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BACKGROUND Permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) implant rates have increased in New Zealand over the past decade. This study aims to provide a contemporary analysis of regional variation in implant rates. METHOD New PPM and ICD implants in patients ≥15 years were identified for ten years (2009 to 2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand public hospital admissions. Age-standardised new implant rates per million adult population were calculated for each of the four regions (Northern, Midland, Central and Southern) and the 20 district health boards (DHBs) across those regions. Trend analysis was performed using joinpoint regression. RESULTS New PPM implant rates increased nationally by 3.4%/year (p

Background The ANZACS‐QI Cardiac Implanted Device Registry (ANZACS‐QI DEVICE) collects nationwide data on cardiac implantable electronic devices in New Zealand (NZ). We used the registry to describe contemporary NZ use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT). Methods All ICD and CRT Pacemaker implants recorded in ANZACS‐QI DEVICE between 1 January 2014 and 31 December 2017 were analyzed. Results Of 1579 ICD implants, 1152 (73.0%) were new implants, including 49.0% for primary prevention and 51.0% for secondary prevention. In both groups, median age was 62 years and patients were predominantly male (81.4% and 79.2%, respectively). Most patients receiving a primary prevention ICD had a history of clinical heart failure (80.4%), NYHA class II‐III symptoms (77.1%) and LVEF ≤35% (96.9%). In the secondary prevention ICD cohort, 88.4% were for sustained ventricular tachycardia or survived cardiac arrest from ventricular arrhythmia. Compared to primary prevention CRT Defibrillators (n = 155), those receiving CRT Pacemakers (n = 175) were older (median age 74 vs 66 years) and more likely to be female (38.3% vs 19.4%). Of the 427 (27.0%) ICD replacements (mean duration 6.3 years), 46.6% had received appropriate device therapy while 17.8% received inappropriate therapy. The ICD implant rate was 119 per million population with regional variation in implant rates, ratio of primary prevention ICD implants, and selection of CRT modality. Conclusion In contemporary NZ practice three‐quarters of ICD implants were new implants, of which half were for primary prevention. The majority met current guideline indications. Patients receiving CRT pacemaker were older and more likely to be female., This paper utilized the ANZACS‐QI Cardiac Implanted Device Registry to describe contemporary use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in New Zealand. Three‐quarters of ICD implants were new implants, of which half were for primary prevention. Compared to primary prevention CRT Defibrillators, those receiving CRT Pacemakers were older and more likely to be female. The ICD implant rate was 119 per million population with regional variation in implant rates, ratio of primary prevention ICD implants, and selection of CRT modality.

INTRODUCTION Implant rates for cardiac implantable electronic devices (CIED), including permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), have increased globally in recent decades. This is the first national study providing a contemporary analysis of national CIED implant trends by sex-specific age groups over an extended period. METHODS Patient characteristics and device type were identified for ten years (2009 to 2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand (NZ) public hospital admissions. CIED implant rates represent implants/million population. RESULTS New PPM implant rates increased by 4.6%/year (p

Background Cardiac resynchronization therapy (CRT) has been shown to improve morbidity and mortality for heart failure (HF) patients. Little is known about the trends in CRT use and outcomes of these patients in New Zealand. Method Mortality, hospitalization events and complications in HF patients in the Northern Region of New Zealand implanted with CRT devices from Jan‐2007 to June‐2015 were reviewed. Results Two‐hundred patients underwent CRT implantation during the study period. There was a gradual increase in CRT‐D implantation (n = 157) but the number remained static for CRT‐P (n = 43). Patients who received CRT‐P were older (mean age 65.9 ± 14.0 years vs 61.5 ± 10.2 years, P

International audience; Background: Patients with nonischemic dilated cardiomyopathy (DCM) may be at lower risk for ventricular arrhythmias compared with those with ischemic cardiomyopathy (ICM). In addition, DCM has been identified as a predictor of positive response to cardiac resynchronization therapy (CRT).Objectives: The aim of this study was to investigate the impact of an additional implantable cardioverter-defibrillator over CRT, according to underlying heart disease, in a large study group of primary prevention patients with heart failure.Methods: This was an observational, multicenter, European cohort study of 5,307 consecutive patients with DCM or ICM, no history of sustained ventricular arrhythmias, who underwent CRT implantation with (n = 4,037) or without (n = 1,270) a defibrillator. Propensity-score and cause-of-death analyses were used to compare outcomes.Results: After a mean follow-up period of 41.4 ± 29.0 months, patients with ICM had better survival when receiving CRT with a defibrillator compared with those who received CRT without a defibrillator (hazard ratio for mortality adjusted on propensity score and all mortality predictors: 0.76; 95% confidence interval [CI]: 0.62 to 0.92; p = 0.005), whereas in patients with DCM, no such difference was observed (hazard ratio: 0.92; 95% CI: 0.73 to 1.16; p = 0.49). Compared with recipients of defibrillators, the excess mortality in patients who did not receive defibrillators was related to sudden cardiac death in 8.0% among those with ICM but in only 0.4% of those with DCM.Conclusions: Among patients with heart failure with indications for CRT, those with DCM may not benefit from additional primary prevention implantable cardioverter-defibrillator therapy, as opposed to those with ICM.

In the era of widespread use of implantable cardioverter-defibrillators (ICDs) for both primary and secondary prevention of sudden cardiac death, a significant proportion of patients experience episodes of multiple ventricular tachycardia/fibrillation over a short period of time requiring device interventions. The episodes are termed ventricular arrhythmia (VA) or electrical storms. VA storm is a tragic experience for patients, with many psychological consequences. Current management for VA storms remains complex. Acutely, administration of β-blockers, amiodarone and sedation or intubation is generally required to suppress sympathetic tone. Interventional treatment includes catheter ablation and sympathetic blockade by left cardiac sympathetic denervation. Strategies to modify autonomic tone to suppress VAs are the rationale of various novel interventions that have been published in recent studies. All patients with VA storm should be considered for transfer to an experienced high-volume tertiary centre for evaluation and treatment to prevent further recurrence of VA storm.

Aims Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF). The intervenous ridge (IVR) may be incorporated into ablation strategies to achieve PVI; however, randomized trials are lacking. We performed a randomized multi-centre international study to compare the outcomes of (i) circumferential antral PVI (CPVI) alone ( minimal ) vs. (ii) CPVI with IVR ablation to achieve individual PVI ( maximal ). Methods and results Two hundred and thirty-four patients with paroxysmal AF underwent CPVI and were randomized to a minimal or maximal ablation strategy. The primary outcome of recurrent atrial arrhythmia was assessed with 7-day Holter monitoring at 6 and 12 months. PVI was achieved in all patients. Radiofrequency ablation time was longer in the maximal group (46.6 ± 14.6 vs. 41.5 ± 13.1 min; P < 0.01), with no significant differences in procedural or fluoroscopy times. At mean follow-up of 17 ± 8 months, there was no difference in freedom from AF after a single procedure between a minimal (70%) and maximal ablation strategy (62%; P = 0.25). In the minimal group, ablation was required on the IVR to achieve electrical isolation in 44%, and was associated with a significant reduction in freedom from AF (57%) compared with the minimal group without IVR ablation (80%; P < 0.01). Conclusion There was no statistically significant difference in freedom from AF between a minimal and maximal ablation strategy. Despite attempts to achieve PVI with antral ablation, IVR ablation is commonly required. Patients in whom antral isolation can be achieved without IVR ablation have higher long-term freedom from AF (the Minimax study; ACTRN12610000863033).

Background Implantable cardioverter‐defibrillator (ICD) therapy is indicated for selected heart failure patients for the primary prevention of sudden cardiac death. Little is known about the outcomes in patients selected for primary prevention device therapy in the northern region of New Zealand. Method Heart failure patients with systolic dysfunction who underwent primary prevention ICD/cardiac resynchronization therapy‐defibrillator (CRT‐D) implantation between January 1, 2007, and June 1, 2015, were included. Complications, mortality, and hospitalization events were reviewed. Results Three hundred and eighty‐five primary prevention devices were implanted (269 ICD, 116 CRT‐D). Mean age at implant was 59.1 ± 11.4 years. Mean duration of follow‐up was 3.64 ± 2.17 years. The commonest cause of death was heart failure (41.8%). Only 2 patients died from sudden arrhythmic death. The 5‐year heart failure mortality rate was 6%, whereas the 5‐year sudden arrhythmic death rate was 0.3%. Heart failure hospitalizations were commoner in those who received ICD than CRT‐D (67.7% vs 25.8%, P < .001). Maori patients have low implant rates (14%) with relatively high rates of admissions with heart failure and ventricular arrhythmia admissions, Conclusions Even in appropriately selected heart failure patients who received primary prevention devices, only a small percentage died as a result of sudden arrhythmic death. CRT‐D should be the device of choice where appropriate in heart failure patients. Significant challenges remain to improve access to device therapy and maximize benefit to those who do get implanted.

Heart failure (HF) is a common health problem and has reached epidemic in many western countries. Despite the current era of HF treatment, the risk of sudden cardiac death (SCD) in HF remains significant. Implantable cardioverter defibrillator (ICD) support has been shown to reduce the risk of SCD in patients with HF and impaired left ventricular function. Prophylactic ICD implantation in HF patients seems a logical step to reduce mortality through a reduction in SCD. However, ICD implantation is an invasive procedure, and both short- and long-term complications can occur. This needs to be carefully considered when evaluating the risk-benefit ratio of ICD implantation for individual patients. As the severity of HF increases, the proportion of SCD compared with HF-related deaths decreases. The challenge lies in identifying patients with HF who are at significant risk of SCD and who would most benefit from an ICD in addition to other anti-arrhythmic strategies. This review offers insight on the applicability and practicability of ICD for this growing population.

Objective Among primary prevention patients with heart failure receiving cardiac resynchronisation therapy (CRT), the impact of additional implantable cardioverter defibrillator (ICD) treatment on outcomes and its interaction with sex remains uncertain. We aim to assess whether the addition of the ICD functionality to CRT devices offers a more pronounced survival benefit in men compared with women, as previous research has suggested. Methods Observational multicentre cohort study of 5307 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias having CRT implantation with (cardiac resynchronisation therapy defibrillator (CRT-D), n=4037) or without (cardiac resynchronisation therapy pacemaker (CRT-P), n=1270) defibrillator functionality. Using propensity score (PS) matching and weighting and cause-of-death data, we assessed and compared the outcome of patients with CRT-D versus CRT-P. This analysis was stratified according to sex. Results After a median follow-up of 34 months (interquartile range 22–60 months) no survival advantage, of CRT-D versus CRT-P was observed in both men and women after PS matching (HR=0.95, 95% CI 0.77 to 1.16, p=0.61, and HR=1.30, 95% CI 0.83 to 2.04, p=0.25, respectively). With inverse-probability weighting, a benefit of CRT-D was seen in male patients (HR 0.78, 95% CI 0.65 to 0.94, p=0.012) but not in women (HR 0.87, 95% CI 0.63 to 1.19, p=0.43). The excess unadjusted mortality of patients with CRT-P compared with CRT-D was related to sudden cardiac death in 7.4% of cases in men but only 2.2% in women. Conclusions In primary prevention patients with CRT indication, the addition of a defibrillator might convey additional benefit only in well-selected male patients.

Several chemotherapeutic agents, including newer drugs, can have toxic cardiac effects. In this month's Case Study, To and colleagues present their patient who had capecitabine-induced cardiogenic shock. They examine the best course of action for this serious complication of chemotherapy. Background A 52-year-old woman underwent successful resection of stage IIB primary mucinous adenocarcinoma of the appendix and was started on capecitabine chemotherapy. Five days into the first course, after initially experiencing diarrhea, nausea, vomiting and a transient episode of retrosternal chest pain radiating to the left scapula, she presented to the emergency department with cardiogenic shock. Investigations Electrocardiography, transthoracic echocardiography, laboratory investigation of cardiac biomarkers, coronary angiography and endomyocardial biopsy. Diagnosis Capecitabine-induced cardiogenic shock. Management Supportive treatment with dopamine, milrinone, norepinephrine (noradrenaline) and levosimendan.

Aims The Goldenberg risk score, comprising five clinical risk factors (New York Heart Association class >2, atrial fibrillation, QRS duration >120 ms, age >70 years, and urea >26 mg/dL), may help identify patients in whom the survival benefit of the defibrillator may be limited. We aim at assessing whether this score can accurately predict the long-term all-cause mortality risk of patients receiving cardiac resynchronization therapy (CRT) and identify those who are more likely to benefit from the defibrillator. Methods and results In this retrospective observational cohort study, 638 patients with ischaemic or non-ischaemic dilated cardiomyopathy who had CRT-defibrillator (CRT-D) ( n = 224) vs. CRT-pacemaker (CRT-P) ( n = 414) implantation were prospectively followed up for survival outcomes. The long-term outcome of patients with CRT-D vs. CRT-P was compared within risk score categories and in patients with severe renal dysfunction. Mean follow-up in surviving and deceased patients was 62.7 and 32.5 months, respectively. This score showed higher discriminative performance in all-cause mortality prediction in CRT-D vs. CRT-P patients (area under the curve 0.718 ± 0.041 vs. 0.650 ± 0.032, respectively, P = 0.001). In those with scores 0–2, a CRT-D device decreased mortality rates in the first 4 years of follow-up compared with CRT-P (11.3 vs. 24.7%, P = 0.041), but this effect attenuated with longer follow-up duration (21.2 vs. 32.7%, P = 0.078). In this group, the benefit of CRT-D during the follow-up was seen after adjusting for traditional mortality predictors (hazard ratio 0.339, P = 0.001). No significant differences in mortality rates were seen in patients with score ≥3 (57.9% with CRT-D vs. 56.9%, P = 0.8) and those with severe renal dysfunction (92.9% in CRT-D vs. 76.2%, P = 0.17). Similar results were seen following propensity score matching. Conclusion A simple risk stratification score comprising five clinical risk factors may help identify CRT patients who are more likely to benefit from the presence of the defibrillator.

Catheter ablation for paroxysmal atrial fibrillation (PAF) is an effective treatment. Favourable outcomes at 6-12 months post-ablation have been reported using the multi-electrode catheter 'pulmonary vein ablation catheter (PVAC)' but little is known about longer term outcomes. There are also limited data on quality of life (QoL) post-atrial fibrillation (AF) ablation beyond 2 years of follow-up.Two hundred three consecutive patients (77 % male, mean age 57.7 ± 11 years) who had a PAF ablation were included. Patients underwent conventional pulmonary vein isolation (PVI) (n = 128) or PVAC ablation (n = 75). Patients' symptoms were scored at baseline, at clinic follow-up and on questionnaire follow-up using the validated Canadian Cardiovascular Society Severity of AF (CCS-SAF) scale. The 'AF Effect on QualiTy of life' (AFEQT) questionnaire was used on questionnaire follow-up.Mean questionnaire follow-up was 854 ± 176 days with 74 % response rate. The majority of patients (91.6 % overall) were highly symptomatic at baseline with CCS-SAF class 3 or 4 symptoms. CCS-SAF class on follow-up questionnaire decreased significantly from baseline for both groups (mean 1.69 ± 1.7 for PVAC and 1.45 ± 1.5 for PVI, p = 0.001 and p 0.001, respectively) with no difference between groups (p = 0.52) and the majority being class 0 or 1 (59.9 % overall). Mean AFEQT questionnaire scores were similar between both groups (78.1 ± 25 vs. 82 ± 23, p = 0.35). Total procedure time was significantly shorter in the PVAC group (135 ± 54 vs. 178 ± 43 min, p 0.001).There was a comparable and significant improvement in QoL post-ablation in patients who underwent ablation using PVAC catheter and conventional techniques.

Coronary artery spasm (CAS) is characterised by chest pain at rest and transient ST segment elevation on the ECG. The natural history of variant angina is not fully understood. Patients with CAS are younger, mostly female subjects and usually do not have traditional cardiovascular risk factors other than cigarette smoking. Cardiac arrhythmias are known to be associated with CAS. Ventricular arrhythmia is a well-recognised complication and sudden cardiac death has also been documented. The most important diagnostic tool in CAS is coronary angiography. 24 h ECG Holter monitoring can be very useful in the diagnosis of ventricular arrhythmias caused by CAS. The mainstay therapy for CAS is calcium channel blockers and nitrates. The use of β-blockers, especially the non-selective group, can promote attacks or prolong vasospastic state. The indication for implantable cardioverter defibrillator (ICD) implantation in a patient with CAS is still not clearly established. The role of primary prevention with the use of ICD is controversial; however, ICD implantation should be considered in high risk patients despite optimal medical treatment.

A 69 year-old obese female with poorly controlled ventricular rates in atrial fibrillation (AF) underwent single chamber pacemaker implantation followed by an atrioventricular node ablation one month later. The chest X-ray performed after the ablation showed the header of pulse generator facing medially (arrow) with satisfactory right ventricular, mid-septal lead positioning (Fig. 1A). During a coronary angiogram for angina six months later, the right anterior fluoroscopic view of the pacing lead showed a double twist within the right atrium (arrow) (Fig. 1B). In addition, the pulse generator had flipped horizontally (arrow) (Fig. 1C). The patient denied ‘twiddling’ with the device. Fortunately, pacemaker lead function remained normal. Traditional Twiddler’s syndrome occurs when circular rotation of the device retracts the leads out of the heart with leads

Percutaneous left atrial appendage (LAA) occlusion is commonly performed using umbrella-shaped devices. However, the utility of such devices is highly dependent on the underlying anatomy of the appendage. For the first time, we report the use of an Occlutech PFO closure device to successfully occlude a left atrial appendage that possessed a circumferential ridge at its mouth. PFO closure devices would also be suitable for the occlusion of left atrial appendages when an incomplete surgical closure results in a circumferential ridge.

Background: Implantable cardioverter defibrillator (ICD) implantation rates within New Zealand are low by international standards. We aimed to assess whether adults suffering a community cardiac arrest had an indication for ICD implantation prior to the event. Methods: All adult patients suffering a community cardiac arrest in the Wellington region between 1 June 2007 and 31 May 2008 attended by the ambulance service were reviewed. Cardiac history, risk factors, investigations and co-morbidity data were collected from hospital medical records. All cases where an indication was potentially present were independently assessed by two electrophysiologists. Results: 144 cardiac arrests occurred in the studyperiod. The survival rate to hospital discharge was 10% (n= 15). Fifty (34%) of patients had no known pre-existing cardiovascular disease, 38 patients (26%) had documented cardiomyopathy, and 45 (31%) had documented previo a t p p d w j ( a

Conclusion: Suboptimal use of secondary prevention drugs in high risk ACS patients treatedwith urgent CABG surgery may contribute to subsequent adverse events. Greater efforts to optimise the use of these medications are still needed in 2010. doi:10.1016/j.hlc.2010.06.711

Introduction Atrial fibrillation (AF) ablation under therapeutic warfarin reduces periprocedural risk of complications, compared to periprocedural bridging with low molecular weight heparin (LMWH). The aim of study was to compare the safety of an uninterrupted warfarin protocol in patients undergoing AF ablation without intracardiac echocardiography and to assess the experience of patients who had previous ablation with bridging protocol on the change of anticoagulation protocol. Method Two anticoagulation regimes for patients undergoing AF ablation were evaluated—uninterrupted warfarin group (120 in Group 1) and bridging LMWH group (100 in Group 2). Bleeding complications were compared between the two groups. Patients in Group 1 who had had previous ablation on bridging LMWH were asked to comment on their experience with the change of protocol at 4 weeks post discharge. Drug cost comparison in two groups was performed. Results Preprocedural INR in Group 1 was 2.48±0.42 compared to 1.08±0.16 in Group 2 (95% CI 1.38 to 1.41, p Conclusions AF ablation under therapeutic warfarin is safe without echocardiography guidance, associated with improved patients9 experience and potentially cost saving in long term.

Background:Medicationand lifestyleadherence following an acute coronary syndrome (ACS) can significantly improve outcomes but is influenced by patient, system and environmental factors. The EARLY PREVENT study is investigating using electronic linkage to pharmaceutical dispensing records as the electronic core of a personalised program to support appropriate medication and lifestyle adherence. The aim of this sub-study was to better understand our ACS population and the potential barriers to adherence as background to the development of a postdischarge adherence intervention program. Methods: We identified all NZ residents (1/8/07 to 18/5/09),who resided inCountiesManukaudistrictHealth Board at the time of their ACS admission. The cohort was divided into four groups by ethnicity and then patients were randomlyselected toapproach for interview toassess predictors of medication adherence. Results: 188 patients consented to be interviewed (Maori 27%, Pacific 20%, Indian 26%,& Euro/other 27%). Compared to other ethnicities, Europeans are approximately 10 years older (p< 0.0001),more likely retired (p< 0.0001), less likely to have diabetes (p 0.006) or experience barriers around access to a telephone (p< 0.0001), internet (p= 0.05), transport (p= 0.0003), funding prescriptions (p= 0.004), taking pills as prescribed (p= 0.03), reporting cultural fit with GP (p= 0.0004), and understanding need for lifelong statins (p= 0.005). Conclusion:Culturally and language appropriate interventions to assess for barriers to adherence and to develop solutions should be a feature of proactive ACS discharge planning and would be relatively simple to instigate.