Treatment Outcome and Prognosis of Patients with Hepatocellular Carcinoma with Inferior Vena Cava and/or Cardiac Invasion

( Seawon Hwang ),( Bo Hyun Jang ),( Pil Soo Sung ),( Jeong Won Jang ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: The incidence of hepatocellular carcinoma (HCC) extending to inferior vena cava (IVC) and/or right atrium (RA) is rare and median survival has been reported to be about 2 to 3 months. Although according to BCLC staging and treatment strategy, sorafenib or symptomatic treatment is recommended in these patients, some reports suggested that active treatment had resulted in prolonged survival. Thus, this study was aimed to investigate the efficacy of active treat- ment for HCC patients with IVC and/or RA invasion and the causes of death. Methods: A total of 2127 patients newly diagnosed as HCC from January 1, 2002 to December 31, 2014 at Seoul St. Mary’s hospital were reviewed. Out of these patients, 44 had IVC and/or RA invasion at the time of diagnosis. Patients were divided into control group (n=10) in which only supportive care was given and actively treated group (n=34). Results: In this study, median follow up period was 3.3 months. There was no significant difference between control and actively treated group in terms of age (57.4±14.3 vs. 52.4±12.4, p=0.28), CTP score (A/B/C, n=4/5/1, n=19/14/1, P=0.387) and number or the largest size of intrahepatic tumor. In treated group, transarterial chemoembolization (TACE, n=17, 49%) and hepatic arterial infusion chemotherapy (HAIC, n=15, 43%) were the most prevalent modalities and 4 patients additionally received radiation therapy. Median survival was 5.8 (range, 0.2-56.0) months for all patients. There was a significant difference in median survival between the control and treated group [median, 1.5 (range, 0.2.5-7.4) vs. 8.0 (range, 1.6-56.0) ; log-rank test, p=0.01]. Causes of death were investigated in 24 patients and these were tumor progression (n=13, 54.2%), liver failure (n=6, 25.0%), HCC rupture (n=3, 12.5%), infection (n=1, 4.2%) and ARDS (n=1, 4.2%). Conclusions: Treatment group showed a better prognosis than control group. And half of patients died from cancer progression, not pulmonary embolism or heart failure by IVC and/or RA tumor thrombosis. Therefore active treatment could improve the survival rate in HCC patients with IVC and/or RA invasion. Further study with a larger population of subjects would be needed to verify these findings.

Tumor Expression of High-Temperature-Required Protein A2 Negatively Predicts Recurrence in Patients with Hepatocellular Carcinoma after Liver Transplantation

( Seawon Hwang ),( Pil Soo Sung ),( Wonhee Hur ),( Eun Sun Jung ),( Jeong Won Jang ),( Si Hyun Bae ),( Jong Young Choi ),( Young Kyoung You ),( Dong-gu Kim ),( Seung Kew Yoon ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: High-temperature-required protein A2 (HtrA2) is a serine protease located at mitochondrial intermembrane space. Although there were several reports on the association of tumor HtrA2 expression and survival outcomes of the patients with lung or ovarian cancer, the expression of HtrA2 has not been studied in hepatocellular carcinoma (HCC). In this study, we aimed to identify the prognostic value of tumor HtrA2 expression in patients with HCC after liver transplantation (LT). Methods: From Jan 2005 to Dec 2009, 82 patients who underwent LT due to HCC at Seoul St. Mary's Hospital were enrolled in this study. Tumor HtrA2 expression in surgical specimens of 82 patients was measured by immunohistochemistry. Results: Among 82 patients, 21 patients (25.6%) showed negative HtrA2 expression, 40 patients (48.8%) showed weakly positive, 3 patients (3.7%) showed strong focally positive, and 18 patients (22.0%) showed strong diffuse positive. There were no significant differences in the serum levels of AFP and PIVKA, and also no differences in the histologic findings of tumor size, number, Edmondson- Steiner grading and microvessel invasion between the HtrA2 negative negative and HtrA2 positive patients at baseline. Median recurrence free survival (RFS) was 109.9 (range, 1.8-156.3) months for all patients. Kaplan-Meier survival analysis showed that patients with positive HtrA2 expression had significantly longer RFS than those with negative HtrA2 expression (median, 77.0 (range, 2.3-156.3) months vs. 112.0 (range, 1.8-156.2) months; log-rank test, P=0.023). Moreover, multivariate analysis demonstrated that HtrA2 expression was an independent predictor of recurrence free survival. (hazard ratio, 3.93; 95% CI, 1.037-14.895; P=0.044). Conclusions: In conclusion, we found that tumor expression of HtrA2 negatively predicts recurrence in patients with HCC after LT. As we know, this is the first report to show the association between HtrA2 expression in HCC and patient outcome. Future study will demonstrate the mechanism of protective effects of HtrA2 expression in HCC using in vitro and in vivo models.

Prevalence of HCV NS5A Pre-Treatment Resistance Associated Substitution in Genotype 1b

( Seawon Hwang ),( Pil Soo Sung ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ),( Jeong Won Jang ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: After direct acting antiviral (DAA) agents for hepatitis C were introduced, there was an advance in HCV treatment. The most common HCV genotype (GT) is 1b and now the first choice for GT-1b HCV is daclatasvir + asunaprevir in Korea. This DAA agents combination therapy has shown sustained virologic response (SVR) rates of 90%. However, the SVR rate decreased to 39% in patients with nonstructural protein 5A (NS5A) pre-treatment resistance associated substitution (RAS) at L31 or Y93. Therefore, we aimed to measure the prevalence of NS5A RAS in HCV GT-1b patients. Methods: A total of 1144 patients who visited 8 Catholic medical centers in Korea to treat hepatitis C from Mar 9, 2015 to Mar 9, 2017 were enrolled in this study. Among them, 773 patients were with GT-1b. The NS5A regions were amplified by nested polymerase chain reaction. Results: Among 773 patients with GT-1b, NS5A RAS were positive in 108 patients (14%). Y93 substitutions were observed in 93 (93/773, 12.03%) patients, L31 substitutions were observed in 21 (21/773, 2.72%) patients and 6 (6/773, 0.78%) patients were confirmed as having both of Y93 and L31 substitutions. Regarding Y93 substitutions, Y93H (89/773, 11.5%), Y93C (1/773, 0.13%), Y93F (1/773, 0.13%), Y93F/C (1/773, 0.13%) and Y93S (1/773, 0.13%) were observed. And regarding L31 substitutions, L31M (14/773, 1.81%), L31F (3/773, 0.39%), L31V (3/773, 0.39%) and L31M/I (1/773, 0.13%) were observed. Fifty-eight patients out of 108 patients (58/108, 53.7%) were treated with DAA agents. (7 patients with daclatasvir + asunaprevir, 30 patients with ledipasvir/sofosbuvir, 9 patients with sofosbuvir + daclatasvir, 12 patients with ledipasvir/sofosbuvir + ribavirin). Among 58 patients, liver cirrhosis (LC) was identified in 20 patients (20/58, 34.5%), compensated LC with 17 patients (17/58, 29.3%) and decompensated LC with 3 patients (3/58, 5.2%). Conclusions: This study is a multicenter, real-world, cohort study involving large numbers of patients in Korea. Therefore, this data on NS5A RAS could represent the Korean population.

Efficacy and Tolerability of Elbasvir/Grazoprevir and Ombitasvir/Paritaprevir/Ritonavir with Dasabuvir in HCV Genotype I-Infected Korean Patients : Analyses in Real-Life Settings

( Seawon Hwang ),( Sung Won Lee ),( Pil Soo Sung ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ),( Jung Hyun Kwon ),( Sun Hong Yoo ),( Soon Woo Nam ),( Hae Lim Lee ),( Nam Ik Han ),( Hee Yeon 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Elbasvir/grazoprevir (EBR/GZ) and ombitasvir/paritaprevir/ritonavir with dasabuvir (OBV/PTV/r+DSV) were recently approved for treatment of hepatitis C virus (HCV) genotype (GT) 1 infection in Korea. This study evaluated the efficacy and tolerability of the newer direct-acting antivirals (DAAs), EBR/GZ and OBV/PTV/r+DSV, compared to daclatasvir with asunaprevir (DAC+SUN) and ledipasvir/sofosbuvir (LDV/SOF)±ribavirin (RBV) in a large real-world cohort. Methods: A total of 845 patients with HCV GT 1 infection who received interferon-free DAA regimens between 2015 and 2018 were consecutively enrolled. Treatment responses and adverse events (AEs) were compared between the DAA groups. The characteristics related to sustained virological response 12 weeks off therapy (SVR12) were analyzed. Results: Mean age was 59.3±12.2 years and 45.4% (384/845) of patients were male and 29.7% (251/845) of patients had cirrhosis. Among 845 patients, 531 received DAC+SUN, 128 EBR/ GZ, 64 OBV/PTV/r+DSV and 66 LDV/SOF±RBV in GT 1b. The SVR rates in GT 1b were 94.6% (423/447) in patients treated with DAC+SUN, 95.2% (20/21) with EBR/GZR, 100% (18/18) with OBV/PTV/r+DSV and 98.3% (57/58) with LDV/SOF±RBV. In subgroup analyses, there were no differences in SVR12 across DAA regimens, in terms of prior treatment experience, the presence of cirrhosis or CKD/ESRD, or patient age. However, higher SVR 12 rates were observed in patients with EBR/GZ or OBV/ PTV/r+DSV than those with other DAAs among the groups with high baseline viral load (>800,000 IU/ml) and NS5A RASs. Overall, EBR/GZ and OBV/PTV/r+DSV were well-tolerated and only one (0.78%) patient receiving EBR/GZ discontinued treatment due to skin rash and no patient receiving OBV/PTV/r+DSV discontinued treatment due to possible drug-related side effects, whereas 15 (2.82%) patients receiving DAC+SUN discontinued treatment due to possible drug-related side effects. Grade 3 AEs for AST/ALT elevation were identified in one (0.78%) patient in EBR/GZ group, no one in OBV/PTV/r+DSV group, 14 (2.64%) in DAC+SUN group and one in LDV/SOF±RBV group. For 45 GT 1a-infected patients, all (100%) achieved SVR12 with LDV/SOF±RBV (28/28) and OBV/PTV/r+DSV (4/4) regimens. All well tolerated DAAs with no grade 3 AEs or discontinuation. Conclusions: Newer DAAs, EBR/GZ and OBV/PTV/r+DSV, are safe and highly efficient for HCV GT-1 across a diverse patient population. Difficult-to-treat patient characteristics, such as cirrhosis, prior failed therapy, high baseline viral load, and NS5A RASs do not seem to impact SVR12 to these DAAs

Predictive Factors to Trans-Arterial Radioembolization Based Treatment with Yttrium-90

( Seawon Hwang ),( Jung Suk Oh ),( Pil Soo Sung ),( Jeong Won Jang ),( Si Hyun Bae ),( Jong Young Choi ),( Ho Jong Chun ),( Seung Kew Yoon ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Trans-arterial radioembolization (TARE) is a form of radiation therapy performed by selective intra-arterial injection of microspheres loaded with Yttrium-90. TARE has been shown in many clinical trials to be safe and effective in the management of unresectable HCC. The aim of this study is to identify prognostic factors for overall survival (OS) and time to progression (TTP) in patients with HCC undergoing TARE. Methods: This study included 65 consecutive HCC patients who underwent TARE from Jul 2009 to Jan 2018. The tumor responses to TARE were assessed according to modified Response Evaluation Criteria in Solid Tumors (mRECIST). Results: Study cohort comprised nineteen patients (29.2%) in BCLC-A stage, 21 (32.3%) patients in BCLC-B stage and 25 (38.5%) patients in BCLC-C stage. Among 65 patients, 4 (6.2%) obtained complete response (CR) and 27 (41.5%) showed partial response (PR) at 3 months after TARE. Median OS was 19.47 months and TTP was 4.83 months. Fifty-one patients underwent salvage treatment after TARE and 18 achieved objective response (OR); 14 achieved CR and 4 achieved PR. Multivariate analysis showed that the presence of portal vein tumor thrombus (PVTT) (hazard ratio [HR], 5.862; 95% confidence interval [CI], 2.380-14.437, P=0.000) and multiplicity of HCC nodules (HR, 2.205; 95% CI, 1.058-4.594, P=0.04) were independent factors for OS. The presence of PVTT (HR, 3.961; 95% CI, 1.924-8.155, P=0.000) and tumor diameter >10 cm (HR, 2.167; 95% CI 1.152-4.076, P=0.016) were independent prognostic factors for TTP. Subgroup analysis of 40 patients without PVTT showed that the degree of tumor burden (HR, 44.317; 95% CI, 5.042-389.505, P=0.001), the achievement of OR at 3 months after TARE (HR, 8.561; 95% CI, 3.321-103.738, P=0.001) and receiving salvage treatment (HR, 24.307; 95% CI, 4.709-125.481, P=0.000) were shown to affect OS. Conclusions: TARE is an effective therapy for patients with advanced HCC. And PVTT before TARE is an independent predictive factor for both OS and TTP.

Consecutive Increment of Serum AFP Level Is a Useful Surrogate Marker in Predicting HCC in Liver Cirrhosis Patients

( Hee Chul Nam ),( Seawon Hwang ),( Pil Soo Sung ),( Young Joon Lee ),( Jeong Suk Oh ),( Ho Jong Chun ),( Jeong Won Jang ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: The role of alpha-feto protein (AFP) in the diagnosis of hepatocellular carcinoma (HCC) is getting smaller due to the advances of imaging modalities. However, consecutive increment of AFP level in liver cirrhosis patients is presumed to be associated with the higher risk of developing HCC in clinical settings. Such a notion instigated us to analyze serial AFP levels of HCC patients in a retrospective manner. Methods: From January 2002 to December 2016, 2259 patients were diagnosed with HCC in Seoul St. Mary’s hospital. Among them 236 cirrhotic patients were found to have a serial record of AFP measurements for over one year. We assessed AFP levels at the time the diagnosis of HCC was made and compared them with that of patients at 3,6 and 12 months prior to the diagnosis. Results: At the time the diagnosis was made, the patients’ baseline characteristics were as follows; mean age was 58.89 years (32-87), median tumor size was 2.1cm (0.7-26.3), median AFP level was 20.35 ng/mL (0.75-32134). Median AFP level of 12 months, 6 months and 3 months before the diagnosis of HCC was 6.26 ng/mL (0.6-513), 8.73 ng/mL (0.66-1287.86), 12.95 ng/mL (0.91-1461), respectively. We divided patients by two groups; one was AFP over 20 ng/mL at the time of diagnosis of HCC, and the other one was not. In elevated AFP group (n=119), median AFP level of 12 months, 6 months and 3 months before the diagnosis of HCC and at the time of the diagnosis of HCC was 12.79 ng/mL (0.81-513), 24.58 ng/ mL (1.25-1287.86), 43.41 ng/mL (2.54-1461), 278.03 ng/mL (11.8-19017), respectively. In non-elevated AFP group (n=115), median AFP level of 12 months, 6 months and 3 months before the diagnosis of HCC and at the time of the diagnosis of HCC was 4.54 ng/mL (0.6-74.78), 4.68 ng/mL (0.66-91), 5.04 ng/mL (0.91-17.9), 4.99 ng/mL (0.75-18.29), respectively. Repeated-measure ANOVA was used to analyze the significance of increase in consecutive AFP levels in HCC surveillance. In elevated AFP group, Consecutive increment of AFP level was statistically significant in time dependent manner (P≤0.000) with linear relationship (P≤0.000). There was no significant change of consecutive AFP level In non-elevated AFP group. Consequentially, there was significant difference of AFP level between the two groups in time dependently (P≤0.000). Conclusions: Early detection of HCC with relatively smaller sizes was possible due to the close observation of increase in serial AFP levels. We suggest increase in serial AFP level as a strong surrogate marker in the prediction of HCC and that those with consecutive increments of AFP levels for more than 2 times should be candidates for active surveillances for HCC.

Interferon-Free Treatment Achieves High Rate of Sustained Virological Response in Kidney and Liver Transplanted Patients Infected with Hepatitis C Virus

( Dong Jin Yoon ),( Pil Soo Sung ),( Seawon Hwang ),( Jeong Won Jang ),( Si Hyun Bae ),( Seung Kew Yoon ),( Jong Young Choi ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Recently, several studies have shown that direct acting antivirals (DAAs) can be effective in treating patients with relapsed hepatitis C virus (HCV) infection after liver or kidney transplantation. In this single center study, we aimed to evaluate the sustained virological response (SVR) rates among Korean liver or kidney transplant recipients. Methods: We identified 15 liver or kidney transplant recipients (mean age 57 ± 8.4 yeas, 7 males) treated with DAAs. Nine patients received liver transplantation (LT) and 6 patients received kidney transplantation (KT). Among them, 11 patients were infected with genotype 1B HCV and 4 patients with genotype 2. The mean interval between transplantation day and DAA start day was 876 days. Mean HCV RNA level was 3,010,319 IU/ mL. Eleven patients received combination therapy of DAA and ribavirin and 4 patients were treated with DAA monotherapy. Most patients were taking Tacrolimus or Cyclosporin as immunosuppressant. The primary endpoint was sustained virologic response at 12 weeks after the end of treatment (SVR12). Results: The SVR12 rate by an intention-to-treat analysis is 92% (11/12). Patient who failed to reach SVR12 (genotype 1B) was initially treated with Ledipasvir/sofosbuvir and ribavirin. At 12 weeks, HCV RNA level was 0, but after 24 weeks, the level increased to 315,222 IU/mL, and at 36 weeks, 1,719,237 IU/ mL. Interestingly, 5 patients treated with DAA monotherapy all reached SVR12. Patients did not show increase in AST/ALT and serum creatinine level or decrease in hemoglobin. Conclusions: Treatment of HCV with the DAAs provided high rates of SVR12 in Korean liver and kidney transplant recipients on immunosuppression. ITT analysis SVR12 was 92% across different treatment regimens.

Association of Preemptive Anti-HBV Therapy with Im-proved Long-Term Survival in Patients with Hepatocellu-lar Carcinoma Undergoing Transarterial Therapy

( Jeong Won Jang ),( Sun Hong Yoo ),( Seawon Hwang ),( Pil Soo Sung ),( Sung Won Lee ),( Jung Hyun Kwon ),( Soon Woo Nam ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: The effect of preemptive antiviral therapy (AVT) on survival in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains unknown. The study aimed to determine whether preemptive AVT can allow improved long-term survival in patients undergoing transartieral therapy. Methods: A total of 2546 newly diagnosed HBV-related HCC patients treated with transarterial therapy as initial therapy between 2000 and 2016 were screened for the analysis of two groups based on preemptive use of antivirals. Patients who had co-existing other diseases, previous AVT, and other treatment options within 2 years of transarterial therapy were excluded. Treatment effects were analyzed using propensity score (PS) matching (1:1) separately for the entire cohort and each subgroup. The primary endpoint was overall survival. For patients initiating antivirals, analyses were done on an intention-to-treat basis. Results: Overall, 1547 patients met the inclusion criteria and 1286 were PS-matched for the two groups. Mean follow-up duration was 32.0 ± 36.6 months. In the entire unmatched cohort, patients receiving preemptive AVT survived significantly longer than those not, with the 10-year survival rates of 26.8% vs. 9.6%, respectively (P<0.001). Among AVT-untreated patients, high baseline HBV viremia and HBV reactivation during treatment were significantly associated with shorter survival, but these effects were not observed when analyzed together with AVT-treated patients. Regarding the types of antivirals, survival was significantly longer in patients receiving high-potency than low-potency antivirals. In the PS-matched cohort, the preemptive-AVT group survived significantly longer than the non-preemptive group. Preemptive AVT remained an independent factor for survival. Multivariable stratified analysis further verified the association of preemptive AVT with decreased risk of mortality in all patient subgroups. Sensitivity analyses also confirmed the estimated treatment effect in each matched subgroup stratified by tumor stage and baseline viremia status. Conclusions: Preemptive AVT is associated with significantly improved long-term survival among patients undergoing transarterial therapy. High-potency antivirals are best indicated for this approach.

Safety and Efficacy of Daclatasvir and Asunaprevir with Chronic HCV Genotype 1b Infection and Chronic Kidney Disease: Multicenter Cohort Study

( Seok-hwan Kim ),( Myeong Jun Song ),( Seawon Hwang ),( Pil Soo Sung ),( Jeong Won Jang ),( Si Hyun Bae ),( Jong Young Choi ),( Seung Kew Yoon ),( Hee Yeon Kim ),( Chang Wook Kim ),( Do Seon Song ),( 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: We aimed to evaluate the efficacy and safety of Daclatasvir (DAV) and Asunaprevir (ASV) in patients with chronic hepatitis C virus (HCV) genotype 1b according to chronic kidney disease (CKD) stage. Methods: 274 HCV patients at 8 catholic medical centers enrolled from Mar, 2015 to Aug, 2018. We evaluated the virological responses at each week 4, 12, 24 and the 12-week sustained virologic response (SVR12) according to CKD stage. CKD stage categorized by grade 1 (eGFR≥90), grade 2 (eGFR 60-89), grade 3 (eGFR 30-59), grade 4 (eGFR <30). The tolerability and safety of patients were also evaluated. Results: Of these 245 patients, there had no resistance-associated variant of NS5A (NS5A RAVs). 23 and 6 patients showed indeterminate and NS5A mutation RAVs. According to NS5A mutation, SVR12 showed 95.1%, 100%, and 16.6 % in no RAVs, indeterminate, and NS5A mutation, respectively. According to CKD stage, SVR12 of grade 1(n=111), 2(n=138), 3(n=18), and 4(n=7) showed 94.5%, 94.2%, 88.8%, and 85.7%, respectively. CKD stage did not affect SVR12 rates. Treatment failure and relapse according to CKD grade 1 2, 3, and 4 showed 2.7%(n=3) and 2.7%(n=3), 3.6%(n=5) and 2.7%(n=3), 11.1%(n=2) and 0%, 0% and 14.2%, respectively. DCV and ASV were well tolerated among the majority of patients and adverse events (anemia, elevated liver enzyme) were occurred in 3.6%, 12.4%, respectively. Conclusions: In this study, DAV and ASV combination therapy for CKD patients with HCV infection achieved high sustained virological response with few adverse events.

Endoscopic Electrosurgery in Patients with Cardiac Implantable Electronic Devices

Myong Ki Baeg,Sang Woo Kim,고선혜,Yoon Bum Lee,Seawon Hwang,Bong-Woo Lee,Hye Jin Choi,Jae Myung Park,In-Seok Lee,Yong-Seog Oh,Myung-Gyu Choi 대한소화기내시경학회 2016 Clinical Endoscopy Vol.49 No.2

Background/Aims: Patients with cardiac implantable electronic devices (CIEDs) undergoing endoscopic electrosurgery (EE) are at a risk of electromagnetic interference (EMI). We aimed to analyze the effects of EE in CIED patients. Methods: Patients with CIED who underwent EE procedures such as snare polypectomy, endoscopic submucosal dissection (ESD), and endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) were retrospectively analyzed. Postprocedural symptoms as well as demographic and outpatient follow-up data were reviewed through medical records. Electrical data, including preprocedural and postprocedural arrhythmia records, were reviewed through pacemaker interrogation, 24-hour Holter monitoring, or electrocardiogram. Results: Fifty-nine procedures in 49 patients were analyzed. Fifty procedures were performed in 43 patients with a pacemaker, and nine were performed in six patients with an implantable cardioverter-defibrillator. There were one gastric and 44 colon snare polypectomies, five gastric and one colon ESDs, and eight ERCPs with EST. Fifty-five cases of electrical follow-up were noted, with two postprocedural changes not caused by EE. Thirty-one pacemaker interrogations had procedure recordings, with two cases of asymptomatic tachycardia. All patients were asymptomatic with no adverse events. Conclusions: Our study reports no adverse events from EE in patients with CIED, suggesting that this procedure is safe. However, because of the possibility of EMI, recommendations on EE should be followed.