Edwin Kevin Heist

Three‐Dimensional Anatomy of the Left Atrium by Magnetic Resonance Angiography: Implications for Catheter Ablation for Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) has become one of the primary treatments for symptomatic drug‐refractory atrial fibrillation (AF). During this procedure, delivery of ablation lesions to certain regions of the left atrium can be technically challenging. Among the most challenging regions are the ridges separating the left pulmonary veins (LPV) from the left atrial appendage (LAA), and the right middle pulmonary vein (RMPV) from the right superior (RSPV) and right inferior (RIPV) pulmonary veins. A detailed anatomical characterization of these regions has not been previously reported.

Complications from catheter ablation of atrial fibrillation: a systematic review.

Atrial fibrillation (AF) is the most common arrhythmia requiring treatment that is encountered in clinical practice. Recent advances in the understanding of underlying mechanisms of AF have led to the increased use of catheter ablation (CA) as a treatment modality for paroxysmal, persistent, or long-standing persistent AF in patients with symptomatic AF despite treatment with antiarrhythmic medications. Because of the complexity in technique and anatomic location of the ablation sites, it is not surprising that CA of AF is associated with a greater risk of procedural complications compared with simpler cardiac ablation procedures. Major and minor complications, including life-threatening complications, have been described and quantified. This systematic review describes the potential risks of CA that have been reported over a period and provides insights into the evolving strategies to minimize these complications, thus making CA techniques safer and potentially more efficacious for AF.

Incidence and Predictors of Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment for patients with symptomatic aortic stenosis who are at high risk for surgical aortic valve replacement. The development of conduction abnormalities is a major complication in the postprocedural period of TAVR.

Stress cardiomyopathy: diagnosis, pathophysiology, management, and prognosis.

Stress cardiomyopathy is now a well-recognized reversible cardiomyopathy, with a clinical presentation mimicking Acute Coronary syndrome in the absence of significant coronary artery disease. It is often encountered in postmenopausal females and is usually precipitated by acute emotional or physical stressors. In this review, we have attempted to summarize relevant data regarding diagnosis, typical and atypical presentations, pathophysiology, management options, and prognosis. Typically, patients present with chest pain and shortness of breath, transient electrocardiographic changes, moderate troponin elevation, and are found to have wall motion abnormalities (apical and midventricular akinesis with preserved basal segment systolic function) without obstructive coronary lesions, with complete resolution in next few weeks. The precise pathophysiology remains unclear, but excessive catecholamine stimulation, metabolic disturbances, and dysfunction of microcirculation are thought to be the underlying mechanisms.

Inpatient vs. elective outpatient cardiac resynchronization therapy device implantation and long-term clinical outcome

AIMS It remains unclear whether cardiac resynchronization therapy (CRT) device implantation during inpatient (IP) hospitalization affords the same benefit as elective outpatient (OP) implantation. We hypothesized that IPs undergoing CRT device implantation during acute hospitalization may have worse outcomes compared with elective OP implantation. METHODS AND RESULTS We retrospectively separated patients undergoing CRT implants at Massachusetts General Hospital into OP (n= 196) and IP (n = 105) cohorts. Long-term outcomes, measured as heart failure (HF) hospitalization, all-cause mortality, ventricular assist device placement, or heart transplant over a 2-year follow-up period, were estimated by the Kaplan-Meier method. Propensity scores were generated to balance the baseline co-morbidities between IP and OP. Baseline age, gender, left ventricular ejection fraction, and aetiology of cardiomyopathy were comparable between OP and IP (66.8 ± 11.8 vs. 67.5 ± 13.4 years, 78 vs. 84% males, 24 vs. 23%, and 39 vs. 50% ischaemic, P = NS). Inpatients had greater burden of diabetes mellitus (40 vs. 27%, P = 0.028), renal insufficiency (47 vs. 25%, P< 0.001), and right ventricular dysfunction (54 vs. 39%, P = 0.026) compared with OPs. At 2-year follow-up, IP implant was associated with greater risk of HF hospitalization (HR 1.6, 95% CI 1.03-2.48, P = 0.038) compared with elective OP implants. After propensity score adjustment, there was no statistically significant difference in HF hospitalization between the IP and OP groups (HR 1.031, 95% CI 0.61-1.78, P = 0.91). CONCLUSION Compared with OP CRT implants, IPs are at increased risk for recurrent HF hospitalization; however, the increased risk is attributable to greater co-morbidities in the IP population.

Diagnostic Accuracy of a Novel Mobile Phone Application for the Detection and Monitoring of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, associated with significant morbidity, increased mortality, and rising health-care costs. Simple and available tools for the accurate detection of arrhythmia recurrence in patients after electrical cardioversion (CV) or ablation procedures for AF can help to guide therapeutic decisions. We conducted a prospective, single-center study to evaluate the accuracy of Cardiio Rhythm Mobile Application (CRMA) for AF detection. Patients >18 years of age who were scheduled for elective CV for AF were enrolled in the study. CRMA finger pulse recordings, utilizing an iPhone camera, were obtained before (pre-CV) and after (post-CV) the CV. The findings were validated against surface electrocardiograms. Ninety-eight patients (75.5% men), mean age of 67.7 ± 10.5 years, were enrolled. No electrocardiogram for validation was available in 1 case. Pre-CV CRMA readings were analyzed in 97 of the 98 patients. Post-CV CRMA readings were analyzed for 92 of 93 patients who underwent CV. One patient left before the recording was obtained. The Cardiio Rhythm Mobile Application correctly identified 94 of 101 AF recordings (93.1%) as AF and 80 of 88 non-AF recordings (90.1%) as non-AF. The sensitivity was 93.1% (95% confidence interval [CI] = 86.9% to 97.2%) and the specificity was 90.9% (95% CI = 82.9% to 96.0%). The positive predictive value was 92.2% (95% CI = 85.8% to 95.8%) and the negative predictive value was 92.0% (95% CI = 94.8% to 95.9%). In conclusion, the CRMA demonstrates promising potential in accurate detection and discrimination of AF from normal sinus rhythm in patients with a history of AF.

Does Prior Valve Surgery Change Outcome in Patients Treated with Cardiac Resynchronization Therapy

Cardiac valve surgery (CVS) has been implicated as a potential barrier to optimal response after cardiac resynchronization therapy (CRT) though prospective data regarding outcome remains limited. We sought to determine CRT response in patients with a prior history of CVS.

Esophageal temperature monitoring during AF ablation: multi-sensor or single-sensor probe? Response to letter to the editor.

Thank you for giving us the opportunity to respond to Dr. Feld’s valid concerns.1 As stated in the article, the ablation strategy was altered when heating was encountered along the posterior wall.2 Specifically, in addition to limiting power to 25 Watts and duration to 30 seconds, the catheter was moved away from the esophagus along with a further decrease in power and/or duration of ablation lesions. We believe the need to move further away from the esophagus given the increased temperature rises may have contributed the increased ablation time in the multisensor probe group. Although it is reasonable to assume that increased ablation time would lead to more injury, this was not found in 2 prior studies investigating patient and procedural characteristics between those with esophageal injury and those without.3,4 Furthermore, as shown in Table 3 of our article, there was no significant difference in total energy applied in those with injury and those without injury among those who had an esophageal endoscopy (EGD) performed in either temperature probe cohort. Feld et al. also raise concerns regarding the introduction of selection bias because EGDs were only performed on patients with a temperature rise ≥39 ◦C. We too raised this as a limitation of our study in the article. This critique is based on the belief that the multisensor probe has greater sensitivity; however, that assumes the multisensor probe itself did not play any role in the development of increased temperature rises within the esophagus and potential injury. Our study did not evaluate the sensitivity of the temperature probes to detect injury as EGDs were not performed in all patients; therefore, it cannot be assumed the multisensor probe is more sensitive. In our article, we compared the percentage of esophageal injury in only those with EGDs performed rather than comparing the percentage of injury within the respective cohorts as a whole. There is the potential that some injury was missed; however, it is impossible to know if a higher percentage of lesions would have been found in those without a temperature rise in the single-sensor group versus the multisensor group. We agree with Feld et al. that the multisensor probe is usually enface fluoroscopically rather than in an anteroposterior configuration. However, we disagree that only an anteroposterior configuration is necessary to affect the relationship between the esophagus and the left atrium (LA). The multisensor probe is of much greater width (18 mm vs 3 mm). The esophagus is mobile and can change configuration throughout the procedure, which may be a protective mechanism.5 We hypothesize that the greater width of the multisensor probe may create a more persistent increase in contact surface area of LA to esophagus. We did not study the difference in material or design of the probes themselves, as was studied by Deneke et al. with a different catheter

Three-Dimensional Cardiac Mapping Characterizes Ventricular Contractile Patterns during Cardiac Resynchronization Therapy Implant: A Feasibility Study

Electroanatomic mapping systems track the position of electrodes in the heart. We assessed the feasibility of characterizing left ventricular (LV) performance during cardiac resynchronization therapy (CRT) implant utilizing an electroanatomic mapping system to track the motion of CRT lead electrodes, thus deriving ventricular contractility surrogates.