluman@amc.uva.nl ABSTRACT Purpose: Tetralogy of Fallot (TOF) is associated with unemployment and lower educational levels.

This could be caused by brain damage through previous cyanosis, prenatal cerebral impairments or perioperative damage. The aim of this study is to investigate the presence of brain damage in adults with TOF and to investigate relations with occupational outcomes.

Methods and results: In a single centre cohort study, brain damage and its possible relevance was studied in 67 TOF patients through magnetic resonance imaging (MRI) of the brain, a neuropsychological examination (NPE) and a questionnaire on work experiences. Median age was 37 years (range 20 – 69) and gender distribution was equal. Cerebral infarctions were seen in 12 (19%) patients. White matter hyperintensities (WMH) were seen in 35 patients (55%) and not related to age. In patients aged younger than 40 years (n=37), infarctions were seen in 4 (11%) and WMH in 12 patients (32%). Twentyone participants (32%) showed signs of cognitive impairment in at least one domain of NPE. No relation was found between MRI findings and NPE. Fifty two patients (78%) were employed, working 4 days per week (± 1) and 31 hours per week (range 4 – 40) on average. Nineteen (37%) experienced job related problems attributed to their cardiac condition. No relation was found between unemployment or other job related problems and signs of cerebral damage (infarction, WMH, impaired NPE). Likewise, no association was found between clinical parameters (age at surgery, number of surgeries, previous shunt) and signs of cerebral damage.

Conclusion: Many adults with TOF show signs of cerebral damage at MRI or NPE at relatively young age. However, cerebral damage did not seem to influence job participation at adult age.

Other factors for unemployment need further investigation.

Keywords: Tetralogy of Fallot; cognitive impairment; brain damage

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Abstracts

SESSION II DEVICES/CRT

A NOVEL IMPLANTATION STRATEGY IN PACEMAKER DEVICE INFECTION IN PACEMAKER DEPENDENT PATIENTS

IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS AND OLDER PEOPLE: THE DUTCH CLINICAL PRACTICE

F.S. van den Brink; V.F. van Dijk; J. Gelissen; E. Daeter; U. Sonker; P. Klein; J. Balt (Sint Antonius Hospital, Nieuwegein) f.van.den.brink@antoniusziekenhuis.nl

D. Yilmaz; J.W. Blom; M. Muller; M.J. Schalij; L. van Erven (Leiden University Medical Center, Leiden) d.yilmaz@lumc.nl

ABSTRACT

ABSTRACT

Purpose: Treatment of pacemaker (PM) device infections is challenging in pacemaker dependent patients. We propose a novel implantation strategy for this group of patients

Purpose: Benefit and burden of implantable cardioverter-defibrillator (ICD) therapy is more debatable in older people , compared to younger peers, especially when primary prevention is concerned. It is estimated that 20% of the annual ±5000 ICD procedures concern patients ≥75 years of age. We aimed to evaluate the current practice ICD implants and pulse generator change in the Netherlands.

Methods: Patients who were PM dependent and were admitted with a PM infection received a combined procedure of LV epicardial implantation of a PM lead and subsequent extraction of the infected system. No temporary pacing wire was used and the PM generator was placed in the left flank.

Results: Between 2012 and 2015 we treated 16 patients who were PM dependent with a PM infection. The majority of patients was male (81% (13/16)). The mean age was 71 years (50-91). The cause of infection was valvular endocarditis in 38% (6/16), lead infection in 25% (4/16) and isolated pocket infection in 38% (6/16).

All patients underwent epicardial implantation of a LV lead (Medtronic Enpath 1084T bipolar lead) and extraction of the infected device. There was no peri-procedural mortality and no-post procedural tamponades occurred. There was one complication in the form of a haemorrhage at the infected device extraction site. In the mean follow up period of 18 months there were 4/16 deaths, none of which were attributable to epicardial LV implantation. LV lead thresholds were 1.07mv (0.25-2.8mV) upon implantation which increased to 1.18mv (0.4-2.75mV) at the last recorded LV threshold measurement. There were no re-infections of the epicardial lead or device.

Conclusion: Epicardial left ventricle pacemaker implantation and subsequent extraction of an infected pacemaker in pacemaker dependent patients is feasible and safe with good long term outcome.

Keywords: pacemaker; infection; implantation

RATIONALE AND DESIGN OF DUTCH OUTCOME IN ICD THERAPY (DO-IT) REGISTRY M. Hulleman; M. van Barreveld; N. Bruinsma; M.G.W. Dijkgraaf; A.E. Zwinderman; A.A.M. Wilde (Academic Medical Center Amsterdam on behalf of the DO-IT investigators) m.hulleman@amc.nl ABSTRACT Purpose: Indication for implantable cardioverter defibrillator (ICD) therapy for primary prevention of sudden cardiac death (SCD) in heart failure patients is based on left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) class. There is ongoing debate whether LVEF and NHYA class are accurate selection criteria, as the majority of patients never receive therapy. The risk of SCD might be stratified by clinical risk factors. We aimed to register ICDs for primary prevention in heart failure patients to identify subgroups with different risk of SCD and to assess the cost-effectiveness of ICDs. Methods: DO-IT included approximately 1500 consecutive patients in all 28 ICD implanting centres in the Netherlands. The inclusion criteria were based on the Class I indications for ICD implantation in patients from AHA/ESC Guidelines. The primary outcomes are ICD therapy and survival during at least two years of follow-up. We will develop prediction rules relating baseline characteristics to death or appropriate shock over time using multivariate Cox- and logistic regression. An economic evaluation will compare targeted supply of ICDs based on these prediction rules.

Results: Patients were included between September 10th 2014 and May 13th 2016 (Figure 1).

Average age is 66y (±11), 73% are men, average LVEF is 26.1% (±6). Most patients are in NYHA II (60%), with ischemic cardiomyopathy in 56%.

Conclusion: The DO-IT Registry is a large nationwide cohort of patients receiving ICDs for primary prevention of SCD, suitable to identify subgroups of patients who might benefit more or less from ICD implantation.

Keywords: Implantable Cardioverter Defibrillator; primary prevention; multicenter registry Figure 1. Inclusion of patients in DO-IT registry.

Methods: Representatives from all Dutch ICD implanting centres were interviewed. Questions aimed to evaluate: out-patient care, pre-operative patient education on end-of-life-care issues, social cognitive evaluation of patients, clinical evaluation of all patients prior to ICD replacement and the management for the option to downgrade or not replace a device.

Results: The response rate was 86%. Management appeared diverse amongst hospitals.

Although physicians consistently reported to perceive age ≥80 years as incentive for more elaborate patient evaluation and to have had cases in which devices were downgraded or not replaced, end-of-life-care discussions were not part of standard pre– procedure consultation in 67%. Patients were invited at the out-patient clinic prior to elective device replacements at 46% of the centres. At 17% of the centres, replacements as indicated during technical follow up were performed after administrative clinical evaluations. Separate social-cognitive evaluation was solely based on clinical impression at 83% or not performed at 8%.

Conclusion: An increasing proportion of ICD patients are of high age. Management is diverse and a structured framework for the care and evaluation of such patients is however absent in most hospitals.

Keywords: implantable cardiac defibrillators; cardio geriatrics; octogenarians

INCREASED AUTOMATED EXTERNAL DEFIBRILLATOR USE AND SURVIVAL OF OUTOF-HOSPITAL CARDIAC ARREST IN THE NIJMEGEN AREA J. Nas; J. Herrmann; J.L. Bonnes; J. Thannhauser; K. van der Wulp; P.M. van Grunsven; M.J. de Boer; M.A. Brouwer (Radboud University Medical Center, Nijmegen) j.nas@radboudumc.nl Purpose: Out-of-hospital cardiac arrests (OHCAs) are a major healthcare problem with relatively low survival rates. To improve outcome, in the region of Nijmegen extensive initiatives have been undertaken to train civilian volunteers in resuscitation and automated external defibrillator (AED) use. In this light, we compared AED use and outcome after OHCA over the past years.

Methods: We studied two cohorts of consecutive patients with an OHCA, one with patients transported to the Radboudumc between 2008-2011, the other in the period 20132015. We compared AED use in cases not witnessed by the Emergency Medical Service and the following outcome measures: any return of spontaneous circulation in the field (field ROSC) and survival to discharge.

Results: In total, 417 patients were studied: 192 resuscitated between 2008-2011 and 225 between 2013-2015. In the latter period, the AED was attached more often (44% vs.

21%) and shocked more frequently (36% vs. 13%) when compared to 2008-2011 (both p<0.001). Field ROSC did not differ between study groups (77% vs. 75%, p=0.791), but survival to discharge was higher in the most recent cohort (44% vs. 34%, p=0.028).

Survival only increased in patients with shockable first-observed rhythm (2008-2011: 42% vs. 2013-2015: 57%, p=0.01).

Conclusion: Survival to discharge of OHCA patients transported to the Radboudumc has increased from 34% in 2008-2011 to 44% in 2013-2015, which is mainly driven by better outcomes in case of a shockable first-observed rhythm. The twofold increase in the use of AEDs seems the primary contributor to these improved outcomes.

Keywords: out-of-hospital cardiac arrest; survival; automated external defibrillator Table 1. Baseline characteristics and outcomes for the cohorts 2008-2011 and 2013-2015.

Values in N (%) or medians (interquartile ranges). EMS: emergency medical service, AED: automated external defibrillator, CPR: cardiopulmonary resuscitation, ROSC: return of spontaneous circulation.

2008-2011 n = 192 Male

138

p-value (70)

0.711

Age (years)

64

(53–76)

63

(53–74)

0.528

71

(37)

81

(38)

0.859

(70)

137

Bystander witnessed EMS response time

128 7 21

(5-10) (11)

5 35

(63)

0.308

(0-10)

0.096

(16)

0.466

Bystander CPR

105

(56)

124

(56)

0.870

Shockable rhythm

136

(72)

136

(63)

0.065

AED attached

35

(21)

82

(44)

<0.001

AED shocked

21

(13)

66

(36)

<0.001

Any field ROSC Survival to discharge

NHJ 1611 Abstracts NVVC incl omslag_proef6.indd 4

158

Public location

EMS witnessed

4

2013-2015 n = 225 (72)

147

(77)

169

(75)

0.791

65

(34)

100

(44)

0.028

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Abstracts

SESSION II DEVICES/CRT (continued)

THE ADDED VALUE OF ICD IMPLANTATION FOR SECONDARY PREVENTION IN PATIENTS WITH A VENTRICULAR ARRHYTHMIA IN THE CONTEXT OF ACUTE CARDIAC ISCHEMIA AND A HISTORY OF MYOCARDIAL INFARCTION; SPIRIT STUDY. J. Brouwer; V.F. van Dijk; L. Boudestein; L.V.A. Boersma; J.C. Balt (Sint Antonius Hospital, Nieuwegein) j.brouwer1@antoniusziekenhuis.nl; j.brouwer@students.uu.nl

IMPROVED PATIENT SELECTION FOR CARDIAC RESYNCHRONIZATION THERAPY BY NORMALIZATION OF QRS DURATION TO LEFT VENTRICULAR DIMENSION A. Zweerink; L. Wu; G.J. de Roest; R. Nijveldt; C.C. de Cock; A.C. van Rossum; C.P. Allaart (VU Medical Center, Amsterdam) a.zweerink@vumc.nl ABSTRACT

ABSTRACT Purpose: Patients with a ventricular arrhythmia (VA) without reversible cause often have an indication for an ICD. In patients with a history of myocardial infarction (MI) and a VA in the context of an acute coronary syndrome (ACS), the trigger causing the VA is unclear.

These patients often receive an ICD for secondary prevention. The purpose of this study is to analyze both the benefit and risk of ICD therapy in this patient population.

Methods: We conducted a retrospective, observational study. Patients who received an ICD from 2008 to 2011, were analyzed. Patients were included if they presented with VA in the context of an ACS, with a history of MI, but with LVEF>35%. Control groups consisted of patients admitted with VA with a history of MI, but without ACS at presentation, either with LVEF >35% or below 35%. The primary endpoint is to evaluate the incidence of appropriate and inappropriate ICD therapy.

Results: 146 patients were included, mean follow-up was 5.3 years. Appropriate ICD therapy occurred in 44,2% of the patients in de study group versus 54,9% and 69,2% in the control groups. 30,2% received an appropriate ICD shock versus 31,4% and 46,2% in the control groups. Overall mortality was 11,6%, 21,6% and 32,7% in the three groups.

Conclusion: Patients with a VA in the context of an ACS, with a history of MI, have a similar rate of appropriate ICD therapy compared to control groups of patients with secondar y prevention ICD indications.

Keywords: ICD; ventricular arrhythmia; acute coronary syndrome Table 1. Baseline characteristics and main results.

Study group N=43 (29,5%)

Control group LVEF>35% N=51 (34,9%)

Control group 2 LVEF<35% N=52 (35,6%)

p-value

Baseline characteristics

Male gender

40 (93,0%)

44 (84,6%)

42 (82,4%)

0,3

Age at implantation ICD (years)

69,0 ±8,77

67,3 ±9,61

67,4 ±10,218

0,698

LVEF (%)

46,23 ±7,454

44,39 ±7,505

25,61 ±5,988

Rhythm on presentation

0,028

Ventricular fibrillation

27 (64,3%)

19 (36,5%)

23 (45,1%)

Ventricular tachycardia

15 (35,7%)

32 (62,7%)

29 (55,8%)

Results

Mean follow-up (years)

5,39 ±1,072

5,45 ±1,57

4,98 ±2,28

0,343

ICD therapy

22 (51,2%)

31 (60,8%)

37 (71,2%)

0,137

Appropriate ICD therapy

19 (44,2%)

28 (54,9%)

36 (69,2%)

0,046

Appropriate ICD shock

13 (30,2%)

16 (31,4%)

24 (46,2%)

0,185

Mortality

5 (11,6%)

11(21,6%)

17 (32,7%)

0,049

Purpose: This study evaluates the relative importance of two components of QRS prolongation, myocardial conduction velocity and travel distance of the electrical wave front (i.e. path length), for the prediction of acute response to Cardiac Resynchronization Therapy (CRT) in left bundle branch block (LBBB) patients.

Methods: Thirty-two CRT candidates (ejection fraction <35%, LBBB) underwent Cardiac Magnetic Resonance (CMR) imaging to provide detailed information on left ventricular (LV) dimensions. LV end-diastolic volume (LVEDV) was used as primary measure for path length, subsequently QRSd was normalized to LV dimension (i.e. QRSd divided by LVEDV) to adjust for conduction path length. Invasive pressure-volume loop analysis at baseline and during CRT was used to assess acute pump function improvement, expressed as LV stroke work (SW) change.

Results: During CRT, SW improved by +38±46% (p<0.001). Baseline LVEDV was positively related to QRSd (R=0.36, p=0.044). Despite this association, a paradoxical inverse relation was found between LVEDV and SW improvement during CRT (R=-0.40; p=0.025). Baseline unadjusted QRSd was found to be unrelated to SW changes during CRT (R=0.16; p=0.383), whereas normalized QRSd (QRSd/LVEDV) yielded a strong correlation with CRT response (R=0.49; p=0.005), see figure 1. Other measures of LV dimension, including LV length, LV diameter and LV end-systolic volume, showed similar relations with normalized QRSd and SW improvement.

Conclusion: Since normalized QRSd reflects myocardial conduction properties, these findings suggest that myocardial conduction velocity rather than increased path length mainly determines response to CRT. Normalizing QRSd to LV dimension might provide a relatively simple method to improve patient selection for CRT. Keywords: Cardiac Resynchronization Therapy (CRT); conduction velocity; Cardiac Magnetic Resonance (CMR) Figure 1. Figure 1 shows scatter plots illustrating (A) no significant correlation between unadjusted QRS duration and acute strokework (SW) changes during CRT; and (B) the positive correlation between QRS duration normalized to left ventricular end-diastolic volume (QRS/LVEDV), and acute SW changes during CRT.

* Plus-minus values are means ±SD. ** P-value < 0,05 was considered statistically significant. *** LVEF = Left Ventricular Ejection Fraction.

HEALTH CARE CONSUMPTION OF ADULTS WITH CONGENITAL HEART DISEASE MOTIVATED TO START USING MOBILE HEALTH M.J. Schuuring; Moreno Monteiro; D.R. Koolbergen; A.P.C.M. Backx; D. Robbers-Visser; M. Groenink; B.J. Mulder; B.J. Bouma (Academic Medical Center, Amsterdam) m.j.schuuring@amc.uva.nl ABSTRACT Purpose: Many adults with congenital heart disease (CHD) are lifelong affected by cardiac events.

Mobile health (mHealth) brings opportunities to enhance monitoring and hence timely response in an attempt to improve outcome. CHD patients use mHealth only scarcely, but the majority is motivated to start using mHealth. We aimed to determine health care consumption of these adults with CHD who are motivated to start using mHealth.

Conclusion: The relatively young adult CHD population motivated to start using mHealth has a high health care consumption. New mHealth initiatives in these patients with a chronic condition and a need for lifelong surveillance are needed in order to reveal whether a reduction in morbidity and mortality and improvement in quality of life can be achieved.

Keywords: congenital heart disease; mobile health; heart failure; arrhythmia; quality of life Figure.

Methods: Consecutive adult patients with CHD who visited the outpatient clinic in the Academic Medical Center in Amsterdam were asked to fill out questionnaires on mHealth. Exclusion criteria for this study were being mentally impaired, or illiterate in Dutch. Of 124 adults 93% had a smartphone and 75% was motivated to start using mHealth. Data on health care consumption in the past five years and clinical characteristics were collected of these motivated patients.

Results: A substantial health care consumption was found in these patients with CHD motivated to start using mHealth (median age 38 (range 18-64) years, 39% male). See Figure. Patients visited the outpatient clinic particularly. Of these patients 24% had one or more unplanned emergency visit and 36% had one or more hospital admission and/or intervention. A high health care consumption was seen in adults with CHD using anti-arrhythmia (OR 10.9, P 0.001) and adults with a complex CHD (OR 4.1, P 0.023).

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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SESSION III VALVULAR DISEASES

VALVE-CONTAINING PROSTHETICS ARE A MAIN PREDICTOR AND TARGET OF INFECTIVE ENDOCARDITIS IN ADULTS WITH CONGENITAL HEART DISEASE J.M. Kuijpers; D.R. Koolbergen; M.Groenink; K.C.H. Peels; C.L.A. Reichert; M.C. Post; H.A. Bosker; E.M.C.J. Wajon; A.H. Zwinderman; B.J.M. Mulder; B.J. Bouma (Academic Medical Center Amsterdam) j.m.kuijpers@amc.uva.nl ABSTRACT Purpose: Adult congenital heart disease (ACHD) predisposes to infective endocarditis (IE), while prosthetics associated with repair or palliation may constitute additional IE targets. We aimed to determine the role of prosthetic material as a predictor and target of IE in ACHD.

were infected in 17%. Distribution of causative agents differed between prosthetic-material (35% Staphylococci, 13% Streptococci, 38% other, 13% culture negative) and native-tissue infections (17% Staphylococci, 58% Streptococci, 16% other, 8% culture negative).

Conclusion: Our findings, essentially informing IE prevention guidelines, indicate valve-containing prosthetics as an important risk-factor and target for IE in ACHD. Other prosthetics are not associated with increased long-term risk and rare targets of infection, if present.

Keywords: infective endocarditis; congenital heart disease; adults Figure

Methods: We selected patients included in the CONCOR registry per October 2015. Predictors of IE were determined using Cox regression analysis, cumulative incidence using the complement Kaplan-Meier estimator. Data concerning the location and causative agent of IE was collected.

Results: In 14224 patients (51% female, median age 34years), 124 IE cases occurred in 93562person-years. Presence of valve-containing prosthetics strongly predicted IE risk (HR=5.48; 95%CI,3.58-8.38), short- and long-term after implantation (0-6months: HR=17.29; 7.34-40.70, 6-12months: HR=15.91;6.76-37.45, beyond 12months: HR=5.26;3.52-7.86).

Non-valve-containing prosthetics predicted risk only in the first 6months after implantation (HR=3.34;1.33-8.41). Cumulative incidence at 12years was 34.6 (95%CI,23.2-45.8) first cases/1000patients in those with baseline valve-containing prosthetics, 5.1 (2.6-7.4) in those with only non-valve-containing prosthetics and 4.7 (2.2-7.1) in those without prosthetics (FIGURE). Among IE patients with valve-containing prosthetics, these prosthetics were infected in 81%. Among IE patients with non-valve-containing prosthetics, these prosthetics

RESULTS OF AORTIC VALVE REPAIR FOR AORTIC REGURGITATION A.E. de Wit; P.M.J. Verhorst; G. Mecozzi (Universitair Medisch Centrum, Groningen) annickdewit@hotmail.com Purpose: Valve-preserving surgery of the aortic valve has become a standard approach in the treatment of aortic root aneurysm and aortic regurgitation (AR). By avoiding lifelong anticoagulation therapy it offers a good alternative for the composite graft replacement.

Recently there is a renewed interest in this valve-preserving surgery and it is only performed in a small number of expertise centers. This study was performed to gain more data on valve-preserving surgery in one of these expertise centers in the Netherlands, the Thorax Centrum Twente (TCT) in Enschede. We studied the outcome of the aortic valve repair procedures looking at incidence of recurrent AR and valverelated complications, reduction in symptoms of AR and mortality rate. Outcome was compared with existing results of valve-preserving surgery.

Methods: Over a 3-year period, 69 consecutive patients underwent valve-preserving surgery in the TCT. In this retrospective cohort study, clinical and echocardiographic data were collected from medical records. Follow-up was complete in 100% (cumulative follow-up: 123 patient-years).

Results: Overall freedom from relevant recurrent AR (≥ grade II) at 12, 24 and 36 months after surgery was 92%, 87% and 83% respectively. Freedom from valve-related complications at 1 and 3 years after surgery was 91% and 89% respectively. There was a significant reduction in preoperative symptoms 3 months after the surgery (p < 0.001). The 30-day mortality rate was 2,9%. There were no late deaths.

Conclusion: Aortic valve repair procedures in the TCT are performed with low morbidity and mortality in patients with AR and aortic root aneurysm. Valve-preserving surgery is performed safely in the TCT and with acceptable early and mid-term outcomes.

Keywords: aortic regurgitation; aortic valve repair; valve-preserving surgery Figure 1. Freedom from postoperative aortic regurgitation ≥ grade II after aortic valve repair procedures.

LONG TERM STRUCTURAL INTEGRITY AND DURABILITY OF THE MEDTRONIC COREVALVE SYSTEM AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION N. El Faquir; B. Ren; M. Faure; P. Geeve; A.M. Maugenest; M.L. Geleijnse; P.P. de Jaegere; R.P. Budde; N.M. Van Mieghem (Erasmus Medical Center, Rotterdam) Nahid_8@hotmail.com; n.elfaquir@erasmusmc.nl ABSTRACT Purpose: Long-term transcatheter heart valve durability data is scarce, yet transcatheter aortic valve implantation (TAVI) is already considered in low risk patients with a longer life expectancy. The aim of this study was to explore the long-term integrity and durability of the Medtronic CoreValve System (MCS) after TAVI. Methods: 20 consecutive patients treated with MCS were invited at least 4 years after TAVI for integrated multi-modality imaging including transthoracic echocardiography (TTE), multislice computed tomography (CT) and rotational angiography (R-angio).

Results: Overall the median follow-up time was 5 years. By TTE no patient had significant increase in transprosthetic gradients, maximum aortic valve velocity or VTI ratio. CT was performed twice post TAVI in 11 patients (median: at 5 months and 6 years) by which comparison showed increased valve circularity from 82.4±5.3% to 84.4±5.4%(p=0.019) and expansion 83.3 ± 8.6% to 86.0 ± 7.2%(p=0.005) at the inflow level. R-angio in 9 patients confirmed comparable results to CT albeit the maximum diameter at the inflow level and dimensions at the level of the nadir were significantly smaller. No valve fractures were observed by CT or R-angio.

Conclusion: Our study demonstrates intact transcatheter valve integrity and durability at a median of 5 years after TAVI with the Medtronic Corevalve. Interestingly valve circularity and expansion of the MCS increased over time. Our findings require further research in larger studies.

Keywords: TAVI; long term; durability

THE EFFECT OF TRANSCATHETER AORTIC VALVE REPLACEMENT ON COGNITION – A PROSPECTIVE PILOT STUDY R. de Vries; M. Abawi; P. Agostoni; P. Stella (University Medical Center, Utrecht) m.abawi@umcutrecht.nl ABSTRACT Purpose: Transcatheter aortic valve replacement (TAVR) is frequently associated with new cerebral ischemic lesions detected with diffusion weighted magnetic resonance imaging (DWMRI) which could result in cognitive decline. The aim of this study was to prospectively evaluate the changes of cognitive performance after TAVR. Methods: Eligible patients were prospectively enrolled and periprocedural, clinical and imaging data were collected. Cognitive status was measured before and 3-6 months after the procedure using Mini Mental State Examination (MMSE), quantitative clock-drawing test, Trail Making Test (TMT) and a verbal memory test.

Results: Fifty-five participants (mean age 80±6 years, 47% male) were enrolled from whom 58% (n=32) completed the neuropsychological assessment before and during the follow-up time. Patients who did not complete the follow-up were comparable in age (78±6 years) and level of education. Postoperative, immediate verbal memory significantly improved compared to baseline (29.9±4.1 vs. 28.0±4.7, p=0.02), and a trend toward better delayed verbal memory was seen during the follow-up (4.1±2.2 vs. 4.7±1, p=0.08).

Conclusion: Patients undergoing transcatheter aortic replacement were less likely to develop cognitive decline at short-term follow-up. However, there was significantly improvement in immediate verbal memory suggesting better cerebral perfusion after the procedure.

Keywords: Transcatheter Aortic Valve Replacement; stroke; cognition

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Netherlands Heart Journal, Volume 25, Supplement, November 2016

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SESSION III VALVULAR DISEASES (continued)

5-YEAR OUTCOMES AFTER PERCUTANEOUS MITRAL VALVE REPAIR WITH THE MITRA­­CLIP: REFINING SELECTION CRITERIA

PROGRESSIVE TRICUSPID REGURGITATION IS ASSOCIATED WITH ADVERSE EVENTS IN REPAIRED TETRALOGY OF FALLOT

J.F. Velu; F.A. Kortlandt; T. Hendriks; R.A.J. Schurer; A.J. van Boven; B. Van den Branden; J.A.S. Van der Heyden; B.J. Bouma; Benno J. Rensing; J. Baan (Academic Medical Center, Amsterdam) j.f.velu@amc.nl

O.I. Woudstra; J.P. Bokma; M.M. Winter; P. Kiès; M.R.M. Jongbloed; H.W. Vliegen; B.J.M. Mulder; B.J. Bouma (Academic Medical Center Amsterdam) o.i.woudstra@amc.uva.nl

ABSTRACT Purpose: The aim of the study was to assess the durability of the outcome after percutaneous mitral valve repair in order to optimize patient selection.

Methods: Between January 2009 and January 2016, 618 consecutive patients were included in the registry and treated with 1-4 MitraClips in 5 Dutch centers. The survival of the treated patients was analyzed up to 5 years. The outcome was quantified with survival, symptoms and mitral regurgitation (MR) grade.

Results: The cumulative survival was 97% after 30 days, 84% after 1 year and 40% after 5 years.

Preprocedural, 13% of the patients were in NYHA class I or II and 69% of the patients after 1 year. MR ≤ grade 2 was preprocedural present in 4% of the patients and in 65% after 1 year. Multivariate Cox regression analysis showed that increased age 7079;≥80 (hazard ratio (HR):2.6;3.1;HR-based score:2;2), devices for arrhythmias or conduction disorders (HR:1.6;HR-based score:1), previous valve surgery (HR:2.4;HRbased score:1), prior NYHA class III/IV;IV/IV (HR:1.9;3.9;HR-based score:1;3), elevated NT-proBNP levels 2000-4999;≥5000 (HR:1.7;3.1;HR-based score:1;2) and MR grade 4 (HR:1.8;HR-based score:1) predicted survival after MitraClip implantation.

Conclusion: The current risk model identifies a substantial well-defined group of patients with a poor prognosis and a limited reduction in symptoms after MitraClip-treatment in whom MitraClip treatment is questionable. The risk model can be used as a clinical tool to improve output in real-world patients referred for MitraClip treatment. The vast majority (over 70%) of the patients benefits from MitraClip treatment in terms of survival and symptom reduction.

Keywords: MitraClip; mitral regurgitation; riskmodel Figure 1. HR-based score. HR: hazard ratio.

CURRENT MITRACLIP EXPERIENCE, SAFETY AND EFFICACY IN THE NETHERLANDS Z.Rahhab; F. Kortlandt; J. Velu; R.A.J. Schurer; V. Delgado; P. Tonino; A.J. Boven; B. Van den Branden; M. Voskuil; J. Hoorntje; M. van Wely; K van Houwelingen; G. Bleeker; J. Baan; J van der Heyden; N.M. Van Mieghem (Erasmus Medical Center, Rotterdam) z.rahhab@erasmusmc.nl

ABSTRACT Purpose: The course of tricuspid regurgitation (TR) in repaired tetralogy of Fallot (rTOF) and risk factors for TR deterioration are unknown. This study aims to identify the course of TR, risk factors for TR deterioration, and whether TR progression is predictive for adverse events in rTOF patients.

Methods: In this dualcenter cohort study, rTOF patients included in a prospective national registry with ≥2 echocardiography’s available were included. TR grade and data on adverse events (death, heart failure, ventricular tachycardia, supraventricular tachycardia) were collected. Progressive TR was defined as increase into moderate TR or severe TR at follow-up.

Results: 226 patients were included (57% men, age 33±12 years). TR severity was ≤mild in 76% and ≥ moderate in 24% of patients. During 8.2±3.6 years of follow-up, TR grade remained stable in 88% and progressed in 12% of patients. Criteria for progressive TR were fulfilled after 4.7(2.0-6.9) years: 17 patients increased from ≤mild to moderate, 1 from ≤mild to severe, 9 from moderate to severe, and 1 remained severe. Age over 40 (OR 3.28, 95%C.I. 1.32-8.18), NYHA class ≥2 (OR 2.68, 95%C.I. 1.09-6.60), and pulmonary regurgitation fraction ≥ 20% (OR 3.44, 95%C.I. 1.38-8.57) were associated with progressive TR. 68 events occurred in 51 patients. In multivariable analysis, progressive TR was associated with adverse events (HR 2.78, 95%C.I. 0.97-7.95).

Conclusion: Progression of TR occurred in 12% of rTOF patients and was associated with adverse events. Symptomatic patients over 40 years of age undergoing pulmonary valve replacement should be considered for tricuspid valve plasty.

Keywords: Tetralogy of Fallot; tricuspid regurgitation Figure 1. Kaplan Meier event-free survival curve of patients with stable tricuspid regurgitation (TR) and patients with progressive TR.

Keywords: valvular heart disease; mitral valve; mitral valve therapies Figure.

ABSTRACT Purpose: MitraClip is a percutaneous edge-to-edge repair technique for patients with at least moderate-to-severe mitral regurgitation (MR). Data on procedural safety and efficacy in the Netherlands is scarce. We aim to provide an informative overview about the current MitraClip procedural experience in the Netherlands.

Methods: Anonymized demographic and procedural data of 1151 consecutive MitraClip patients, treated between January 2009 and June 2016, from 12 Dutch Hospitals were analyzed.

Data was collected by product-specialists in collaboration with local operators. Effect on MR was intra-procedurally assessed by transoesophageal echocardiography. Technical and device success were defined according to modified-MVARC definitions.

Results: The overall cohort had a median (IQR) age of 76 (69-82) years and 59 % were males.

Patients presented with MR ≥ moderate at baseline with a clear predominance of functional MR (72%). Overall, 611 (53%) patients were treated with one Clip, 486 (42%) with ≥2 Clips and 54 (5%) received no Clip. The number of patients with ≥ 2 Clips increased from 22% in 2009 to 52% in 2016. Device and technical success were respectively 91% and 95%, and was consistent over the years. Overall 94% had a significant MR reduction with MitraClip.

Procedural time declined from 145 minutes in 2009 to 55 minutes in 2016.

Conclusion: MitraClip experience in the Netherlands is growing, shows a stable patient selection practice with excellent technical and procedural success. Procedure time decreased and more patients were treated with ≥ 2 Clips.

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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SESSION IV ATRIAL FIBRILLATION/ARRYTHMIAS

THORACOSCOPIC SURGICAL ABLATION IN PATIENTS WITH ADVANCED ATRIAL FIBRILLATION: RESULTS FROM THE AFACT STUDY ON HEALTH-RELATED QUALITY OF LIFE IN RELATION TO PROCEDURAL OUTCOME

Figure 1. A No AF Recurrence.

W.R. Berger; A.H.G. Driessen; M.F.A. Bierhuizen; F.R. Piersma; N.W.E. van den Berg; J. Neefs; S.P.J. Krul; W.J.P. van Boven; J.R. de Groot (Academic Medical Center Amsterdam) w.r.berger@amc.uva.nl ABSTRACT Purpose: The Atrial Fibrillation Ablation and AutonomiC Modulation via Thoracoscopic Surgery(AFACT) study assessed the efficacy and safety of ganglion plexus(GP) ablation in patients with advanced atrial fibrillation(AF) undergoing thoracoscopic surgical ablation. In this substudy, we evaluated the effect on quality of life(Qol) at 6 and 12 months follow-up.

Methods: Patients with paroxysmal or persistent AF undergoing thoracoscopic AF surgery were randomized to either additional epicardial ablation of the four major GPs or control. Followup was performed every 3 months for 1 year. Short form 36(SF-36) QoL questionnaires were collected at baseline, 6 and 12 months follow-up. AF recurrence was defined as any atrial tachycardia documented on ECG or >30 seconds on 24h-holter after a 3-month blanking period.

Figure 2. B AF Recurrence.

Results: In the AFACT-study, 240 patients(age 60±8 years, 73% men, 68% enlarged left atrium, AF duration 6(1-35) years, 59% persistent) were included and randomized to GP ablation(n=117) or control(n=123). In both randomization groups patients showed significant improvement in physical and mental health at 6(both p<0.01) and 12 months(both p<0.01) relative to baseline. Patients with AF recurrences(31%) showed a significant increase in physical health(13%, p<0.01), but not mental health, and scored significantly lower on 6/8 SF-36 subscales compared to the general Dutch population, while patients without recurrence had similar QoL-scores as the general population after 12 months follow-up (figure1).

Conclusion: Thoracoscopic AF surgery results in a substantial improvement in QoL in patients with advanced AF, regardless of additional GP ablation. Patients without AF recurrence show greater improvement in quality of life than patients with AF recurrence.

Keywords: atrial fibrillation; thoracoscopic AF surgery; quality of life

CATHETER-BASED PULMONARY VEIN ISOLATION WITH POINT-BY-POINT CRYOABLATION FOR PAROXYSMAL ATRIAL FIBRILLATION: 10 YEARS FOLLOW-UP

WHAT REALLY HAPPENS TO YOUR PRESUMED HEALTHY ATRIAL FIBRILLATION PATIENT DURING THE COURSE OF 10 YEARS

M.Vroomen; F. van Rosmalen; J. Schroder; R. Manusama; S. Philippens; H.J.G.M. Crijns; L. Pison (Maastricht University Medical Center, Maastricht) mindyvroomen1@gmail.com

B. Weijs; E.A.M.P. Dudink; C.B. de Vos; J.G.L.M. Luermans; R.G. Tieleman; R. Pisters; E.C. Cheriex; H.J.G.M. Crijns (Maastricht University Medical Center, Maastricht) bob.weijs@mumc.nl

ABSTRACT

ABSTRACT

Purpose: The cornerstone of catheter ablation (CA) for atrial fibrillation (AF) is electrical isolation of the pulmonary veins (PVs). This is the first report providing 10 years follow-up data of isolation of the PVs using initial basic point-by-point cryothermal energy (cryoPVI) targeting arrhythmogenic veins only.

Purpose: Healthy AF patients eventually will outgrow their low thromboembolic risk. The specialist caring for the patient should suggest a structural plan for follow-up, but this may be challenging in the healthy AF patient.

Methods: All consecutive patients between July 2001 and September 2005 with paroxysmal AF (PAF) who underwent a point-by-point cryoPVI were enrolled. All procedures were performed using a 6.5mm tip cryoablation catheter (Crycor Inc). Only PVs harbouring PV potentials as demonstrated with a circular mapping catheter placed at the ostium (Lasso, Biosense-Webster Inc.) were targeted. For each application cryoenergy was delivered twice during 2.5 to 5 minutes (maximum -70 ºC). The endpoint was complete electrical isolation of all arrhythmogenic PVs, based on complete entrance block or isolation of all PV potentials.

Results: A total of 73 patients were included (age, 49±10 years; left atrial size, 41.5±4.4 mm; and AF duration, 5±3.8years). Of all PVs 88% of the left superior, 77% of the left inferior, 77% of the right superior and 22% of the right inferior were isolated. Five patients were lost to follow-up (FU). The mean FU duration was 126 months [7-191], 56 patients reached 10 years FU. ECG documented AF recurred in 81% and 63% underwent at least one re-ablation. Ten patients maintained sinus rhythm (SR) without AAD and re-intervention.

Conclusion: Point-by-point isolation of arrhythmogenic PVs does not result in lasting SR; not only due to early reconnection but also due to late re-occurrences possibly due to progression of atrial disease.

Keywords: atrial fibrillation; ablation; follow-up

Methods: Forty-one consecutive idiopathic AF patients (56±10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography.

Baseline characteristics and echocardiographic parameters were equal in both groups.

Results: During a follow-up of 10.7±1.6 years, cardiovascular disease (MACCE, significant CAD, CHF, AHT, all-cause death) developed significantly more often in AF patients as compared to controls (61% vs. 27%, log rank p<0.001). Even after the initial 5 years of follow-up, survival curves show divergent patterns (log rank p=0.003). Multivariable Cox regression analysis revealed that initial posterior wall width, a history of AF and age were significant predictors of CVD development. Median duration to reach a CHA2DS2VASc of 2 or higher among AF patients was 3.5 years (25th-75th percentile 0.16-6.4) years. A total of 15% (3/20) patients with CHA2DS2-VASc>1 did not have (N)OAC at follow-up, with a mean duration of untreated thromboembolic risk of 6.9±4.9 years.

Conclusion: The majority of initially healthy AF patients develop cardiovascular diseases with consequent change in thromboembolic risk profile within a short time-frame. A comprehensive followup, ideally by a dedicated (primary-care) nurse, is necessary.

Keywords: lone/idiopathic atrial fibrillation; follow-up; thromboembolic risk Figure 1.

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Netherlands Heart Journal, Volume 25, Supplement, November 2016

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SESSION IV ATRIAL FIBRILLATION/ARRYTHMIAS (continued)

VARIATION IN ATRIAL EXCITATION DURING SINUS RHYTHM UNRAVELED BY HIGHRESOLUTION EPICARDIAL MAPPING E.M.J.P. Mouws; E.A.H. Lanters; C.P. Teuwen; J.M.E. van der Does; C. Kik, P. Knops; A. Yaksh; J.A. Bekkers; A.J.J.C. Bogers; N.M.S. de Groot (Erasmus Medical Center, Rotterdam) e.mouws@erasmusmc.nl ABSTRACT Purpose: Knowledge of atrial excitation during sinus rhythm(SR) enables detection of propagation abnormalities associated with development of atrial fibrillation(AF). We investigated differences in atrial excitation during SR between patients with ischemic and/or valvular heart disease(IHD,VHD,I/VHD) with or without AF. Methods: Intra-operative epicardial mapping(N=128/192 electrodes, inter-electrode distances: 2mm) of the right atrium(RA), Bachmann’s bundle(BB), left atrioventricular groove(LAVG) and pulmonary vein area(PVA) was performed during SR in 381patients(289 male; age 67±10years) with IHD and/or VHD. Results: SR origin was located in the RA superior intercaval region in 232patients. BB activation occurred via one wavefront from right-to-left(N=163, 64%), from the central part(N=18, 7%) or via multiple wavefronts(N=72, 28%). Central activation of BB more often occurred in patients with I/VHD or VHD(I/VHD: N=9, 17%; VHD: N=7, 10%; IHD: N=2,2%; p=0.024). LAVG activation occurred via 1)BB: N=108, 43%, 2)PVA: N=9, 3% or 3)BB and PVA: N=136, 54%; depending on which route had the shortest interatrial conduction time(p<0.001). VHD patients more often had LAVG activation via PVA.Total activation times were higher in patients with AF(AF: 136±20(92-186)ms; No AF: 114±17(74-156)ms;p<0.001),due to prolongation of RA(p=0.018) and BB conduction times(p<0.001). Epicardial breakthroughs(EBs) occurred mainly at RA and were more often observed in IHD patients(IHD: N=111, 48%;VHD: N=12, 15%;I/VHD: N=13, 20%;p<0.001).

Conclusions: Atrial excitation is affected by underlying heart disease and AF. Interatrial conduction via both BB and PVA, instead of BB only, occurs more frequently in VHD patients. EBs are more often observed on RA. Alterations in atrial excitation associated with the pathogenesis of AF also involves the RA. Keywords atrial fibrillation; atrial excitation; high-resolution epicardial mapping

LEFT VENTRICULAR HYPERTROPHY IN LOW RISK ATRIAL FIBRILLATION PATIENTS Ö. Erküner; E.A.M.P. Dudink; B. Weijs; R. Nieuwlaat; H.J.G.M. Crijns (Maastricht University Medical Center, Maastricht) omer.erkuner@mumc.nl ABSTRACT Purpose: To assess differences in progression of atrial fibrillation (AF) and the occurrence of major adverse cardiac and cerebrovascular events (MACCE) in low-risk AF patients with and without echocardiographic left ventricular hypertrophy (LVH).

Methods: We included 893 patients from the Euro Heart Survey on AF with a baseline echo­ cardiogram and rhythm follow-up. Patients without risk factors for stroke according to CHA2DS2-VASc score were included, disregarding gender and hypertension. The occurrence of AF progression and MACCE after 1-year were assessed for the groups with and without hypertension, i.e. isolated hypertension and solitary AF respectively, subdivided by the presence of LVH. AF progression was defined as paroxysmal AF at baseline becoming persistent/permanent AF after 1-year.

Results: LVH was present in 64 (13%) of 486 solitary AF patients and in 134 (33%) of 407 isolated hypertension patients. In the hypertensive patients with LVH, AF progression was more prevalent (21.9% vs. 8.6%, p=0.014), occurrence of MACCE did not differ. In contrast, in the solitary AF group, MACCE was significantly more prevalent in the patients with LVH (10.6% vs. 2.1%, p=0.009), whilst AF progression rates were similar.

Conclusion: Solitary AF patients with isolated LVH show more MACCE after 1 year compared to those without, suggesting early vascular remodelling as a mechanism. In contrast, isolated hypertension patients with LVH show more AF progression. LVH seems a key marker of a vulnerable vascular system in patients with low-risk AF. Tackling LVH by vascular prophylactic or anti-hypertension therapy may decrease MACCE and AF progression in these patients.

Keywords: atrial fibrillation; left ventricular hypertrophy; major adverse cardiac and cerebrovascular events Figure 1. Differences in AF progression and MACCE rates after 1 year of follow-up for patients with and

Figure 1. Upper panels: incidences and frequency histograms of EBs in patients without and with AF separately. Lower panels: incidences and frequency histograms of EBs in patients with IHD, VHD and I/ VHD separately.

without LVH, subdivided in solitary AF and isolated HT. AF: atrial fibrillation; HT: hypertension; LVH: left ventricular hypertrophy; MACCE: major adverse cardiac and cerebrovascular events. *=statistical significance.

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Abstracts

SESSION IV ATRIAL FIBRILLATION/ARRYTHMIAS (continued)

NOACS, ARE THEY SAFE TO INITIATE IN CONGENITAL HEART DISEASE? H. Yang; J.F. Heidendael; J.R. de Groot; R.J.G. Peters; G.Tj. Sieswerda; F.J. Meijboom; T.C. Konings); G. Veen M.C. Post; B.J. Bouma; B.J.M. Mulder (Academic Medical Center Amsterdam; NLHI, Utrecht) h.yang@amc.uva.nl ABSTRACT Purpose: Efficacy and safety of new oral anticoagulants (NOACs) have not yet been demonstrated in adult with congenital heart disease (ACHD). Using The Non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prevention (NOTE) registry, we aim to evaluate the safety of initiation of NOACs in ACHD. Methods: This is a multicenter prospective registry of ACHD using NOAC for prevention of thrombo­ embolism. At baseline, patient characteristics and medical history were collected. The time period of evaluation for the safety of NOAC initiation was set within 30 days after initiation of NOACs. Patients were followed 1 month or 6 months after initiation of NOACs to register any adverse events (thromboembolism, bleeding events, death, intervention).

Results: So far, 208 adults (median age 43 years, 55% male) with various CHD (simple 15%; moderate 44%; complex 41%) using NOACs (apixaban 46%; rivaroxaban 30%; dabigatran 21%; edoxaban 2%) have been included. Most patients (n=203) used NOAC due to non-valvular atrial arrhythmias (median CHA2DS2-VASc 1[IQR 0-2];median HASBLED 0[IQR 0-1]). Before NOAC initiation, 52% used vitamin K antagonist, 4% used antiplatelet agent. The 30-days evaluation was taken place in 105 patients. No major adverse event took place (see table 1). Five patients had complaints of minor bleeding, most often with nose bleeding (n= 3), menorrhagia (n=1) and hematoma (n=1). Other side effects such as dizziness, headaches, weakness, cutaneous eruption were only rarely reported (n=4). One patient dropped out due to frequent nose bleeding.

Conclusion: Initiation of NOACs in ACHD seems safe with no major adverse events and with limited minor side effects.

Keywords: adult congenital heart disease; NOAC; anticoagulation

DOUBLE-CONTRAST, SINGLE-PHASE COMPUTED TOMOGRAPHY ANGIOGRAPHY FOR RULING OUT LEFT ATRIAL APPENDAGE THROMBUS PRIOR TO ATRIAL FIBRILLATION ABLATION C. Teunissen; J. Habets; B.K. Velthuis; M.J. Cramer; P. Loh ((University Medical Center Utrecht, Utrecht) c.teunissen-2@umcutrecht.nl ABSTRACT Purpose: Prior to atrial fibrillation (AF) ablation, computed tomography angiography (CTA) is increasingly used for left atrial appendage (LAA) thrombus detection. LAA filling defects on CTA may represent thrombus or incomplete contrast mixing with blood. A pre-bolus of contrast material with delay before the CTA contrast bolus can help distinguish between thrombus and incomplete contrast mixing. We present results from a doublecontrast, single-phase CTA protocol used in our daily clinical practice.

Methods: In patients who underwent AF ablation between 2011-2015, double-contrast, singlephase CTA was performed prior to ablation. Two contrast boluses (30 and 70 ml) with 25-second interbolus delay were administered followed by prospectively triggered cardiac CTA. Only patients with left atrial (LA) or LAA filling defects underwent transesophageal echocardio­graphy (TEE) to rule out thrombus.

Results: Prior to ablation, 605 CTA-scans were performed (median radiation dose: 3.1mSv). In 579 CTA-scans (95.7%), the LA and LAA completely filled with contrast. In 26 CTA-scans (4.3%) the LAA showed a filling defect whereby thrombus could not be excluded. In 2 of those 26 patients (7.7% and 0.3% of the total population), TEE verified LAA thrombus.

Low-risk LAA filling defects on CTA (n=7/26) with an inhomogeneous aspect, Houndsfield Unit values >100, and an indefinite border were all caused by incomplete contrast mixing. No thromboembolic complications occurred perioperatively or during 6 month follow-up.

Conclusion: Prior to AF ablation, incidence of LAA filling defects on double-contrast, single-phase CTA is low. TEE remains warranted in all but low-risk filling defects to rule out thrombus.

Keywords: atrial fibrillation; computed tomography angiography; left atrial appendage thrombus

Table 1. Adverse events under the use of NOACs within 1 month follow-up.

All n=105) Major adverse event (thromboembolism, major bleeding, intervention, death), n

0

Minor bleeding, n

5

Side-effects, n

4

Drop-outs, n

1

Figure. Three patients with false positive CTA scan.

LAA filling defects were classified as high (A), intermediate (D) and low (G) risk of thrombus. The patients with a high and low risk filling defect were in AF during performance of CTA, the patient with an intermediate risk filling defect was in sinus rhythm. A: CTA in axial view showing LAA filling defect (yellow arrow). The area of low attenuation shows a homogeneous aspect, HU 50-70 and a well-defined convex border. B: TEE showing severe spontaneous echo contrast (red arrow) in the LAA without thrombus. C: low velocity measured by pulse Doppler. D: CTA in axial view showing LAA filling defect (yellow arrow). The area of low attenuation shows a inhomogeneous aspect, HU 70-110 and a well-defined convex border. E: TEE showing no thrombus and no spontaneous echo contrast (red arrow). F: high velocity measured by pulse Doppler. G: CTA in axial view showing LAA filling defect (yellow arrow). The area of low attenuation shows a inhomogeneous aspect, HU 150-250 and an ill-defined border. H: TEE showing moderate spontaneous echo contrast in the LAA without thrombus (red arrow). I: low velocity measured by pulse Doppler.

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Netherlands Heart Journal, Volume 25, Supplement, November 2016

13-10-16 15:24

Abstracts

SESSION V CORONARY ARTERY DISEASE/ ELECTROPHYSIOLOGY

INVASIVE MINIMAL MICROVASCULAR RESISTANCE (MMR); A NEW INDEX TO ASSESS MICROCIRCULATORY FUNCTION INDEPENDENT ON THE PRESENCE OF OBSTRUCTIVE CORONARY ARTERY DISEASE G.A. de Waard; S.S. Nijjer; M.A. van Lavieren; N.W. van der Hoeven; R.P. Petraco; M. Echavarria-Pinto; S. Sen; T.P. van de Hoef; P. Knaapen; P.M. van de Ven; J. Escaned; J.J. Piek; J.E. Davies; N. van Royen (VU Medical Center, Amsterdam) g.dewaard@vumc.nl ABSTRACT Purpose: Coronary microcirculatory dysfunction (MCD) portends a worse cardiovascular outcome.

Invasive assessment of MCD by coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) is affected by the presence of coronary artery disease (CAD). In this study, we investigate the minimal microvascular resistance (mMR) as a measure of MCD and sought to determine whether mMR is influenced by CAD. Methods: 482 simultaneous measurements of intracoronary distal Doppler flow velocity and pressure were obtained in 301 patients. mMR is measured during the hyperemic wavefree period and defined as the ratio between distal coronary pressure and flow velocity.

Measurements were divided into two cohorts. Cohort 1 was a paired analysis involving 81 pairs with both a vessel with obstructive CAD and a vessel without CAD. Cohort 1 was used to investigate whether HMR, CFR and mMR are modulated by the presence of obstructive CAD. The figure shows an exemplary measurement of the physiological measurements obtained in a patient of Cohort 1. Cohort 2 involved 341 measurements and was used to confirm the findings of Cohort 1.

Results: CFR was significantly lower and HMR was significantly higher in vessels with CAD than vessels without CAD within the same patient: 2.12±0.79 vs. 2.56±0.63; P<0.001 for CFR, and 2.61±1.22 vs. 2.31±0.89 mmHg·cm-1·s; P=0.04 for HMR. mMR did not differ in obstructed and non-obstructed vessels: 1.54±0.77 vs. 1.53±0.57 mmHg·cm-1·s; P=0.90. Cohort 2 confirmed these findings, showing a significant relationship for CFR and HMR with DS% (r=0.454; P<0.001 for CFR and r=0.177; P=0.002 for HMR), while mMR was independent of DS% (r = 0.020; P=0.72).

Conclusion: mMR is a novel index to assess MCD that is not modified by the presence of obstructive CAD. The correlation between epicardial stenosis severity and hyperemic microcirculatory resistance is phasic-dependent. It is only observed when measured during whole-cycle, whereas no relation exists for the mMR, which is measured during the diastolic wave-free period in hyperemic conditions Keywords: coronary physiology; interventional cardiology; microvascular dysfunction Figure.

VALIDATION OF NATIONAL CLAIM DATA IN ACUTE MYOCARDIAL INFARCTION PATIENTS. D.C. Eindhoven; L.N. van Staveren; J.A. van Erkelens; A. Mosterd; J. van Wijngaarden; V.A.W.M. Umans; M.J. Schalij; C.J.W. Borleffs (Leiden University Medical Center, Leiden) d.c.eindhoven@lumc.nl ABSTRACT Purpose: The purpose of the current study is to validate national claim data of patients after acute myocardial infarction in the Netherlands.

Methods: In order to assess validity of national claim data, four representative hospitals were assessed by comparing national claim data of each hospital (‘National registry’) to data obtained from reviewing local patient records (‘Validation registry’). In both registries, the national diagnose-codings for ST-Elevated myocardial infarction (STEMI) and Non-STElevated myocardial infarction (NSTEMI) in 2012 and 2013 were extracted. Additionally, data on medication use at one year after myocardial infarction was extracted from the Dutch Pharmacy Information System (FIS) (‘National registry’) and from the local patient records of four Dutch hospitals (‘Validation registry’). The data was compared at three stages: 1) validation of diagnosis and treatment coding; 2) validation of allocation of follow-up hospital; 3) validation of follow-up medical treatment after 365 days.

Results: In total, 3.980 patients (‘National registry’) and 4.026 patient (‘Validation registry’) were compared at baseline. After one year follow-up, 2.776 acute myocardial infarction patients from the national registry were evaluated. The validation registry resulted in 2.714 patients and in 1.995 cases information from the patient records was available.

Baseline characteristics and individual medication use are presented in table 1.

Conclusion: Data on optimal medical treatment in Dutch acute myocardial infarction patients extracted by national diagnose-codings are comparable with local patient records.

The use of claim data as quality measurement will be discussed at the scientific meeting of the Netherlands Society of Cardiology.

Keywords: validation; quality registries; optimal medical treatment Table 1: Comparison of National registry and Validation registry.

Baseline

National registry

Validation registry

N (%)

N (%)

Total number of patients

3.980

4.026

Age (yrs)

65,8 ±

65,8 ± 12,8

Male gender

2.726 (68%)

2.762 (69%)

Deceased < 180days

313 (8%)

247 (6%)

Deceased < 365days

388 (10%)

301 (8%)

STEMI

2.028 (51%)

2.037 (51%)

NSTEMI

1.952 (49%)

1.989 (49%)

Treated with percutaneous coronary intervention

2.700 (67%)

2.903 (72%)

One year follow-up

National registry

Validation registry

Total number of patients expected for follow up

2.776

2.714

Final diagnosis

Number of patients on whom information is available

1.995

Aspirin

2.246 (82%)

1.696 (85%)

Thienopyridine

2.207 (79%)

1.578 (79%)

Statin

2.525 (91%)

1.857 (93%)

Beta-blocker

2.386 (86%)

1.616 (81%)

ACE inhibitor

2.213 (80%)

1.664 (83%)

Continuous data is presented as mean ± standard deviation. Categorical data is presented as number and percentages.

10-YEAR CLINICAL OUTCOMES OF AN EARLY INVASIVE STRATEGY VERSUS A SELECTIVE INVASIVE STRATEGY IN HIGH-RISK PATIENTS WITH NON-ST SEGMENT ELEVATION ACUTE CORONARY SYNDROME: THE ICTUS TRIAL N.P.G. Hoedemaker; P. Damman; P. Woudstra; A. Hirsch; F. Windhausen; J.P.G. Tijssen; R.J. de Winter (Academic Medical Center, Amsterdam) n.p.hoedemaker@amc.uva.nl ABSTRACT Purpose: Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can be treated with an early invasive (EI) or a selective invasive (SI) strategy. Previously, we could not demonstrate a long-term benefit of an early invasive strategy at 5 years. We present the 10-year clinical outcomes of the ICTUS study

follow-up of death, myocardial infarction (MI) and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records.

Results: 604 patients were assigned to an early invasive strategy and 596 patients to a selective invasive strategy. The median age was 62 years and approximately 75% of the patients were male. Ischemic ECG changes were present in 50% of patients. The results of this abstract are currently under embargo at the European Society of Cardiology Congress 2016, as it will be presented as a Clinical Trial Update.

Conclusion: We hope to present our results at the NVVC Najaarscongres 2016.

Keywords: NSTE-ACS; treatment strategy; long-term outcomes

Methods: We conducted a multicentre trial on 40 Dutch hosptials and randomly assigned 1200 NSTEACS patients to an early invasive or a selective invasive strategy. We collected 10-year

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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SESSION V CORONARY ARTERY DISEASE/ ELECTROPHYSIOLOGY (continued)

CORONARY ARTERY STENOSIS: MORE THAN MEETS THE EYE R. Pisters; I. Ramakers; J.C.A. Hoorntje; L.F. Veenstra; M. Ilhan; M. Stein; G.Weijers; B.C.G. Gho; S. Rasoul (Zuyderland Medical Center, Heerlen; Maastricht University Medical Center, Maastricht) ron.pisters@home.nl

PREVENTION OF SUDDEN CARDIAC DEATH IN ADULTS WITH CONGENITAL HEART DISEASE: PERFORMANCE OF CURRENT GUIDELINES J.T. Vehmeijer; Z. Koyak; W. Budts; L. Harris; B.J.M. Mulder; J.R. de Groot (Academic Medical Center Amsterdam) j.t.vehmeijer@amc.uva.nl

ABSTRACT

ABSTRACT

Purpose: Visual assessment of coronary angiography cannot accurately predict the significance of moderate coronary stenosis (50-70%). Fractional flow reserve (FFR) is a guide wire based procedure that expresses maximum achievable blood flow to the myocardium, supplied by a stenotic artery, as a fraction of normal maximum flow. Adenosine induced hyperaemia is the critical prerequisite for FFR assessment. However, due to its side effects some patients poorly tolerate adenosine. The instantaneous wave-free ratio (iFR®) is a new adenosine-independent index of coronary stenosis severity. We aimed to compare FFR and iFR measurements in patients with moderate coronary stenosis.

Purpose: Sudden cardiac death(SCD) is one of the main causes of mortality in adults with congenital heart disease(ACHD). Validated risk prediction models for SCD are lacking.

The 2014 Consensus Statement on Arrhythmias in ACHD specified ICD indications for ACHD for the first time. These were mainly extrapolated from patients with acquired heart disease, and later largely adopted by the ESC. We aim to assess the discriminative ability of these ICD indications in ACHD.

Methods and results: Between November 2015 and May 2016 149 consecutive patients were included in which 203 coronary stenoses were measured using both iFR and FFR. iFR measurements were technically simple and feasible in all patients without procedure related complications.

Mean(SD) iFR and FFR were 0.87(0.11) and 0.84(0.09), respectively. iFR showed a significant correlation with FFR [r= 0.77; p<0.001]. Receiver-operating characteristic analysis identified an area under the curve (AUC) of 0.91 suggesting a high accuracy of iFR as a diagnostic test for FFR. Analysis of an iFR-only strategy with a treatment cut-point ≤0.89 revealed a diagnostic classification agreement with the FFR-only strategy in 157 lesions (77.3%) with a sensitivity of 83.9%, a specificity of 74.5%, a positive predictive value of 59.1%, and a negative predictive value of 91.3 %. PCI would have been deferred in 115 lesions (56.7%) based on iFR and in 141 lesion (69.5%) based on FFR. Conclusion: Real-time iFR measurements are easily performed and have excellent diagnostic performance. iFR has the potential to expose fewer patients to adenosine, but still requires prospective clinical endpoint trial evaluation.

Keywords: coronary angiography

THE IMPACT OF LEFT VENTRICULAR MASS ON VENTRICULAR FIBRILLATION WAVEFORM CHARACTERISTICS OF THE SURFACE ELECTROCARDIOGRAM J. Thannhauser; J.L. Bonnes; J. Nas; S.W. Westra; G. Meinsma; R.M.G. Janssen; M.J. de Boer; J.L.R.M. Smeets; W. Keuper; M.A. Brouwer (Radboud University Medical Center, Nijmegen) jos.thannhauser@radboudumc.nl ABSTRACT Purpose: The ventricular fibrillation (VF) waveform has been related to outcome after cardiac arrest. Recently, the concept that low voltage-low frequency VF is a mere proxy for considerable time delay has been challenged. In prior myocardial infarction, several studies demonstrated significantly lower amplitudes, already at the start of VF. To further study the impact of pre-existing myocardial disease on the VF waveform, we investigated the effect of left ventricular (LV) mass.

Methods: Cohort study of patients with defibrillation testing after a first ICD-implantation at the Radboudumc (2010-2014). Characteristics of induced VF were calculated from the surface ECG (leads I,II,aVF,V1,V3,V6): mean amplitude, dominant frequency and amplitude spectrum area (AMSA). Patients were dichotomized according to the LV mass (: ≥132 g/m2; : ≥109 g/m2, ASE-guidelines).

Results: In total, 177 patients were analyzed (63±13 years, 75% male), with a mean LV mass of 114±30 g/m2. In patients with an increased LV mass (n=57), mean amplitude (leads I,V3) and AMSA (leads I,aVF,V3) were significantly higher than in patients with a normal mass. In all other leads these amplitude characteristics were slightly higher (except V1). Frequency characteristics did not differ between the study groups.

Conclusion: In this study of early, induced VF, the amplitude of the VF waveform is related to the LV mass, showing higher amplitudes with increasing mass. These findings add to the current concept, in that the VF waveform is not only a reflection of time delay, but also depends on pre-existent myocardial characteristics. These new insights may contribute to future VF-guided resuscitation algorithms.

Keywords: ventricular fibrillation; Fourier analysis; left ventricular mass Figure 1. The impact of left ventricular mass on the VF waveform.

AMSA=amplitude spectrum area; LV=left ventricular; ECG=electrocardiogram.

Methods: Of 25,790 ACHD in an international multicenter registry, we identified all SCD cases, matched at a 1:n ratio to living controls by age, gender, congenital defect and surgical repair. We assessed all primary prevention ICD indications listed in both documents.

We excluded patients with a class III indication. To test discriminative ability, we used conditional logistic regression models to calculate odds ratios (OR) and ROC-curves with area under the curve(AUC).

Results: Consensus statement: 125 cases (excluding Eisenmenger patients – a class III indication – median age 33 years, 67% males) and 230 controls were analyzed. In total, 41% of SCD cases and 18% of controls had an ICD indication(OR 5.9, p < 0.001, AUC: 0.68).

ESC guidelines: 157 cases (including Eisenmenger patients, median age at death 33 years, 64% males), and 292 controls were analyzed; 35% and 14% had an ICD indication, respectively(OR 5.5, p <0.001, AUC: 0.67).

Conclusion: Only a limited number of SCD cases had an ICD indication according to these guidelines.

This may cause under-implantation of ICD’s in ACHD. The discriminative ability of both guidelines was also poor. Guideline indications can only extrapolated from acquired heart disease to ACHD to a limited extent. Risk stratification for SCD in ACHD therefore remains a work in progress.

Keywords: sudden cardiac death; implantable cardioverter-defibrillator; guidelines; congenital heart disease

POST-MORTEM GENETIC TESTING IN YOUNG VICTIMS OF SUDDEN ARRHYTHMIC DEATH SYNDROME N. Lahrouchi; H. Raju; E.M. Lodder; J. Ware; R. Tadros; J. Skinner; J. Tfelt-Hansen; C. van der Werf; M. Cohen; M. Christiansen; S. Cook; M. Sheppard; S. Sharma; A.A.M. Wilde; C.R. Bezzina; E.R. Behr (St. George’s University of London, London, UK) n.lahrouchi@amc.uva.nl ABSTRACT Purpose: Sudden cardiac death in the young (<40 years) can occur as a result of inherited cardiomyopathy or primary electrical disease. If sudden death is unexplained despite an appropriate autopsy and toxicological assessment the term Sudden Arrhythmic Death Syndrome (SADS) may be used. Establishing a genetic etiology of SADS allows for appropriate screening and management of relatives at risk of SADS. We assessed the yield of postmortem next-generation sequencing (NGS) in young victims of SADS. Methods: We performed NGS in 189 young sudden cardiac death cases that had structurally normal hearts and negative toxicological analysis at autopsy. NGS targeted the coding region of genes associated with primary electrical disease (n=30) and cardiomyopathy (n=64). Variants with a minor allele frequency >1/1000 in public databases, synonymous variants not located at splice sites were excluded from further analysis.

The retained variants were prioritized using a scoring system that combined in silico pathogenicity prediction tools, conservation and allele frequency in the general population. The pathogenicity of each variant was further assessed through an extensive literature review. Variants were finally classified as ‘pathogenic’, ‘likelypathogenic’ and ‘variant of unknown significance’ Results: NGS was successful in 182 cases. Ten patients (5.5%) were found to harbour a ‘pathogenic’ variant in genes linked to the primary electrical diseases, whereas no patient had a ‘pathogenic’ variant in a cardiomyopathy gene. In addition, 20 patients (11%) and 19 patients (10%) had ‘likely-pathogenic’ variants in respectively primary electrical disease and cardiomyopathy genes. In 63 patients (35%), no rare variant was identified. RYR2 was the gene with the most pathogenic/likely pathogenic variants Conclusion: We identified pathogenic/likely pathogenic variants in 27% of SADS cases. These variants represent a starting point for genotype-phenotype studies in the respective families that may allow for presymptomatic diagnosis in a substantial number of families.

Keywords: sudden cardiac death; post-mortem genetic testing; next-generation sequencing

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Netherlands Heart Journal, Volume 25, Supplement, November 2016

13-10-16 15:24

Abstracts

SESSION VI HEART FAILURE

GENDER-RELATED LONG-TERM MORTALITY IN PATIENTS WITH ACUTE HEART FAILURE: EQUAL PROGNOSTIC IMPROVEMENT BETWEEN MEN AND WOMEN IN RECENT YEARS

LOOK BEYOND THE CARDIAC DEFECTS: EXERCISE RESPONSE AND LUNG FUNCTION ARE DETERMINANTS OF EXERCISE CAPACITY IN TETRALOGY OF FALLOT

J.C. van den Berge; A.A. Constantinescu; R.T. van Domburg; J.W. Deckers; K.M. Akkerhuis (Erasmus Medical Center, Rotterdam) j.vandenberge@erasmusmc.nl

J.P. Bokma; E.M.N. Kornaat; M.M. Winter; P. Kies; R. van Kimmenade; P.G. Pieper; G.J. Sieswerda; M.C. Post; B.J.M. Mulder; B.J. Bouma (Academic Medical Center, Amsterdam) j.p.bokma@amc.nl

ABSTRACT

ABSTRACT

Purpose: Since there is limited and inconsistent data regarding gender-related long-term mortality among patients with acute heart failure (AHF), we investigated and compared long-term mortality in men and women with this syndrome. Further, we determined whether the temporal trend in mortality over the last decades was different between both genders.

Purpose: Most adults with Tetralogy of Fallot (TOF) have a reduced exercise capacity. Previous studies reported only weak associations with cardiac function but little information is available on other underlying causes. Our objective was to determine which factors may lead to exercise intolerance.

Methods: From 1985 until 2008, all consecutive patients aged 18 years and older admitted with AHF at the Intensive Coronary Care Unit were included in this prospective registry.

Results: We included 1810 patients (64% men). Compared to women, men were generally three years younger; in addition, men had more commonly ischemic HF, previous HF and HF with poor left ventricular ejection fraction. Conversely, women more often had diabetes and hypertension. Men had a significantly higher mortality than women (Figure 1), with ten-year mortality rates of 79% versus 72% (adjusted HR 1.36; 95% CI 1.18-1.55).

Compared to the first two decades, ten-year mortality risk of men decreased in the most recent period (adjusted HR 0.85; 95% CI 0.73-0.97). A comparable improvement of the long-term prognosis was observed in women (adjusted HR 0.87; 95% CI 0.71-1.06).

Conclusion: Men admitted with AHF had higher long-term mortality rates as compared to women.

Importantly, the recent improvement in long-term prognosis was comparable between men and women, suggesting an equal survival benefit for both genders from therapeutic developments in the last decades. Despite the encouraging temporal trend, new therapeutic options are needed in both men and women in order to improve the poor prognosis of AHF. Keywords: acute heart failure; gender differences; mortality over time Figure 1. Kaplan-Meier curve of cumulative mortality: men vs. women.

GALECTIN-3 AS A MARKER OF MYOCARDIAL FIBROSIS IN HYPERTROPHIC CARDIO­ MYO­PATHY D.H.F. Gommans; G.E. Cramer; J. Bakker; M. Michels; H-J. Dieker; J. Timmermans; M.A. Fouraux; C.L.M. Marcelis; F.W.A. Verheugt; M.J.M. Kofflard; R.A. de Boer; M.A. Brouwer (Radboud University Medical Center, Nijmegen) frank.gommans@radboudumc.nl ABSTRACT Purpose: Myocardial fibrosis, assessed with late gadolinium enhancement (LGE) imaging, is a characteristic feature of patients with hypertrophic cardiomyopathy (HCM) and associated with adverse prognosis. Galectin-3 is a serum biomarker that has been related to fibrogenesis and holds prognostic value in patients with heart failure. As galectin-3 might be a convenient marker of fibrosis and prognosis in HCM, we sought to assess the association between galectin-3 and LGE in patients with HCM. Methods: HCM patients without a history of coronary artery disease (n=95) underwent cardiovascular magnetic resonance imaging (1.5T) with cine and LGE imaging to assess left ventricular (LV) geometry and fibrosis. A blood sample was obtained the same day for determination of galectin-3 concentration (BGMedicine). An elevated galectin-3 was defined as >17.8 ng/ml (FDA cut-off value for risk stratification).

Results: Median galectin-3 concentration was 16.8 ng/ml (13.3-20.3) and galectin-3 was elevated in 39/95 patients (41%). LGE was present in 60/95 HCM patients (63%) and no difference was seen between patients with and without an elevated galectin-3 (64 vs. 63%, p=.87).

Patients with an elevated galectin-3 were older, had hypertension more often and renal function was lower. In addition, these patients had dyspnea and atrial fibrillation more often (table).

Conclusion: Galectin-3 was elevated in about 40% of our HCM population and not associated with the presence of LGE. These results do not support galectin-3 as a marker of myocardial fibrosis in HCM. Galectin-3 was however associated with risk factors for atherosclerotic disease, atrial fibrillation and dyspnea. In lack of follow-up studies, the prognostic value of galectin-3 remains to be determined in HCM.

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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Methods: This multicenter study included adult TOF patients from the randomized Redefine trial (inclusion right ventricular ejection fraction <50%, no severe valvular dysfunction). At study baseline, patients underwent cardiopulmonary exercise testing, cardiovascular magnetic resonance imaging, and completed questionnaires on quality of life (SF 36) and daily physical activity (SQUASH). Multivariable linear regression analysis was used to determine factors associated with exercise capacity (as percentage of predicted VO2max).

Results: A total of 95 patients were included (70% male, age 39±12 years old, right ventricular ejection fraction 44±8%, VO2max 81±18% of predicted). Patients had, on average, a normal mental 53 (46-56) and health-related 53 (48-57) quality of life (Dutch norm 50).

In multivariable analysis: low peak heart rate (β: 0.30/beat, p=0.002), low peak systolic blood pressure (β: 0.17/mmHg, p=0.004), and reduced health-related quality of life (β: 0.77/point, p<0.001) were associated with reduced exercise capacity. In subgroup analysis of 25 patients with spirometry analysis, reduced forced expiratory volume in 1 sec (p=0.01) and forced volume vital capacity (p=0.003) were associated with reduced exercise capacity.

Conclusion: In adults with tetralogy of Fallot, reduced exercise capacity was related with chronotropic dysfunction and pulmonary dysfunction. Therefore, pulmonary valve replacement is not always the right solution in symptomatic TOF patients, cardiopulmonary rehabilitation may be more useful in a subset of patients.

Keywords: Tetralogy of Fallot; congenital heart disease; exercise testing

Keywords: hypertrophic cardiomyopathy; galectin-3; late gadolinium enhancement Table Non-elevated Gal-3 (n=56)

Elevated Gal-3 (n=39)

p-value

Age (years)

50 ± 14

59 ± 15

.004

Men

38 (68%)

20 (51%)

.10

Atrial fibrillation

5 (9%)

12 (31%)

.006

Hypertension

18 (32%)

21 (54%)

.03

Recent creatinin (μmol/l)

78 ± 11

93 ± 18

<.001

• Family history of SCD

7 (13%)

4 (10%)

1.0

• Syncope

3 (5%)

1 (3%)

.64

• Non-sustained VT (holter)

11 (22%)

5 (14%)

.34

• Abnormal BP response

7 (13%)

5 (14%)

1.0

• Maximal wall thickness ≥30mm

2 (4%)

0 (0%)

.51

• Chest pain

6 (11%)

10 (26%)

.06

• Dyspnea (NYHA class ≥ II)

18 (32%)

23 (59%)

.009

• Maximal LV wall thickness (mm)

18 (14-22)

17 (14-20)

.78

• LV mass indexed to BSA (g/m2)

64 (52-84)

61 (52-82)

.67

• LGE present

35 (63%)

25 (64%)

.87

• LGE extent in patients with LGE (% of LV mass)

8 (3-13)

9 (4-13)

.85

Risk factors for SCD

Symptoms

CMR Imaging

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Abstracts

SESSION VI HEART FAILURE (continued)

GROWTH-DIFFERENTIATION FACTOR 15 PREDICTS ADVERSE CARDIAC EVENTS IN ADULTS WITH CONGENITAL HEART DISEASE

Figure 1. Kaplan-Meier curves presenting the event-free survival (primary endpoint) and the heart failure-free survival (secondary endpoint), stratified according to GDF-15 quartiles.

V.J.M. Baggen; A.E. van den Bosch; J.A. Eindhoven; M. Witsenburg; J.A.A.E. Cuypers; E. Boersma; J.W. Roos-Hesselink (Erasmus Medical Center, Rotterdam) v.baggen@erasmusmc.nl ABSTRACT Purpose: Growth-differentiation factor 15 (GDF-15) offers prognostic information in coronary heart disease and chronic heart failure. Its usefulness as potential biomarker in adults with congenital heart disease (ACHD) is unknown. The objective of this study is to investigate the association of GDF-15 with adverse cardiac events in ACHD. Methods: We prospectively included consecutive patients who routinely visited the adult congenital cardiology outpatient clinic between April 2011 and April 2013. Patients underwent clinical examination, electrocardiography, echocardiography and venous blood sampling. Plasma GDF-15 was measured by batch analyses. The primary endpoint was a composite of ‘death, heart failure, hospitalization, arrhythmia, thromboembolic event or cardiac reintervention’ and the secondary endpoint was a composite of ‘death or heart failure’. Cox regression was used to assess the predictive value of GDF-15, adjusted for age, sex, systemic ventricular function and NT-proBNP. Results: In total, 587 patients were included (median age 33 [IQR 25-41] years, 58% male, 90% New York Heart Association class I). Patients were followed for a median of 42 [IQR 37-46] months. GDF-15 was independently associated with the primary endpoint (n=160, adjusted hazard ratio per two-fold increase 1.34 [95% CI 1.09-1.65], P = 0.006) and with the secondary endpoint (n=48, adjusted hazard ratio per two-fold increase 1.60 [95% CI 1.132.26], P = 0.008).

Conclusion: GDF-15 provides prognostic information, independent of age, sex, systemic ventricular function and NT-proBNP. Therefore, GDF-15 could play an important role in the monitoring and management of patients with ACHD. Keywords: adult congenital heart disease; biomarkers; growth factors; prognosis

DOES BOSENTAN IMPROVE CLINICAL OUTCOME OF ADULTS WITH CONGENITAL HEART DISEASE UNDERGOING CARDIAC SURGERY?

EFFECT OF VALSARTAN ON 10-YEAR SURVIVAL AND CLINICAL EVENTS IN PATIENTS WITH A SYSTEMIC RIGHT VENTRICLE

I.M. Blok; A.C.M.J. van Riel; M.J. Schuuring; D.R. Koolbergen; M.G. Hazekamp; B.A.J.M. de Mol; W.K. Lagrand; B.J.M. Mulder; B.J. Bouma (Academic Medical Center Amsterdam) i.m.blok@amc.uva.nl

A.C. van Dissel; H.W. Vliegen; P.G. Piepe; A.P.J. van Dijk; G.T. Sieswerda; J.W. RoosHesselink; B.J.M. Mulder; B.J. Bouma (Academic Medical Center Amsterdam) a.c.vandissel@gmail.com

ABSTRACT

ABSTRACT

Purpose: During cardiac surgery, an endothelin-1 release induces elevation of the pulmonary vascular resistance (PVR). We determined whether perioperative treatment with bosentan, an endothelin-1 receptor antagonist, improves outcome in adults with congenital heart disease (CHD) undergoing cardiac surgery.

Purpose: Treatment with ACE-inhibitors for 3 years improves survival in patients with left ventricular failure beyond the original trial period. To establish the long-term effects of valsartan on survival and clinical events in patients with a systemic right ventricle, we extended follow-up on the in 2006-initiated Dutch randomized, placebo-controlled trial of patients with transposition of the great arteries (TGA).

Methods: In a prospective randomized open label study, adults with CHD who were scheduled for cardiac surgery were randomized to either 17-week perioperative bosentan therapy or no therapy. Primary endpoint was peakVO2 six weeks postoperatively. Secondary endpoints were intensive care unit admission time, tricuspid annular plane systolic excursion (TAPSE) and NTproBNP at six and twelve weeks postoperatively.

Results: Sixty-eight patients were included (mean age 44 years, 63% male): 36 receiving bosentan, 32 controls. Following cardiac surgery, three patients died in-hospital (bosentan 0, controls 3, p=0.099). The primary endpoint of peakVO2 six weeks postoperatively did not differ between the bosentan (21.7±7.7 mg/kg/min) and control group (20.3±8.2 mg/kg/min; p=0.520). The secondary endpoints were comparable as well. However, subgroup analyses showed a significantly higher TAPSE six weeks postoperatively in patients with symptoms (NYHA>1), high pulmonary pressures, or low preoperative right ventricular function (RVF) who received bosentan therapy.

Methods: Of the 86 survivors at the end of the 3-year trial period, data on vital status and clinical events were collected through linkage with the national mortality registry and patient records. Clinical events comprised (supra)ventricular arrhythmia, worsening of heart failure, tricuspid valve surgery and death. Analysis was done on an intention-to-treat basis according to the original randomization groups.

Results: At 10 years, overall survival was 90% and did not differ between the valsartan and placebo group with 3 deaths occurring in each of the treatment arms. Patients originally assigned to valsartan had a significantly lower risk of developing a clinical event: at 10 years, 34% remained event-free in the valsartan group versus none in the placebo group (p=0.044; Figure 1). In particular, the subgroup of patients symptomatic at baseline (N=25) experienced a lower risk for clinical events after valsartan treatment as compared to placebo (p=0.012).

Conclusion: Our results do not support routine use of bosentan in adult CHD patients undergoing cardiac surgery. However, in patients with symptoms, pulmonary arterial hypertension or impaired RVF, bosentan may improve RVF postoperatively.

Conclusion: Upon 10-year follow-up, treatment with valsartan for 3 years showed no survival benefit as compared to placebo. However, valsartan treatment led to a significant reduction in development of clinical events¾particularly in symptomatic patients. Treatment with valsartan should be considered in all TGA patients.

Keywords: congenital heart disease; cardiac surgery; bosentan

Keywords: transposition of the great arteries; valsartan; long-term follow-up Figure 1. Event-free survival curves for the valsartan and placebo groups.

Kaplan-Meier curves illustrate event-free survival on basis of the intention-to-treat principle in all patients originally assigned to either valsartan (N=44) or placebo arm (N=44). Time=0 refers to the date of randomization in the original trial. The dotted line indicates the 3-year end of trial period.

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Abstracts

SESSION VI HEART FAILURE (continued)

HOW TO MAKE CARDIAC REFERRALS BY GP’S MORE EFFICIENT AND PROMOTE A PATIENT AND PHYSICIAN FRIENDLY APPROACH IN NONCOMPLEX CARDIAC PATHOLOGY (NCP) P.N. Breuls; A. Evertse; E. Los; J. Caljouw (Stichting Koel, Zwijndrecht) nbreuls@gmail.com ABSTRACT Purpose: To reduce inappropriate cardiac referrals (ICR) by General Practionars (GP’s) to outpatient cardiac clinics (OCC) by introducing direct positioning of a cardiologist next to GP’s in primary care and hence reduce health care costs and improving a patient and GP friendly environment without loss of quality of care.

Methods: 50 GP’s (IG) were trained in 4 referral indications (RI): chest pain (CP), heart failure (HF), arrhythmias ( AR) and murmurs (M). Protocols of the Dutch GP Society in these RI were adjusted. In each step a primary care cardiologist (PCC) could be consulted by mail, medical apps, Phone or during consultation at office GP or patient home. 20 GP’s were contacted and considered as controls (CG) who continued their standard approach of medical care.

Results: There were 958 patients (IG), vs 404 (CG). There was a reduction of referrals of NCP’s of 65 % without complications which was associated with great appreciation by patients and GP’s. costs reduction is at least € 135.000 per 1000 patients. There were no reported complications.

Conclusion: Treatment and follow up of NCP by GP’s under close supervision of a PCC reduces ICR’s to OCC by 65% without the loss of quality and reduces costs of public health.

Keywords: primary care cardiology; costs reduction; patient appreciation Table 1. The table shows a reduction of referrals by the IG vs CG, with an increase of cardiac tests on the other hand.

IG

CG N

%

N

%

Total referrals to outward patient clinic

182

20,4 %

233

57,6 %

Total additional tests (% of patient visits)

863

46 %

235

37 %

Netherlands Heart Journal, Volume 25, Supplement, November 2016

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