Jigar Patel

Focal impulse and rotor modulation ablation of sustaining rotors abruptly terminates persistent atrial fibrillation to sinus rhythm with elimination on follow-up: A video case study

Ablation of atrial fibrillation (AF) by using strategies that eliminate AF triggers via pulmonary vein (PV) isolation1 produces a single procedure success of 45%-65% at up to 1 year.2 Importantly, while it is known that PV ectopy may trigger AF, the mechanisms that actually sustain human AF after it has been triggered are unclear. There are 2 prevailing hypotheses. The multiwavelet hypothesis is based on evidence that complex activation in AF represents continuously meandering electrical waves,3 while the localized source hypothesis is based on experimental models in which rapidly activating reentrant circuits (rotors)4 or focal impulses5 cause disorganized AF. There has until now been indirect6 but little7,8 or no3 direct evidence to support sustaining rotors in human AF. We present a gentleman referred because of persistent AF despite prior left atrial radiofrequency Maze and endocardial ablation procedures. In the electrophysiological study, novel computational mapping developed in our laboratory revealed one AF rotor in the right atrium and another in the left atrium. Brief 3-5-minute ablation applications at each rotor (focal impulse and rotor modulation [FIRM]) abruptly terminated AF to sinus rhythm, with non-inducibility on aggressive testing and no AF recurrence by continuous ECG monitoring over 6 months. A video recording of the entire case is provided as an online supplement.

Percutaneous Stellate Ganglion Block Suppressing VT and VF in a Patient Refractory to VT Ablation

Electrical storm is a condition characterized by multiple episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) in a short period of time.

Obese female patients have higher rates of lead dislodgement after ICD or CRT-D implantation

☆ Hiro Kawata — Japanese Heart Rhythm Society (G Medwaves (Stock options), Perminova (Co-founder (Fellowship support), Boston Scientific (Fellowship supp port), Biotronic (Fellowship support), Biosense Webste Birgersdotter-Green — Medtronic (Grant Support/Researc (moderate), Boston Scientific (moderate). ☆☆ Presented in part at the American Heart Associatio November, 2012. ⁎ Corresponding author at: Sulpizio Cardiovascular Dr. La Jolla, CA 92037, United States.

Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction

AIMS After extraction of an infected cardiac implantable electronic device (CIED) in a pacemaker-dependent patient, a temporary pacemaker wire may be required for long periods during antibiotic treatment. Loss of capture and under sensing are commonly observed over time with temporary pacemaker wires, and patient mobility is restricted. The use of an externalized permanent active-fixation pacemaker lead connected to a permanent pacemaker generator for temporary pacing may be beneficial because of improved lead stability, and greater patient mobility and comfort. The aim of this study was to investigate the efficacy and safety of a temporary permanent pacemaker (TPPM) system in patients undergoing transvenous lead extraction due to CIED infection. METHODS AND RESULTS Of 47 patients who underwent lead extraction due to CIED infection over a 2-year period at our centre, 23 were pacemaker dependent and underwent TPPM implantation. A permanent pacemaker lead was implanted in the right ventricle via the internal jugular vein and connected to a TPPM generator, which was secured externally at the base of the neck. The TPPM was used for a mean of 19.4 ± 11.9 days (median 18 days, range 3-45 days), without loss of capture or sensing failure in any patient. Twelve of 23 patients were discharged home or to a nursing facility with the TPPM until completion of antibiotic treatment and re-implantation of a new permanent pacemaker. CONCLUSION External TPPMs are safe and effective in patients requiring long-term pacing after infected CIED removal.

Pocket infections of cardiac implantable electronic devices treated by negative pressure wound therapy.

AIMS Managing an infection of the pocket of a cardiac implantable electronic device (CIED) is frequently challenging. The wound is often treated with a drain or wet-to-dry dressings that allow healing by secondary intention. Such treatment can prolong the hospital stay and can frequently result in a disfiguring scar. Negative pressure wound therapy (NPWT) has been frequently used to promote the healing of chronic or infected surgical wounds. Here we describe the first series of 28 patients in which NPWT was successfully used to treat CIED pocket infections. METHODS AND RESULTS After removal of the CIED and debridement of the pocket, a negative pressure of 125 mmHg continuously applied to the wound through an occlusive dressing. Negative pressure wound therapy was continued for a median of 5 days (range 2-15 days) and drained an average of 260 mL sero-sanguineous fluid (range 35-970 mL). At the conclusion of NPWT, delayed primary closure of the pocket was performed with 1-0 prolene mattress sutures. The median length of stay after CIED extraction was 11.0 days (range 2-43 days). Virtually all infected pockets healed without complications and without evidence of recurrent infection over a median follow-up of 49 days (range 10-752 days). One patient developed a recurrent infection when NPWT was discontinued prematurely and a new device was implanted at the infected site. CONCLUSION We conclude that NPWT is a safe and effective means to promote healing of infected pockets with a low incidence of recurrent infection and a satisfactory cosmetic result.