Aleksandr Voskoboinik

Predictors of acute and long-term success of slow pathway ablation for atrioventricular nodal reentrant tachycardia: a single center series of 1,419 consecutive patients.

Background: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common mechanism of supraventricular tachycardia. Slow pathway (SP) ablation is the first‐line treatment approach with a high acute success rate and a low risk of inadvertent complete atrioventricular (AV) block. However, there is still some uncertainty as to the most appropriate procedural endpoints and the impact of these on risk of recurrence. We report the acute and long‐term results of SP ablation in a large single‐center consecutive series and analyze predictors of acute success and late recurrence.

Extending the Boundaries of Cardiac Resynchronization Therapy: Efficacy in Atrial Fibrillation, New York Heart Association Class II, and Narrow QRS Heart Failure Patients

BACKGROUND Large-scale clinical trials have demonstrated the benefits of cardiac resynchronization therapy (CRT) in patients with New York Heart Association (NYHA) Class III/IV heart failure, systolic left ventricular dysfunction, and a wide QRS. However, additional patient groups may also benefit from CRT. METHODS AND RESULTS We meta-analyzed clinical benefits of CRT in heart failure patients with narrow QRS, atrial fibrillation (AF) and NYHA Class II symptoms. Thirteen trials of 2882 patients contributed to this meta-analysis. In the narrow versus wide QRS group comparison, no difference in benefit was observed for change in left ventricular ejection fraction (standardized mean difference [SMD] 0.30, 95% confidence interval [CI] -0.37 to 0.97) or left ventricular end systolic volume (SMD 0.30, 95% CI -1.14 to 1.74). The benefit was greater in the wide QRS group for the 6-minute walk test (SMD 1.27, 95% CI 0.59 to 1.96) and NYHA class improvement (SMD 1.24, 95% CI 0.72 to 1.75). In the atrial fibrillation (AF) versus sinus rhythm (SR) group comparison, no difference in benefit was observed for change in left ventricular ejection fraction (SMD -0.38, 95% CI -1.28 to 0.53) or NYHA improvement (SMD 0.32, 95% CI -0.77 to 1.40). In the NYHA II versus NYHA III/IV group comparison, no difference in benefit was observed for change in left ventricular end diastolic diameter (SMD 0.05, 95% CI -0.94 to 1.05) or left ventricular end systolic diameter (SMD 0.74, 95% CI -1.98 to 3.46). CONCLUSIONS Large-scale clinical outcome trials of CRT are warranted in heart failure patients with narrow QRS, AF, and NYHA II, given the similar benefits observed to those with wide QRS, SR, and NYHA III/IV for many parameters.

Methamphetamine-associated cardiomyopathy: patterns and predictors of recovery

Methamphetamine abuse is a growing public health problem, and increasing numbers of patients are admitted with methamphetamine‐associated cardiomyopathy (MAC).

Clinical impact of rotor ablation in atrial fibrillation: a systematic review

Aims Rotor mapping and ablation have gained favour over the recent years as an emerging ablation strategy targeting drivers of atrial fibrillation (AF). Their efficacy, however, has been a topic of great debate with variable outcomes across centres. The aim of this study was to systematically review the recent medical literature to determine the medium-term outcomes of rotor ablation in patients with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PeAF). Methods and results A systematic search of the contemporary scientific literature (PubMed and EMBASE) was performed in August 2017. Only studies assessing arrhythmia-free survival from rotor ablation of AF were included. We used the random-effects model to assess the primary outcome of pooled medium-term single-procedure AF-free survival for both PAF and PeAF. Success rates from multiple procedures and complication rates were also examined. We included 11 observational studies (4 PAF and 10 PeAF) with a total of 556 patients (166 PAF and 390 PeAF). Pooled single-procedure freedom from AF was 37.8% [95% confidence interval 5.6-86.3%] at a mean follow-up period of 13.8 ± 1.8 months for PAF and 59.2% (95% CI 41.4-74.9%) at a mean follow-up period of 12.9 ± 6 months for PeAF. There was a marked heterogeneity between studies (I2 = 93.8% for PAF and 88.3% for PeAF). The mean complication rate of rotor ablation among the reported studies was 3.4%. Conclusion The wide variability in success rate between different centres performing rotor ablations suggests that the optimal ablation strategy, particularly targeting rotors, is unclear. Results from randomized studies are necessary before this technique can be considered as an established clinical tool.

How to perform posterior wall isolation in catheter ablation for atrial fibrillation

Catheter ablation has become standard of care in patients with symptomatic atrial fibrillation (AF). Although there have been significant advances in our understanding and technology, a substantial proportion of patients have ongoing AF requiring repeat procedures. Pulmonary vein isolation (PVI) is the cornerstone of AF ablation; however, it is less effective in patients with persistent as opposed to paroxysmal atrial fibrillation. Left atrial posterior wall isolation (PWI) is commonly performed as an adjunct to PVI in patients with persistent AF with nonrandomized studies showing improved outcomes. Anatomical considerations and detailed outline of the various approaches and techniques to performing PWI are detailed, and advantages and pitfalls to assist the clinical electrophysiologist successfully and safely complete PWI are described.

Caffeine and Arrhythmias: Time to Grind the Data

The interaction between arrhythmia episodes and certain lifestyle factors such as obesity and alcohol is well established. There is significant public and professional interest in the role of caffeinated beverages such as coffee, tea, and energy drinks in cardiovascular health. However, many widely held beliefs are not supported by evidence. This study provides a comprehensive review of the impact of caffeinated beverages on cardiac rhythm.

Early Implantation of Primary Prevention Implantable Cardioverter Defibrillators for Patients with Newly Diagnosed Severe Nonischemic Cardiomyopathy

Primary prevention implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with severe systolic dysfunction. Current guidelines suggest a 3‐ to 6‐month waiting period before implantation.

Low Rates of Major Complications for Radiofrequency Ablation of Atrial Fibrillation Maintained Over 14 Years: A Single Centre Experience of 2750 Consecutive Cases

BACKGROUND Despite technological advances, studies continue to report high complication rates for atrial fibrillation (AF) ablation. We sought to review complication rates for AF ablation at a high-volume centre over a 14-year period and identify predictors of complications. METHODS We reviewed prospectively collected data from 2750 consecutive AF ablation procedures at our institution using radiofrequency energy (RF) between January 2004 and May 2017. All cases were performed under general anaesthetic with transoesophageal echocardiography (TEE), 3D-mapping and an irrigated ablation catheter. Double transseptal puncture was performed under TEE guidance. All patients underwent wide antral circumferential isolation of the pulmonary veins (30W anteriorly, 25W posteriorly) with substrate modification at operator discretion. RESULTS Of 2255 initial and 495 redo procedures, ablation strategies were: pulmonary vein isolation (PVI) only 2097 (76.3%), PVI+ LA lines 368 (13.4%), PVI+posterior wall 191 (6.9%), PVI+cavotricuspid isthmus 277 (10.1%). There were 23 major (0.84%) and 20 minor (0.73%) complications. Cardiac tamponade (five cases - 0.18%) and phrenic nerve palsy (one case - 0.04%) rates were very low. Major vascular complications necessitating surgery or blood transfusion occurred in five patients (0.18%). There were no cases of death, permanent disability, atrio-oesophageal fistulae or symptomatic pulmonary vein (PV) stenosis, although there were five TEE probe-related complications (0.18%). Female gender (OR 2.14; 95% CI 1.07-4.26) but not age >70 (OR 1.01) was the only multivariate predictor of complications. CONCLUSIONS Atrial fibrillation ablation performed at a high-volume centre using RF can be achieved with a low major complication rate in a representative AF population over a sustained period of time.

Effect of Dietary Factors on Cardiac Rhythm

The interaction between arrhythmias and certain lifestyle factors such as obesity and alcohol consumption is well-established. There is significant public and professional interest in the role of various diets, vitamins, and minerals in cardiovascular health. However, many widely held beliefs are not supported by the literature. There is limited evidence for routine magnesium and omega-3 poly-unsaturated fatty acids supplementation, while coffee, tea, nuts, antioxidant vitamins, and even chocolate may have some antiarrhythmic properties. Saturated fat, added salt, and excessive energy drink consumption appear to be harmful for patients with rhythm disorders. However most recommendations are based on observation studies, and this remains a fertile area for further research.

A comparison of the electrophysiologic and electroanatomic characteristics between the right and left atrium in persistent atrial fibrillation: Is the right atrium a window into the left?

The right atrium (RA) is readily accessible; however, it is unclear whether changes in the RA are representative of the LA. We performed detailed biatrial electroanatomic mapping to determine the electrophysiological relationship between the atria.