Ventricular Arrhythmia Mortality in Patients with Heart Failure in the United States: Are There Differences Based on Race and Geography?Min Choon Tan MD1,2, Yong Hao Yeo MBBS3, Boon Jian San MBBS4, Justin Z. Lee MD5, Kamala Tamirisa MD6, Yong-Mei Cha MD7, Luis R. Scott MD2, Dan Sorajja MD2, Andrea M. Russo MD81 Department of Internal Medicine, New York Medical College at Saint Michael’s Medical Center, Newark, NJ, USA2 Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA3 Department of Internal Medicine/Pediatrics, William Beaumont University Hospital, Royal Oak, MI, USA4 AIMST University, Malaysia5 Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA6 Texas Cardiac Arrhythmia, Dallas, TX, USA7 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA8 Department of Cardiovascular Medicine, Cooper University Health System/Cooper Medical School of Rowan University, Camden, NJ, USADisclosures: All authors have no relationships relevant to the contents of this paper to disclose.Ethical approval: Not requiredFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectorsWord Count: 780Corresponding author:Andrea M. Russo MDDepartment of Cardiovascular Medicine,Cooper University Health System/Cooper Medical School of Rowan University1 Cooper Plaza,Camden, New Jersey [email protected] progression of heart failure (HF) is associated with detrimental myocardial structural changes, predisposing HF patients to an increased risk of ventricular arrhythmia (VA) events [1]. The evolving landscape in HF management as well as innovative approaches to VA like catheter ablation and neuromodulation, may impact morbidity and mortality. However, real-world data assessing the VA-related mortality trends among patients with HF remain scarce.The Centers for Disease Control and Prevention’s Wide-Ranging Online Data for EpidemiologicResearch (CDC WONDER) is a publicly available online database containing public health data, including mortality data. Death certificate data from CDC WONDER were analyzed from 1999 to2020 for VA-related mortality with comorbid HF among the U.S. population aged ≥ 25 years usingICD-10 codes. Ventricular arrhythmias included ventricular tachycardia (VT) (I47.2) and ventricularfibrillation (VF) (I49.0) as the underlying primary cause of death. Heart failure (I11.0, I13.0, I13.2,I50) was stated as a contributing cause of death. Age-adjusted mortality rates (AAMR) per 1,000,000individuals were calculated by standardizing VA-related mortality with comorbid HF to the 2000 U.S.census population. The trends were determined over time by estimating the annual percent change(APC) using the Joinpoint regression program. Given the deidentified and publicly available data,institutional review board approval was not required.Between 1999 and 2020, a total of 3,514 deaths related to VA with comorbid HF were identified.Overall, there was an increase in annual trends for the AAMR from 0.62 (95% CI, 0.50 - 0.73) in1999 to 1.06 (95% CI, 0.94 - 1.19) in 2020, with an APC of 3.39 (95% CI, 2.07, 4.73) (CentralIllustration) .When stratified by sex, cumulative AAMR was higher in males than females (1.09 [95% CI, 1.04-1.13] vs. 0.49 [95% CI, 0.47-0.52]). Both males and females had a similar increase in AAMR over the22 years; however, the AAPC was higher among males (4.30 [95% CI, 2.88-5.74] vs. 1.64 [95% CI,0.18-3.12]). When stratified by race, African American individuals had the highest AAMR (1.24 [95% CI, 1.14-1.35]), while the AAMR for White, Hispanic and Asian individuals were 0.72 (95% CI, 0.69-0.75), 0.40 (95% CI, 0.33-0.47), and 0.23 (95% CI, 0.16-0.32) respectively. The AAMR was higher in rural regions than in urban regions (0.81 [95% CI, 0.75-0.88] vs. 0.70 [95% CI, 0.68-0.73]). When AAMRs were compared between census regions of the U.S., the South region had the highest AAMR (0.86 [95% CI, 0.81-0.90]), followed by the Midwest (0.80 [95% CI, 0.75-0.85]), Northeast (0.62 [95%CI, 0.57-0.67]), and West region (0.56 [95% CI, 0.51-0.61]).This study provides crucial insight into VA-related mortality temporal trends and disparities among patients with comorbid HF. Despite advances in VA and HF management algorithms, our study revealed a 71% increase in AAMR in VA-related mortality with comorbid HF from 1999 to 2020. The observed growth in AAMR could be attributed to the rising use of cardiac implantable electronic devices, leading to increased recognition of VA as a terminal event [2]. Alternatively, more effective emergency medical services or greater availability of automatic external defibrillators may help to identify VT or VF as the initial rhythm recorded (rather than asystole or pulseless electrical activity). Our study raises the hypothesis that more diligent management of VA, including timely implantation of cardiac defibrillator devices and VT ablation could have an impact on this population.Our study demonstrates disparities in mortality trends, where American Africans and rural regionsrecorded higher AAMR. These may be potentially attributed to structural racism, conscious andunconscious biases, and the heightened socioeconomic challenges and access to medical care, presentin rural areas [3]. Limited or delayed access to complex tertiary care may impact mortality followingthe occurrence of sustained VA. Patients who live in rural or disadvantaged regions may not haveaccess to subspecialty referrals (such as electrophysiology or HF specialists) and may have delayed orlimited access to primary prevention therapies such as implantable cardioverter defibrillators orcardiac resynchronization therapy that may otherwise favorably influence outcomes. This highlightsthe need to address the potential causes of these inequalities and implement a focused policy thatincorporates the concept of social determinants of health to narrow the gap.There are several limitations in our study. First, due to the nature of death certificate data, an accurate assessment of the cause of death cannot be determined. Second, the database has no information at individual levels, such as comorbidity, ejection fraction, duration of diseases, and medical treatments, which are essential confounders for mortality.In conclusion, our study reveals an increase in VA-related mortality with comorbid HF, withdisparities seen in African Americans and rural regions. It underscores the pressing necessity for actions to facilitate the translation of treatment advancements into tangible improvements in mortality outcomes and healthcare inequalities.

Background: Premature ventricular contractions (PVCs) are associated with an increased risk of implanting implantable cardioverter defibrillator (ICD). Therefore, our study aimed to predict the risk factors for implantable cardioverter defibrillator in patients with premature ventricular contractions. Methods: A total of 309 patients (male 57%, mean age 66.73±16.12) in Olmstate Countywho had premature ventricular contractions and received a 24-hour electrocardiography monitoring were included between January 1994 and September 2010 at Mayo Clinic, Rochester, Minnesota. All these patients were continuously followed o Jun 2015. Student’s t-test, Chi-square, univariate and multivariate Logistic regression models were used to estimate the relationship between the risk factors and the incidence of implanting implantable cardioverter defibrillator (ICD) in PVCs patients. Kaplan–Meier curve of survival in PVCs patients with ICD or free-ICD. Results: The average follow-up time was 9.3±3.9 years, in which 43 (13.9%) patients died and 24 (7.8%) patients had received ICD therapy. Sex, age, pulse pressure, early repolarization syndrome (ERS), heart rate, PVC coupling interval, QRS duration, left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD), diabetes were significantly associated with the mortality and the incidence of implanting ICD. Using a multivariate logistic regression model adjusted for potential confounders, showed that LVEF (OR=0.916, 95% CI:0.881 to 0.953, p<0.001) and pulse pressure (OR=1.032, 95% CI:1.001-1.064, p=0.045) were independent factors for ICD implant in PVCs patients. Moreover, implantation of ICD may not reduce mortality in patients with ventricular premature. Conclusions: Increased pulse pressure was associated a higher incidence of ICD in PVCs patients, among many electrocardiographic and clinical variables studied. We also showed that PVs patients with ICD were at high risk of death, and the great pulse pressure was linked with higher morality in PVCs patients.

Background: Left bundle area branch pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure and reduced ejection fraction (HFrEF). Objective: To review current data comparing BVP and LBBP in patients with HFrEF and indication CRT. Methods: We searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications of CRT were included. Two reviewers performed the study selection, data abstraction, and risk of bias assessment. We calculated risk ratios with the Mantel-Haenszel method and mean difference with inverse variance using random effect models. We assessed heterogeneity using the I 2 index, with I 2 > 50% indicating significant heterogeneity. Results: Ten studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time [mean difference (MD) 9.68, 95% CI 4.49-14.87, I 2=95%, P<0.01, minutes] as well as a shorter procedure time (MD 33.68, 95% CI 17.80-49.55, I 2=73%, P<0.01, minutes) during implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRSd (MD 25.13, 95%CI 20.06-30.20, I 2= 51%, P<0.01, milliseconds) a greater left ventricular ejection fraction (LVEF) improvement (MD 5.80, 95% CI 4.81-6.78, I 2=0%, P<0.01, percentage) and a greater ventricular end-diastolic diameter (LVEDD) reduction (MD 2.11, 95% CI 0.12-4.10, I 2=18%, P=0.04, millimeter). There was a greater improvement in New York Heart Association function (NYHA) class with LBBP (MD 0.37, 95% CI 0.05-0.68, I 2=61%, P=0.02).LBBP was also associated with a lower risk of a composite of heart failure hospitalizations and all-cause mortality [Risk ratio (RR) 0.48, 95% CI 0.25-0.90, I 2=0%, p=0.02] driven by reduced heart failure hospitalizations (RR 0.39, 95% CI 0.19-0.82, I 2=0%, p=0.01). However, all-cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR 0.98, 95%CI 0.21-4.68, I 2=0%, p=0.87). Conclusion: Compared to BVP, LBBP is associated with, a greater improvement in LV systolic function, and a lower rate of heart failure-related hospitalization. Dedicated randomized controlled trials and larger patient populations are needed to further elucidate the long-term safety and efficacy of LBBP CRT.

Aims: The MicraTM transcatheter pacing system (TPS) (Medtronic) is the only leadless pacemaker that promotes atrioventricular (AV) synchrony via accelerometer-based atrial sensing. Data regarding the real-world experience with this novel system are currently lacking. We sought to characterize patients undergoing MicraTM -AV implants, describe percentage AV synchrony achieved, and analyze the causes for suboptimal AV synchrony. Methods: In this retrospective cohort study, electronic medical records from 56 consecutive patients undergoing MicraTM -AV implants at the Mayo Clinic sites in Minnesota, Florida, and Arizona with a minimum follow-up of 3 months were reviewed. Demographic data, comorbidities, echocardiographic data, and clinical outcomes were compared among patients with and without atrial synchronous-ventricular pacing (AsVP) ≥70%. Results: Fifty-six percent of patients achieved AsVP ≥70%. Patients with adequate AsVP had smaller body mass indices, a lower proportion of congestive heart failure and pulmonary hypertension. Echocardiographic parameters and procedural characteristics were similar across the two groups. Active device troubleshooting was associated with higher AsVP. The likely reasons for low AsVP were persistent atrial arrhythmias, small A4-wave amplitude, and inadequate device reprogramming. Importantly, in patients with low AsVP, subjective clinical worsening was not noted during follow-up. Conclusion: With the increasing popularity of leadless PM, it is paramount for device implanting teams to be familiar with common predictors of AV synchrony and troubleshooting with MicraTM -AV devices.

Title: Activation Pattern During His-Bundle PacingOmar Yasin MD, MS1, Jamie Bush BS2, Vaibhav Vaidya MBBS1, Jason Tri1, Martin van Zyl, MBBCh1, Peilin Xiao PhD3, Jie Han MD, PhD4, Cory Scheuermann3, Samuel J. Asirvatham, MD1,5, Yong-Mei Cha, M.D1Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USABoston Scientific Corporation, Washington DC, USAThe Second Affiliated Hospital of Chongqing Medical University, Chongqing ChinaThe First Affiliated Hospital of Zhejiang University, Hangzhou, ChinaDepartment of Pediatrics and Adolescent Medicine, Mayo clinic, Rochester, MN, USAFunding: NoneDisclosures: NoneCorresponding AuthorYong-Mei Cha, MD, FHRSDepartment of Cardiovascular Diseases, Mayo Clinic200 1st ST SWRochester, MN 55901Email:[email protected]

Background: A patient with ischemic cardiomyopathy and left bundle branch block (LBBB) who did not respond to standard bi-ventricular pacing underwent attempted left bundle area (LBA) pacing to achieve better cardiac resynchronization (CRT). Methods: LBA pacing failed to correct the LBBB or narrow the QRS. However, simultaneous pacing through the coronary sinus (CS) and LBA pacing leads resulted in marked shortening of the QRS Results: The patient’s EF improved from 30% to 45% two months post procedure and heart failure symptoms improved by one functional class. Conclusions: Simultaneous LBA and CS pacing may improve clinical outcomes compared to either alone.

Background: Asymptomatic recurrences of atrial fibrillation (AF) are common after ablation of AF. Objective: We aimed to analyze the performance of the mobile ECG device using artificial intelligence (AI) algorithm in detection of AF after ablation. Method: A randomized controlled trial of AF screening using a handheld single-lead ECG monitor (BigThumb®) or a traditional follow-up strategy was conducted in patients with non-valvular AF after catheter ablation. Consecutive patients were randomized to either BigThumb Group (BT Group) or Traditional Follow-up Group (TF Group). Monitoring data was collected and analyzed. The ECGs collected by BigThumb were compared using the automated AF detection algorithm, AI algorithm and cardiologists’ manual review. Subsequent changes in adherence on oral anticoagulation of patients were also recorded. Result: We studied 218 patients (109 in BT Group, 109 in TF Group). After a follow-up of 345.4±60.2 days, AF-free survival rate was 64.2% in BT Group and 78.9% in TF Group (P=0.0163), with more adherence on oral anticoagulation in BT Group (P=0.0052). The participants in the BT Group recorded 26133 ECGs during the follow-up, among which 3299 (12.6%) were diagnosed as AF by cardiologists’ manual review. The sensitivity and specificity of the AI algorithm were 94.4% and 98.5% respectively, which are significantly higher than the automated AF detection algorithm (90.7% and 96.2%). Conclusion: We found that follow-up after AF ablation using BigThumb leads to a more frequent detection of AF recurrence and more adherence on oral anticoagulation. Artificial intelligence algorithm improves the accuracy of ECG diagnosis.