David A. Cesario

Noise, artifact, and oversensing related inappropriate ICD shock evaluation: ALTITUDE noise study.

Background: Approximately 12–21% of implantable cardioverter defibrillator (ICD) patients receive inappropriate shocks. We sought to determine the incidence and causes of noise/artifact and oversensing (NAO) resulting in ICD shocks.

Ventricular Tachycardia in the Era of Ventricular Assist Devices

Ventricular Tachycardia in the Era of Ventricular Assist Devices.u2002 Sustained ventricular tachycardia (VT) in patients with advanced cardiomyopathy is a potentially life‐threatening arrhythmia. Newer treatment strategies have evolved that combine the use of catheter ablation to target the substrate for VT and ventricular assist devices (VADs) to hemodynamically support the failing ventricle. This editorial is targeted to the practicing clinician caring for these difficult patients. The current article reviews the use of percutaneous VADs to support catheter ablation of VT, the use of durable VADs to support the failing heart in patients with recurrent VT, ventricular arrhythmias in patients with durable VADs, and the use of catheter ablation to treat VT in patients with durable VADs. (J Cardiovasc Electrophysiol, Vol. 22, pp. 359‐363, March 2011)

Impact of shock energy and ventricular rhythm on the success of first shock therapy: The ALTITUDE first shock study

BACKGROUNDnThe efficacy of shock in converting different ventricular tachyarrhythmias has not been well characterized in a large natural-practice setting.nnnOBJECTIVEnTo determine shock success rate by energy and ventricular rhythm in a large cohort of patients with implantable cardioverter-defibrillators.nnnMETHODSnTwo thousand patients with 5279 shock episodes were randomly sampled for analysis from the LATITUDE remote monitoring system. Within an episode, the rhythm preceding therapy (shock or antitachycardia pacing [ATP]) was adjudicated. Patients who died after unsuccessful implantable cardioverter-defibrillator shocks did not transmit final remote monitoring data and were not included in the study.nnnRESULTSnOf 3677 shock episodes for ventricular tachyarrhythmia, 2679 were treated with shock initially and were classified as monomorphic ventricular tachycardia ( n = 1544), polymorphic/monomorphic ventricular tachycardia (n = 371), or ventricular fibrillation (n = 764). The success rate after the first, second, and final shock averaged 90.3%, 96.4%, and 99.8%, respectively. After unsuccessful initial ATP (n = 998), the first, second, and final shock was successful in 84.8%, 92.9%, and 100% of the episodes. The success rate after the first or second shock was significantly lower after failed ATP compared to shock as first therapy (both P<.001). Among episodes treated initially with shock, the success rate for monomorphic ventricular tachycardia (89.2%) when treated with energy level ≤ 20 J was significantly higher than that for ventricular fibrillation (80.8%) (P = .04). The level of shock energy was a significant predictor of the success of the first shock (odds ratio 1.16; 95% confidence interval 1.03-1.30; P = .013).nnnCONCLUSIONSnThe success rate of first shock as first therapy is approximately 90%, but was lower after failed ATP. Programming a higher level of energy after ATP is suggested.

Treatment of ventricular tachycardia in patients with heart failure.

Heart failure is a major public health concern that is frequently complicated by ventricular arrhythmias. Sustained ventricular tachycardia is associated with an increased risk for progressive heart failure and sudden death. We summarize the current management strategies for ventricular tachycardia in heart failure patients, including implantable cardioverter-defibrillator therapy, pharmacologic therapy, catheter ablation techniques, ventricular assist device therapy, and heart transplantation.

CT Imaging: Cardiac Electrophysiology Applications

An understanding of detailed 3-D cardiac anatomy is important to the field of cardiac electrophysiology. Cardiovascular computed tomographic angiography (CCTA) can comprehensively assess cardiovascular structure and function relevant to the assessment, treatment, and follow-up of patients with electrophysiologically-related disease processes. CCTA provides 3-D visualization of cardiac chambers, coronary vessels, and thoracic vasculature including structures particularly important to cardiac electrophysiology, such as the coronary veins, pulmonary veins, and left atrium. This comprehensive technology is extremely useful for the identification and characterization of cardiovascular substrates relevant to cardiac electrophysiology, and has great relevance to treatment of arrhythmias through preprocedure planning, procedural facilitation, and procedural follow-up.

Electrical dissociation within the left atrium and left atrial appendage diagnosed with transesophageal echocardiography.

The authors describe the case of a 79-year-old man with prior mitral valve repair and a maze procedure who developed recurrent atrial fibrillation, in whom transesophageal echocardiography revealed an accessory lobe of the left atrial appendage in sinus rhythm when the remaining body of the left atrial appendage was in atrial fibrillation or flutter. Electrophysiology confirmed dissociated rhythm within the left atrium. This case emphasizes the need for careful Doppler interrogation of the left atrial appendage and its lobes to look for dissociated atrial rhythm.

Intra-aortic balloon pump for hemodynamic support in hepatobiliary surgery: report of a case

The intra-aortic balloon pump (IABP) can be used transiently to improve cardiac function mechanically, in patients with severe cardiomyopathy and heart failure refractory to medical therapy. In the field of surgery, the IABP is most commonly used for patients with myocardial infarction, congestive heart failure, or other chronic cardiac conditions, who are undergoing cardiac surgery. Conversely, it is rarely used in hepatobiliary surgery, with only two reports found in the literature, excluding cases of emergency cholecystectomy. We describe how we used an IABP successfully during surgery to repair a transected bile duct in a patient with peripartum cardiomyopathy.

Impact of Relaxation Training on Patient-Perceived Measures of Anxiety, Pain, and Outcomes after Interventional Electrophysiology Procedures

Background: Electrophysiology procedures vary in invasiveness, duration, and anesthesia utilized. While complications are low and efficacy high, cases are elective and patient experiences related to anxiety, pain, and perceived outcomes are not well studied. We sought to determine if a 30‐minute audio compact disc (CD) that teaches relaxation techniques and wellness perception prior to an elective procedure impacts validated measures of anxiety, pain, and procedural outcomes.