Joshua M. Cooper

Lead Extraction in the Contemporary Setting: The LExICon Study. An Observational Retrospective Study of Consecutive Laser Lead Extractions

OBJECTIVES This study sought to examine the safety and efficacy of laser-assisted lead extraction and the indications, outcomes, and risk factors in a large series of consecutive patients. BACKGROUND The need for lead extraction has been increasing in direct relationship to the increased numbers of cardiovascular implantable electronic devices. METHODS Consecutive patients undergoing transvenous laser-assisted lead extraction at 13 centers were included. RESULTS Between January 2004 and December 2007, 1,449 consecutive patients underwent laser-assisted lead extraction of 2,405 leads (20 to 270 procedures/site). Median implantation duration was 82.1 months (0.4 to 356.8 months). Leads were completely removed 96.5% of the time, with a 97.7% clinical success rate whereby clinical goals associated with the indication for lead removal were achieved. Failure to achieve clinical success was associated with body mass index <25 kg/m(2) and low extraction volume centers. Procedural failure was higher in leads implanted for >10 years and when performed in low volume centers. Major adverse events in 20 patients were directly related to the procedure (1.4%) including 4 deaths (0.28%). Major adverse effects were associated with patients with a body mass index <25 kg/m(2). Overall all-cause in-hospital mortality was 1.86%; 4.3% when associated with endocarditis, 7.9% when associated with endocarditis and diabetes, and 12.4% when associated with endocarditis and creatinine > or =2.0. Indicators of all-cause in-hospital mortality were pocket infections, device-related endocarditis, diabetes, and creatinine > or =2.0. CONCLUSIONS Lead extraction employing laser sheaths is highly successful with a low procedural complication rate. Total mortality is substantially increased with pocket infections or device-related endocarditis, particularly in the setting of diabetes, renal insufficiency, or body mass index <25 kg/m(2). Centers with smaller case volumes tended to have a lower rate of successful extraction.

Electroanatomic Substrate and Ablation Outcome for Suspected Epicardial Ventricular Tachycardia in Left Ventricular Nonischemic Cardiomyopathy

OBJECTIVES The aim of the study was to define the epicardial substrate and ablation outcome in patients with left ventricular nonischemic cardiomyopathy (NICM) and suspected epicardial ventricular tachycardia (VT). BACKGROUND Ventricular tachycardia in NICM often originates from the epicardium. METHODS Twenty-two patients with NICM underwent detailed endocardial and epicardial bipolar voltage maps and VT ablation for suspected epicardial VT. Eight patients with normal hearts and idiopathic VT served to define normal epicardial electrograms. Low-voltage regions were also assessed for wide (>80 ms), split, or late electrograms. RESULTS Normal epicardial bipolar voltage was identified as >1.0 mV on the basis of the reference population. Confluent low-voltage areas were present in 18 epicardial (82%) and 12 endocardial (54%) maps and were typically over basal lateral LV. In the 18 patients with epicardial VT on the basis of activation/pacemapping, the mean epicardial area was greater than the endocardial low-voltage area (55.3 +/- 33.5 cm(2) vs. 22.9 +/- 32.4 cm(2), p < 0.01). Epicardial low-voltage areas showed 49.7% wide (>80 ms), split, and/or late electrograms rarely seen in the reference patients (2.3%). During follow-up of 18 +/- 7 months, ablation resulted in VT elimination in 15 of 21 patients (71%) including 14 of 18 patients (78%) with epicardial VT. CONCLUSIONS In patients with NICM and VT of epicardial origin, the substrate is characterized by areas of basal LV epicardial > endocardial bipolar low voltage. The electrograms in these areas are not only small (<1.0 mV) but wide (>80 ms), split, and/or late, and help identify the substrate targeted for successful ablation.

Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy

Background—Patients with nonischemic left ventricular cardiomyopathy (LVCM) and ventricular tachycardia (VT) have complex 3-dimensional substrate with variable involvement of the endocardium (ENDO) and epicardium (EPI). The purpose of this study was to determine whether ENDO unipolar (UNI) mapping with a larger electric field of view could identify EPI low bipolar (BIP) voltage regions in patients with LVCM undergoing VT ablation. Methods and Results—The reference value for normal ENDO unipolar voltage was determined from 6 patients without structural heart disease. Consecutive patients undergoing VT ablation over an 8-year period with detailed (>100 points) LV ENDO and EPI mapping and normal LV ENDO BIP voltage were identified. From this cohort, we compared patients with structurally normal hearts and normal EPI BIP voltage (EPI−, group 1) with patients with LVCM and low LV EPI BIP voltage regions present (EPI+, group 2). Confluent regions of ENDO UNI and EPI BIP low voltage (>2 cm2) were measured. The normal signal amplitude was >8.27 mV for LV ENDO UNI electrograms. Detailed LV ENDO-EPI maps in 5 EPI− patients were compared with 11 EPI+ patients. Confluent ENDO UNI low-voltage regions were seen in 9 of 11 (82%) of the EPI+ (group 2) patients compared with none of 5 EPI− (group 1) patients (P<0.001). In all 9 patients with ENDO UNI low voltage, the ENDO UNI low-voltage regions were directly opposite to an area of EPI BIP low voltage (61% ENDO UNI-EPI BIP low-voltage area overlap). Conclusions—EPI arrhythmia substrate can be reliably identified in most patients with LVCM using ENDO UNI voltage mapping in the absence of ENDO BIP abnormalities.

Long-Term Outcome After Successful Catheter Ablation of Atrial Fibrillation

Background—Pulmonary vein isolation (PVI) is increasingly used for treatment of atrial fibrillation (AF), but few reports exist regarding long-term success. We determined 5-year outcomes of PVI among patients with freedom from AF off antiarrhythmic drugs (AAD) for 1 year after PVI. Methods and Results—Consecutive patients with paroxysmal or persistent AF who underwent PVI at the University of Pennsylvania from 2000 to 2003 and were free from AF 1 year after ablation were included. Proximal isolation of PVs and non-PV triggers of AF was performed. Long-term ablation success, defined as freedom from AF off AAD after a single ablation procedure, was determined. All patients had transtelephonic monitoring at 3 to 6 months and 12 months and at least yearly contact thereafter. One hundred twenty-three patients were free of AF without AAD at 1 year. AF freedom off AAD was 85% at 3 years and 71% at 5 years, with an approximate 7% per year late recurrence rate after the first year. Patients with recurrent AF ≥5 years after index PVI were older, had larger left atrial size, more AF triggers and more likely had persistent AF. In multivariate analysis, persistent AF (odds ratio, 2.8; 95% confidence interval, 1.4 to 5.7, P=0.005) and age (odds ratio, 1.1; 95% confidence interval, 1.0 to 1.1, P=0.036) independently predicted long-term AF recurrence. Conclusions—Among patients with paroxysmal or persistent AF and AF freedom 1 year after segmental PVI, the majority (71%) remained free of AF for up to 5 years, with an approximate late recurrence rate of 7% per year. Continued vigilance for recurrent AF after PV isolation is warranted, particularly in patients with persistent AF.

Long‐Term Clinical Efficacy and Risk of Catheter Ablation for Atrial Fibrillation in the Elderly

Introduction: The number of elderly patients with atrial fibrillation (AF) is increasing rapidly, and the safety and efficacy of catheter ablation in this demographic group has not been established.

The V2 Transition Ratio: A New Electrocardiographic Criterion for Distinguishing Left From Right Ventricular Outflow Tract Tachycardia Origin

2011;57;2255-2262 J. Am. Coll. Cardiol. David Lin, Michael P. Riley, and Edward P. Gerstenfeld Fermin C. Garcia, Sanjay Dixit, David J. Callans, Joshua M. Cooper, Rupa Bala, Brian P. Betensky, Robert E. Park, Francis E. Marchlinski, Matthew D. Hutchinson, Origin Distinguishing Left From Right Ventricular Outflow Tract Tachycardia Transition Ratio: A New Electrocardiographic Criterion for 2 The V This information is current as of May 29, 2011 http://content.onlinejacc.org/cgi/content/full/57/22/2255 located on the World Wide Web at: The online version of this article, along with updated information and services, isOBJECTIVES We sought to develop electrocardiography (ECG) criteria for distinguishing left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in patients with idiopathic outflow tract ventricular tachycardia (OTVT) and lead V(3) R/S transition. BACKGROUND Several ECG criteria have been proposed for differentiating left from right OTVT origin; ventricular tachycardias (VTs) with left bundle branch block and V(3) transition remain a challenge. METHODS We analyzed the surface ECG pattern of patients with OTVT with a precordial transition in lead V(3) who underwent successful catheter ablation. Sinus and VT QRS morphologies were measured in limb and precordial leads with electronic calipers. The V(2) and V(3) transition ratios were calculated by computing the percentage R-wave during VT (R/R+S)(VT) divided by the percentage R-wave in sinus rhythm (R/R+S)(SR). RESULTS We retrospectively analyzed ECGs from 40 patients (mean age 44 ± 14 years, 21 female) with outflow tract premature ventricular contractions (PVCs)/VT. Patients with structural heart disease, paced rhythms, and bundle branch block during sinus rhythm were excluded. The V(2) transition ratio was significantly greater for LVOT PVCs compared with RVOT PVCs (1.27 ± 0.60 vs. 0.23 ± 0.16; p < 0.001) and was the only independent predictor of LVOT origin. In 21 prospective cases, a V(2) transition ratio ≥0.60 predicted an LVOT origin with 91% accuracy. A PVC precordial transition occurring later than the sinus rhythm transition excluded an LVOT origin with 100% accuracy. CONCLUSIONS The V(2) transition ratio is a novel electrocardiographic measure that reliably distinguishes LVOT from RVOT origin in patients with lead V(3) precordial transition. This measure might be useful for counseling patients and planning an ablation strategy.

Clinical ResearchHeart Rhythm DisorderThe V2 Transition Ratio: A New Electrocardiographic Criterion for Distinguishing Left From Right Ventricular Outflow Tract Tachycardia Origin

2011;57;2255-2262 J. Am. Coll. Cardiol. David Lin, Michael P. Riley, and Edward P. Gerstenfeld Fermin C. Garcia, Sanjay Dixit, David J. Callans, Joshua M. Cooper, Rupa Bala, Brian P. Betensky, Robert E. Park, Francis E. Marchlinski, Matthew D. Hutchinson, Origin Distinguishing Left From Right Ventricular Outflow Tract Tachycardia Transition Ratio: A New Electrocardiographic Criterion for 2 The V This information is current as of May 29, 2011 http://content.onlinejacc.org/cgi/content/full/57/22/2255 located on the World Wide Web at: The online version of this article, along with updated information and services, isOBJECTIVES We sought to develop electrocardiography (ECG) criteria for distinguishing left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in patients with idiopathic outflow tract ventricular tachycardia (OTVT) and lead V(3) R/S transition. BACKGROUND Several ECG criteria have been proposed for differentiating left from right OTVT origin; ventricular tachycardias (VTs) with left bundle branch block and V(3) transition remain a challenge. METHODS We analyzed the surface ECG pattern of patients with OTVT with a precordial transition in lead V(3) who underwent successful catheter ablation. Sinus and VT QRS morphologies were measured in limb and precordial leads with electronic calipers. The V(2) and V(3) transition ratios were calculated by computing the percentage R-wave during VT (R/R+S)(VT) divided by the percentage R-wave in sinus rhythm (R/R+S)(SR). RESULTS We retrospectively analyzed ECGs from 40 patients (mean age 44 ± 14 years, 21 female) with outflow tract premature ventricular contractions (PVCs)/VT. Patients with structural heart disease, paced rhythms, and bundle branch block during sinus rhythm were excluded. The V(2) transition ratio was significantly greater for LVOT PVCs compared with RVOT PVCs (1.27 ± 0.60 vs. 0.23 ± 0.16; p < 0.001) and was the only independent predictor of LVOT origin. In 21 prospective cases, a V(2) transition ratio ≥0.60 predicted an LVOT origin with 91% accuracy. A PVC precordial transition occurring later than the sinus rhythm transition excluded an LVOT origin with 100% accuracy. CONCLUSIONS The V(2) transition ratio is a novel electrocardiographic measure that reliably distinguishes LVOT from RVOT origin in patients with lead V(3) precordial transition. This measure might be useful for counseling patients and planning an ablation strategy.

Incidence and Predictors of Very Late Recurrence of Atrial Fibrillation After Ablation

Introduction: Radiofrequency catheter ablation can effectively treat patients with refractory atrial fibrillation (AF). Very late AF recurrence (≥12 months post‐ablation) is uncommon and may represent a unique patient cohort.

Single procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: A prospective randomized study

BACKGROUND Current atrial fibrillation (AF) ablation involves isolation of all pulmonary veins (PVs) with or without additional linear lesions. However, whether such extensive ablation is necessary is unclear. OBJECTIVE The purpose of this study was to assess the efficacy of different ablation strategies on long-term AF control. METHODS We prospectively randomized patients to undergo isolation of all versus arrhythmogenic PVs (identified by standardized stimulation protocol). PV isolation was guided by circular mapping catheter. The endpoint was entry/exit block persisting for > or = 20 minutes. Patients were evaluated at three clinic visits (at 6 weeks, 6 months, and 1 year) and multiple transtelephonic monitoring periods. Antiarrhythmic drugs were discontinued at 6 weeks. Primary study endpoint was long-term AF control (freedom or >90% reduction in AF burden off or on previously ineffective antiarrhythmic drugs at 1 year after a single ablation procedure). RESULTS Over a 20-month period, 105 patients (76 men and 29 women, age 57 +/- 9 years; paroxysmal AF = 77) were randomized, and 103 patients completed 1-year follow-up (51 patients in all-PV arm, 52 patients in arrhythmogenic PV arm). The primary endpoint was achieved in 75 (73%) patients and was similar in patients randomized to all-PV arm versus arrhythmogenic PV arm [38 (75%) patients vs 37 (71%) patients, respectively; odds ratio 1.18, 95% confidence interval 0.50, 2.83, P = .70]. Secondary study endpoints, including freedom from AF off antiarrhythmic drugs, total procedure/fluoroscopy times, and occurrence of serious adverse events, were not different between the two groups. CONCLUSION In a randomized comparison, isolation of arrhythmogenic veins was as efficacious as empiric isolation of all veins in achieving long-term AF control.

Reversal of outflow tract ventricular premature depolarization–induced cardiomyopathy with ablation: Effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome

BACKGROUND Outflow tract ventricular premature depolarizations (VPDs) can be associated with reversible left ventricular cardiomyopathy (LVCM). Limited data exist regarding the outcome after ablation of outflow tract VPDs from the LV and the impact of residual VPDs or preexisting LVCM prior to the diagnosis of VPDs on recovery of LV function. OBJECTIVE To examine the safety, efficacy, and long-term effect of radiofrequency ablation on LV function in patients with LVCM and frequent outflow tract VPDs and examine the effect of ablation in patients with LVCM known to precede the onset of VPDs and the impact of residual VPD frequency on recovery of LV function. METHODS Sixty-nine patients (43 men; age 51 ± 16 years) with nonischemic LVCM (left ventricular ejection fraction [LVEF] 35% ± 9%, left ventricular diastolic diameter [LVDD] 5.8 ± 0.7 cm) were referred for ablation of frequent outflow tract VPDs (29% ± 13%). RESULTS VPDs originated in the right ventricular outflow tract in 27 (39%) patients and the left ventricular outflow tract in 42 (61%) patients. After follow-up of 11 ± 6 months, 44 (66%) patients had rare (<2%) VPDs, 15 (22%) had decreased VPD burden (>80% reduction and always <5000 VPDs), and 8 (12%) had no clinical improvement with persistent (5 patients) or recurrent (3 patients) VPDs. Only patients with either rare or decreased VPD burden had a significant improvement in LVEF (ΔLVEF 14% ± 9% vs 13% ± 7% vs -3% ± 6%, respectively, P <.001) and LVDD (ΔLVDD -4 ± 5 vs -2 ± 4 vs 0 ± 4, respectively, P = .038), regardless of chamber of origin. The magnitude of LVEF improvement correlated with the decline in residual VPD burden (r = 0.475, P = .007). Patients with preexisting LVCM had a more modest but still significant improvement in LV function compared to patients without preexisting LVCM (ΔLVEF 8% vs 13%, P = .046). Multivariate analysis revealed ablation outcome, higher LVEF, and absence of preexisting LVCM were independently associated with LVEF improvement. CONCLUSION Frequent outflow tract VPDs are associated with LVCM regardless of ventricle of origin. Significant (>80%) reduction in VPD burden has comparable improvement in LV function to complete VPD elimination. Successful VPD ablation may be beneficial even in patients with preexisting LVCM.