Jason Payne

Initial Experience of Sequential Surgical Epicardial-Catheter Endocardial Ablation for Persistent and Long-Standing Persistent Atrial Fibrillation With Long-Term Follow-Up

BACKGROUNDnPatients with long-standing persistent (LSP) atrial fibrillation (AF) who have previously undergone catheter ablation represent a challenging patient population. Repeat catheter ablation in these patients is arduous and associated with a high failure rate, whereas surgical ablation can be complicated by multiple flutters. We sought to determine if minimally-invasive surgical ablation, followed by catheter ablation of all inducible flutters, would improve success rates over repeat catheter ablation alone.nnnMETHODSnFifteen patients (Sequential) with persistent or LSP AF who failed at least one catheter ablation and one anti-arrhythmic drug (AAD) underwent surgical ablation, followed by planned endocardial evaluation and catheter mapping with ablation during the same hospitalization. Sequential patients were matched to 30 patients who had previously failed at least one catheter ablation and underwent a repeat catheter ablation (catheter-alone). The primary end point was event-free survival of any documented AF recurrence or AAD use.nnnRESULTSnAll patients underwent uncomplicated surgical ablation and electrophysiology procedure. Five Sequential patients had seven inducible flutters that were mapped and ablated. After a mean follow-up of 20.7±4.5 months, 13/15 (86.7%) Sequential patients, but only 16/30 (53.3%) catheter-alone patients, were free of any atrial arrhythmia and off of AAD (p=0.04). On AAD, 14/15 (93.3%) Sequential patients were free of any atrial arrhythmia recurrence, compared to 17/30 (56.7%) catheter-alone patients (p=0.01).nnnCONCLUSIONSnFor patients with atrial fibrillation who have failed catheter ablation, Sequential minimally invasive epicardial surgical ablation, followed by endocardial catheter-based ablation, has a higher early success rate than repeat catheter ablation alone.

Long-Term Prognosis of Deferred Acute Coronary Syndrome Lesions Based on Nonischemic Fractional Flow Reserve

BACKGROUNDnDeferring percutaneous coronary intervention in nonischemic lesions by fractional flow reserve (FFR) is associated with excellent long-term prognosis in patients with stable ischemic heart disease (SIHD). Although FFR is increasingly used for clinical decision making in acute coronary syndrome (ACS) patients with intermediate lesions, its effect on long-term prognosis has not been well established.nnnOBJECTIVESnThis study investigated the clinical and prognostic utility of FFR in ACS patients with percutaneous coronary intervention deferred on the basis of nonischemic FFR.nnnMETHODSnWe studied 206 consecutive ACS patients with 262 intermediate lesions and 370 patients with SIHD (528 lesions) in whom revascularization was deferred on the basis of a nonischemic FFR (>0.75). The primary outcome measure was a composite of myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]).nnnRESULTSnIn the entire cohort, the long-term (3.4 ± 1.6 years) MACE rate was higher in the ACS group than in the SIHD group (23% vs. 11%, pxa0< 0.0001). After propensity score matching (200 patients/group), MACE remained significantly higher (ACS 25% vs. SIHD 12%; pxa0< 0.0001). On Cox proportional hazards analysis for MACE, ACS had a hazard ratio of 2.8 (95% confidence interval: 1.9 to 4.0; pxa0< 0.0001). In both the matched and unmatched cohorts, across all FFR categories, ACS patients had a significantly higher annualized myocardial infarction/target vessel revascularization rate compared with SIHD (pxa0< 0.05). Receiver-operating characteristic analysis identified FFR cutoffs (best predictive accuracy for MACE) ofxa0<0.84 for ACS (MACE 21% vs. 36%; pxa0= 0.007) andxa0<0.81 for SIHD (MACE 17% vs. 9%; pxa0= 0.01).nnnCONCLUSIONSnDeferring percutaneous coronary intervention on the basis of nonischemic FFR in patients with an initial presentation of ACS is associated with significantly worse outcomes than SIHD. Caution is warranted in using FFR values derived from patients with SIHD for clinical decision making in ACS patients.

Uninterrupted New Oral Anticoagulants Compared With Uninterrupted Vitamin K Antagonists in Ablation of Atrial Fibrillation: A Meta-analysis

BACKGROUNDnUse of uninterrupted vitamin K antagonists (VKAs) during ablation of atrial fibrillation is superior to bridging with heparin. Few studies evaluated the use of uninterrupted new oral anticoagulants (NOACs) during ablation of atrial fibrillation. These studies are relatively small in size and mostly underpowered to show differences in the infrequent thromboembolic complications between comparators.nnnMETHODSnWe performed the first meta-analysis of uninterrupted NOAC compared with uninterrupted VKA in ablation of atrial fibrillation. We searched the online databases until May 2015 and report outcomes of interest as odds ratios (ORs) using a random effects model. A total of 3544 atrial fibrillation patients in 8 studies who underwent catheter ablation were included in this analysis.nnnRESULTSnOverall, stroke and/or transient ischemic attack events were of very low incidence with uninterrupted anticoagulation strategy in 6 of 3544. There were no differences in rates of stroke and/or transient ischemic attack between uninterrupted NOAC and uninterrupted VKA, 0.11% vs 0.22% (OR, 0.65; 95% confidence interval [CI], 0.14-2.96; Pxa0= 0.58), nor in major bleeding 0.9% vs 1% (OR, 0.94; 95% CI, 0.48-1.87; Pxa0= 0.87). All bleeding 6.5% vs 7.3% (OR, 0.93; 95% CI, 0.67-1.29; Pxa0= 0.65), minor bleeding 6.3% vs 7.1% (OR, 0.93; 95% CI, 0.67-1.28), and cardiac tamponade 0.6% vs 0.6% (OR, 1.0; 95% CI, 0.43-2.31; Pxa0= 1.0) were all equal with uninterrupted NOACs compared with uninterrupted VKAs. Among 3544 patients, only one death occurred in the VKA group.nnnCONCLUSIONSnUse of uninterrupted NOACs in ablation appears to be as safe and efficacious as use of uninterrupted VKAs.

Association of echocardiographic abnormalities with mortality in men with non-dialysis-dependent chronic kidney disease

BACKGROUNDnThe interrelationship of left ventricular hypertrophy (LVH) with ejection fraction (EF) and their impact on mortality in non-dialysis-dependent chronic kidney disease (NDD-CKD) is unclear.nnnMETHODSnWe examined the associations of EF and LVH with all-cause mortality in a historic cohort of 650 male US veterans with moderate-to-advanced NDD-CKD. EF and LVH were examined both separately and after categorizing patients according to their concomitant EF and presence/absence of LVH. Associations with mortality were examined in Cox models with adjustments for demographics, blood pressure, comorbidities, smoking status, medication use and biochemical characteristics.nnnRESULTSnEF <30 and 30-50% were associated with higher all-cause mortality compared to EF >50% even after multivariable adjustments [multivariable adjusted hazard ratio, 95% confidence interval (CI): 2.83 (1.86-4.30) and 1.38 (1.06-1.78), P < 0.001 for linear trend]. LVH in itself was not associated with mortality [multivariable adjusted hazard ratio, 95% CI: 0.83 (0.66-1.05), P = 0.12], but the presence of LVH combined with an EF <50% was associated with the highest mortality [multivariable adjusted hazard ratios, 95% CI in patients with EF >50% + LVH, EF ≤ 50%-LVH and EF ≤ 50% + LVH, compared to EF >50%-LVH: 0.84 (0.63-1.13), 1.36 (1.00-1.83) and 1.62 (1.07-2.46)].nnnCONCLUSIONSnLow EF is associated with higher mortality in patients with NDD-CKD. In the presence of a low EF, LVH is also associated with higher mortality. Clinical trials are needed to determine if interventions targeting patients with low EF and LVH can lower mortality in NDD-CKD.

Near-zero fluoroscopy implantation of dual-chamber pacemaker in pregnancy using electroanatomic mapping

Background: Complete Heart Block (CHB) is uncommon in pregnancy and challenging to manage due to risks of radiation to the fetus.nnMethods: A 27-year-old with known 1st degree AV block at 11 weeks gestational age presents with a 5-week history of fatigue, dizziness, and severe dyspnea. BP was 110/60

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

Author Correction to: Dynamic Scheduling for Veterans Health Administration Patients Using Geospatial Dynamic Overbooking

The original version of this article unfortunately contained a mistake. The name of Matthew Gerber was incorrectly spelled as Mathew Gerber. The correct spelling is now presented correctly in this correction article.

Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; pu202f=u202f0.12), diabetes (41% vs 50%; pu202f=u202f0.35), or hypertension (94% vs 97%; pu202f=u202f0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank pu202f=u202f0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; pu202f=u202f0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; pu202f=u202f0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

OUTCOMES OF FRACTIONAL FLOW RESERVE BASED DEFERRAL IN SAPHENOUS VEIN GRAFT LESIONS

Background: Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries. Howerver, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the

DOES POST PCI FFR CARRY THE SAME PROGNOSTIC WEIGHT AS NON-ISCHEMIC FFR IN DEFERRED LESIONS?

Background: Deferring PCI based on a non-ischemic FFR has been well established. Growing evidence suggests an increasingly important role of post-PCI FFR in outcome prediction. Whether the FFR value post-PCI contains the same prognostic weight as FFR in deferred lesions is not known.nnMethods: Major