Julie B. Shea

Alterations of heart rate and of heart rate variability after radiofrequency catheter ablation of supraventricular tachycardia. Delineation of parasympathetic pathways in the human heart.

BackgroundPersistent inappropriate sinus tachycardia has been reported as a complication after radiofrequency (RF) ablation of the fast atrioventricular (AV) nodal pathway. The purpose of this study was to evaluate the prevalence of this complication and its mechanism using heart rate variability analysis. Methods and ResultsTime and frequency domain analysis of heart rate was performed in the electrophysiology laboratory immediately before and immediately after RF ablation in 64 patients with supraventricular tachycardia. Ablation targets in these 64 patients included the fast AV nodal pathway (n=3), the slow AV nodal pathway (n=14), a posteroseptal accessory pathway (n=23), and a left lateral accessory pathway (n=24). A control group of 21 patients undergoing diagnostic study but not ablation underwent identical analysis immediately before and at the conclusion of their procedure. Patients undergoing ablation also had time and frequency domain analysis performed on ambulatory 24-hour Holter tapes recorded before ablation and at 1 day, 1 month, and 6 months after ablation. Compared with preablation values, time domain analysis immediately after ablation revealed a significant increase in mean heart rate and significant reductions in heart rate variability expressed as SD, MSSD, and PNN5O in patients undergoing AV nodal modification or posteroseptal accessory pathway ablation. Frequency domain analysis revealed marked attenuation of high frequency (0.15 to 0.40 Hz) components, indicating parasympathetic denervation. These acute changes were not seen after ablation of left lateral accessory pathways or after diagnostic study without ablation. Time and frequency domain analysis of 24-hour ambulatory Holter monitors performed serially after ablation revealed resolution of abnormalities of heart rate and of heart rate variability 1 to 6 months after ablation, with reappearance of the high frequency parasympathetic component suggestive of reinnervation. ConclusionsRF ablation in the anterior, mid, and posterior regions of the low interatrial septum may disrupt preganglionic or postganglionic parasympathetic fibers located in these regions that are destined to innervate the sinus node. Such fibers become more scarce along the left AV groove with increasing distance from the posteroseptal space. Parasympathetic denervation may be one mechanism for persistent inappropriate sinus tachycardia after RF ablation.

HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices

DavidSlotwiner,MD, FHRS, FACC(Chair),Niraj Varma,MD,PhD, FRCP(Co-chair), JosephG.Akar,MD,PhD, George Annas, JD, MPH, Marianne Beardsall, MN/NP, CCDS, FHRS, Richard I. Fogel, MD, FHRS, Nestor O. Galizio, MD, Taya V. Glotzer, MD, FHRS, FACC, Robin A. Leahy, RN, BSN, CCDS, FHRS, Charles J. Love, MD, CCDS, FHRS, FACC, FAHA, Rhondalyn C. McLean, MD, Suneet Mittal, MD, FHRS, Loredana Morichelli, RN, MSN, Kristen K. Patton, MD, Merritt H. Raitt, MD, FHRS, Renato Pietro Ricci, MD, John Rickard, MD, MPH, Mark H. Schoenfeld, MD, CCDS, FHRS, FACC, FAHA, Gerald A. Serwer, MD, FHRS, FACC, Julie Shea, MS, RNCS, FHRS, CCDS, Paul Varosy, MD, FHRS, FACC, FAHA, Atul Verma, MD, FHRS, FRCPC, Cheuk-Man Yu, MD, FACC, FRCP, FRACP From the Hofstra School of Medicine, North Shore Long Island Jewish Health System, New Hyde Park, New York, Cleveland Clinic, Cleveland, Ohio, Yale University School of Medicine, New Haven, Connecticut, Boston University School of Public Health, Boston, Massachusetts, Southlake Regional Health Centre, Newmarket, Ontario, Canada, St. Vincent Medical Group, Indianapolis, Indiana, Favaloro Foundation University Hospital, Buenos Aires, Argentina, Hackensack University Medical Center, Hackensack, New Jersey, Sanger Heart & Vascular Institute, Carolinas HealthCare System, Charlotte, North Carolina, New York University Langone Medical Center, New York City, New York, University of Pennsylvania Health System, Philadelphia, Pennsylvania, The Arrhythmia Institute at Valley Hospital, New York, New York, Department of Cardiovascular Diseases, San Filippo Neri Hospital, Rome, Italy, University of Washington, Seattle, Washington, VA Portland Health Care System, Oregon Health & Science University, Knight Cardiovascular Institute, Portland, Oregon, Johns Hopkins University, Baltimore, Maryland, Yale University School of Medicine, Yale-New Haven Hospital Saint Raphael Campus, New Haven, Connecticut, University of Michigan Congenital Heart Center, University of Michigan Health Center, Ann Arbor, Michigan, Brigham and Women’s Hospital, Boston, Massachusetts, Veterans Affairs Eastern Colorado Health Care System, University of Colorado, Denver, Colorado, and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.

NASPE Expert Consensus Document: Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures

Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures. This article is intended to inform practitioners, payers, and other interested parties of the opinion of the North American Society of Pacing and Electrophysiology (NASPE) concerning evolving areas of clinical practice or technologies or both, that are widely available or are new to the practice community. Expert, consensus documents are so designated because the evidence base and experience with the technology or clinical practice are not yet sufficiently well developed, or rigorously controlled trials are not yet available that would support a more definitive statement. This article has been endorsed by the American College of Cardiology, October 1997.

Age-specific differences in women with implantable cardioverter defibrillators: an international multi center study.

Background: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers.

Provoked and spontaneous high-frequency, low-amplitude, respirophasic noise transients in patients with implantable cardioverter defibrillators.

Respirophasic Noise Transients in ICD Patients. Introduction: Ventricular oversensing (OS) of respirophasic noise transients may cause spurious detections and therapies and pacing inhibition among patients with implantable cardioverter defibrillators (ICDs). The incidence of OS and its relationship to clinical variables and ICD system design are unknown.

Upgrade of permanent pacemakers and single chamber implantable cardioverter defibrillators to pectoral dual chamber implantable cardioverter defibrillators: indications, surgical approach, and long-term clinical results.

SWEENEY, M.O., et al.: Upgrade of Permanent Pacemakers and Single Chamber Implantable Cardioverter Defibrillators to Pectoral Dual Chamber Implantable Cardioverter Defibrillators: Indications, Surgical Approach, and Long‐Term Clinical Results. The aim of this study was to describe the indications for upgrade of pacemakers (PMs) or single chamber (VVIR) ICDs to dual chamber (DDDR) ICDs, surgical approach, hardware hybridization, and clinical outcome. Patients with preexisting PMs or VVIR ICDs may develop indications for ICD therapy or dual chamber pacing, respectively, that can be served by DDDR ICDs that incorporate preexisting transvenous leads. Fifty‐seven patients underwent upgrade from PMs (29/57) or VVIR ICDs (28/57) to pectoral DDDR ICDs. Preexisting transvenous atrial and/or ventricular leads suitable for continued use were incorporated into new DDDR ICDs in 88.5% and 100% of PM and VVIR ICD upgrades, respectively. Acceptable DFTs were achieved in 56 (98.2%) of 57 patients. Appropriate VT/VF therapies were registered among 33.3% of patients during follow‐up. No shocks due to lead noise were observed in any patient with hybridized transvenous leads. Atrial far‐field R wave (FFRW) over‐sensing occurred in 24% of DDDR ICD systems incorporating a preexisting atrial lead. FFRW was overcome by programming reduced atrial sensitivity without interfering with the normal ICD system performance in all instances. Upgrade of PMs and VVIR ICDs to pectoral DDDR ICDs is safe and technically feasible in most patients. Preexisting transvenous leads can be successfully incorporated into new DDDR ICDs, simplifying the surgical procedure, minimizing transvenous hardware, and eliminating the possibility of hazardous pacemaker‐ICD interactions.

Coping With My Partner’s ICD and Cardiac Disease

The Implantable Cardioverter Defibrillator (ICD) is an implantable biomedical device that monitors and treats abnormal heartbeats when they occur. The device is attached to the heart with 1 to 3 leads that carry information from the heart to the ICD, allowing it to record heart function, selectively provide pacing if the heart beats too fast or too slowly, and/or administer high-energy shocks if more serious heart rhythms are detected. The primary purpose of the ICD is to prevent premature sudden cardiac death. However, the device can also provide a sense of security, which allows resumption of normal life activities. Current research has suggested that psychological distress can occur in ICD patients and their partners. Anxiety may be more prevalent in ICD partners than in ICD patients.1 ICD partners are particularly worried about ICD shocks, even more so than the patients themselves.2 This Patient Page describes common challenges associated with the psychological adjustment of ICD partners and offers possible strategies to consider in managing these difficulties. A summary is provided in the Table. View this table: Table. Summary of Suggested Strategies for the Partners of Patients With ICDs Once the ICD has been implanted, lifestyle adjustments can be made that promote health and well-being. However, such adjustments may take time and a bit of work; most people take about 3 months to adjust to such major life changes. A patient’s adjustment often mirrors the partner’s adjustment, so effective coping can improve both of your lives. ### Patient Acceptance Patient acceptance refers to how well an individual adapts to the ICD and accepts its pros and cons. Patients and partners may differ on how well they accept the device. The hope for ICD patients is that they reengage with the confidence of having “an emergency room in the chest”; yet some patients experience difficulty and …

Quality of Life Issues in Patients With Implantable Cardioverter Defibrillators: Driving, Occupation, and Recreation

In the United States over 350,000 individuals die annually from sudden cardiac arrest due to ventricular tachyarrhythmias. Numerous large-scale clinical trials have consistently demonstrated that implantable cardioverter defibrillators (ICDs) reduce mortality among appropriately selected patients who have survived an episode of potentially life-threatening ventricular arrhythmia (secondary prevention) or are at risk for ventricular arrhythmia (primary prevention). Despite the demonstrated success of the ICD, many patients often experience unique physical, emotional, and psychosocial needs that can directly impact their overall quality of life (QOL). The most common psychological disturbances following ICD implantation include stress, anxiety, depression, or fear, typical of any chronic illness. Additionally, ICDs impose unique emotional pressures relating to altered body image, painful shocks, and the possibility of hardware failure. The random nature of shocks commonly induces feelings of isolation and powerlessness and the experience of shocks is directly linked to poor QOL outcomes. Lifestyle changes, such as restrictions on driving, eligibility for employment, marital and social relationships, sexual intimacy, or participation in recreational activities can significantly affect the ICD patients psychological and emotional well-being. The purpose of this article is to review the QOL data from several large-scale clinical trials of ICD patients as well as to examine specific QOL issues such as driving restrictions, occupational, and recreational concerns.

Sexual Health for Patients With an Implantable Cardioverter Defibrillator

Studies examining the quality of life of implantable cardioverter defibrillator (ICD) patients have consistently demonstrated that ICD patient quality of life is at least equal to, if not better than, that of patients treated with medications alone.1 Quality of life may be related in part to the patients ability to resume “pre-ICD” activities; however, sexual activity is rarely included as part of the patient education process. Sexual functioning has not been well studied in ICD patients, but preliminary research has suggested that patients commonly express concerns about fear of ICD shock during sex, varying interest and pattern of sexual activity, and a desire for more information and sexual counseling.2 The purpose of this Cardiology Patient Page is to identify typical issues related to sexual functioning in ICD patients and offer possible strategies for effective management. Despite limited research regarding the social functioning of ICD patients, our collective clinical experience suggests that common barriers exist when it comes to addressing their sexual health. The following sections detail specific barriers to healthy sexual functioning for ICD patients and proposed strategies for overcoming those barriers. ### Communication Between Patients and Healthcare Providers Although some people may believe that sex, love, and intimacy are subjects not to be discussed with others, sexual activity is highly relevant to your health and well-being and is an absolutely appropriate topic of discussion with your doctor. Unfortunately, research has shown a lack of adequate communication about sex between cardiovascular patients and their healthcare providers. Despite estimates that >75% of patients with cardiovascular disease experience some type of difficulty with sexual functioning,3 a lack of communication between patients and doctors persists. Research has shown that 98% of patients reported that they believed their cardiologists should discuss sexual functioning with them; however, only 15% of …

A Patient’s Guide to Living With Atrial Fibrillation

Atrial fibrillation1 (AF) is the most common heart rhythm disturbance in the United States, affecting over 2 million individuals. Over 150 000 new cases of AF are diagnosed each year. It is estimated that approximately 4% of the population over 65 years of age are affected. The incidence of AF increases with age, so that approximately 11% of individuals over 80 years of age are affected. AF is typically characterized by chaotic, disorganized electrical activity in the upper chambers of the heart. When AF occurs, the upper chambers of the heart (atria) quiver rapidly and irregularly (fibrillate). This chaotic beating can cause a range of symptoms. Although this heart rhythm disturbance is not life-threatening, there is an increased risk of stroke or heart failure for some patients who have AF. A healthcare professional can identify an irregular heartbeat by checking your pulse or listening to your heart with a stethoscope, but an electrocardiogram (ECG or EKG) is the most reliable method to detect and confirm the presence of AF. If the AF comes and goes intermittently (commonly called paroxysmal AF), it may be necessary for you to wear a Holter monitor (a portable ECG monitor) or an event recorder to detect it. AF can cause a range of symptoms. Some people are unaware that their hearts are fibrillating, whereas others are immediately aware of the change in their heart’s rhythm. Symptoms can range from mild fatigue to difficultly breathing, shortness of breath, and palpitations. It is unclear why some people experience symptoms while in AF and others do not. In many patients, the symptoms are related to a rapid heart rate. If medications effectively slow the rate, the symptoms disappear. Other patients continue to have symptoms, even if the heart rate is not fast. Occasionally, symptoms are due to …