Rohit Bhagwandien

Evaluation of the need of elective implantable cardioverter-defibrillator generator replacement in primary prevention patients without prior appropriate ICD therapy

Objective It is not clear whether patients who received an implantable cardioverter-defibrillator (ICD) for primary prevention should undergo device replacement if they never experienced an appropriate ICD therapy during the first generator longevity. This study evaluated the incidence and predictors of appropriate ICD therapy after device replacement in this specific population. Methods From two large prospective ICD registries, we identified all primary prevention patients who had a first ICD replacement without previous appropriate ICD therapy. Cox regression analysis was used to identify predictors of appropriate ICD therapy. Results Of 403 primary prevention patients needing first ICD replacement, 275 patients (68%) had not received previous appropriate ICD therapy. Patients without previous appropriate ICD therapy before first ICD replacement (mean age at replacement 62±12 years, 75% male) had a mean follow-up of 86±24 months after the initial implantation and 30±24 months after device replacement. Following replacement, 3-year cumulative incidence of appropriate ICD therapy was 13.7% (95% CI 8.6 to 18.8%). No predictive factors associated with appropriate ICD therapy after replacement could be identified in spite of including seven clinically relevant factors. Conclusions A considerable number of primary prevention patients without previous appropriate ICD therapy before first ICD replacement received appropriate ICD therapy after replacement. As there were no predictors of appropriate ICD therapy after replacement, replacing an ICD is still recommended in all primary prevention patients despite the lack of appropriate ICD therapy during first battery service life.

Regular atrial tachycardias developing after cryoballoon pulmonary vein isolation: incidence, characteristics, and predictors.

AIMS Cryoballoon ablation (CBA) is a well-used technique when performing pulmonary vein (PV) isolation in patients with paroxysmal atrial fibrillation (AF). Our aim is to describe incidence, characteristics, and clinical predictors for developing atrial tachycardias (ATs) after cryoballoon PV isolation in patients with paroxysmal AF. METHODS AND RESULTS The study population consisted of 181 consecutive patients undergoing a first CBA. All patients received an event-recorder before cryoablation and transmitted daily electrocardiogram (ECG) during 1 month before ablation and 3 months after. Further follow-up consisted of 24 h Holter monitoring and ECG registration every 3 months and also in patients presenting with symptoms. A mean follow-up period was 497.9 ± 283.9 days, and 175 patients completed follow-up. In 14 (8%) patients regular ATs were registered. In multivariate logistic regression model, the following parameters were independently associated with ATs after ablation: an additional right PV, treatment with beta-blockers, and presence of AT on event-recording strips before ablation. Seven (4%) patients with registered AT underwent a redo procedure. In two (1.1%) patients ATs were originated in reconnected PVs. In other patients no left AT was induced. No macro re-entrant left AT was documented in any patient. During follow-up, after a redo ablation, no AT was registered. CONCLUSION The incidence of left AT after CBA is low, and no left atrial macro re-entrant tachycardia was found. The following independent predictors of AT development have been identified: an additional right PV, regular AT registered before ablation, and the use of beta-blockers.

Hemoptysis after pulmonary vein isolation with a cryoballoon: an analysis of the potential etiology

Hemoptysis After Pulmonary Vein Isolation With a Cryoballoon. In a series of 359 cryoballoon ablations with a complete registry of complications, clinically important hemoptysis requiring readmission was observed in 2 patients. One patient had preexisting bronchiectasis; the other had no previous history of pulmonary disease. In the first patient the guiding wire was very distal in one of the veins and exceptional low freezing temperatures were recorded in the left inferior pulmonary vein. Similarly, in the second patient exceptional low freezing temperatures were recorded in all 4 veins. Four additional patients mentioned hemoptysis at the 3‐month follow‐up visit, which resolved after temporary cessation of anticoagulation. Hemoptysis can occur after cryoballoon ablation for several reasons, especially when a stringent anticoagulation regimen is adhered to, and when occlusion is associated with very low freezing temperatures. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1067‐1069, September 2011)

Type and rate of atrial fibrillation termination due to rotational activity ablation combined with pulmonary vein isolation

There remains controversy about the optimal ablation technique and termination rate of atrial fibrillation (AF) during catheter ablation in patients with persistent AF. The aim of this study was to determine the rate and timing of AF termination during combined pulmonary vein isolation (PVI) and focal impulse and rotor modulation (FIRM)‐guided ablation of rotational activity (RoAc).

Air entrapment causing early inappropriate shocks in a patient with a subcutaneous cardioverter-defibrillator

The subcutaneous ICD (S-ICD) uses a different approach to sensing in comparison to conventional transvenous devices. A subcutaneous signal is used instead of an intracardiac signal. This may introduce new sensing issues as demonstrated by our case.

Substernal ICD lead implantation in a patient not suitable for subcutaneous ICD implantation without venous access due to superior vena cava syndrome

Case report A 51-year-old man with a dilated cardiomyopathy with a left ventricular ejection fraction of 10% was transferred to our hospital. The patient was known to have superior vena cava (SVC) syndrome related to a JAK2 mutation. He had several hospital admissions in the past with heart failure. His current NYHA class is II–III on optimal heart failure medication. During his hospital stay he experienced several episodes of nonsustained ventricular tachycardia. The patient had, according to current guidelines, a class I indication for an ICD. The patient was recompensated and he was discharged from the hospital with a wearable defibrillator (LifeVest, Cardio Solutions B.V., Landsmeer, The Netherlands) until placement of a definitive ICD. SVC occlusion precluded implantation of endovascular ICD by a superior approach (Figure 1). Furthermore, implantation of an endovascular ICD by a femoral approach was deemed not appropriate considering his high risk of venous thrombosis secondary to his JAK2 mutation and we chose not to use epicardial patches to prevent the risk of restrictive pericarditis. He was also not a suitable candidate for an S-ICD because he had an unfavorable R/T-wave ratio

Left atrial appendage thrombus formation during atrial fibrillation ablation under sufficient heparinization

Left atrial appendage (LAA) is implicated as a major location for cardiac thrombus formation. The percutaneous LAA occlusion (LAAO) procedure is recommended for thromboembolic prevention in certain patients with atrial fibrillation (AF). Transesophageal echocardiography (TEE) is routinely performed prior to AF ablation and …

The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review:

Background: Although the implantable cardioverter defibrillator is successful in terminating life threatening arrhythmias, it might give unwanted shocks in the last phase of life if not deactivated in a timely manner. Aims: This integrated review aimed to provide an overview of studies reporting on implantable cardioverter defibrillator shock incidence and impact in the last phase of life. Methods and results: We systematically searched five electronic databases. Studies reporting on the incidence and/or impact of implantable cardioverter defibrillator shocks in the last month of life were included. Fifteen studies were included. Two American studies published in 1996 and 1998 reported on the incidence of shocks in patients who died non-suddenly: incidences were 24% and 33%, respectively, in the last 24 hours, and 7% and 14%, respectively, in the last hour of life. Six American studies and one Danish study published between 1991–1999 reported on patients dying suddenly: incidences were 41% and 68% in the last 24 hours and 22–66% in the last hour. Four American studies and two Swedish studies published between 2004–2015 did not distinguish the cause of death: incidences were 17–32% in the last month, 3–32% in the last 24 hours, and 8% and 31% in the last hour of life. Three American studies published between 2004–2011 reported that shocks in dying patients are painful and distressing for patients, and distressing for relatives and professional caregivers. Conclusion: If the implantable cardioverter defibrillator is not deactivated in a timely manner, a potentially significant proportion of implantable cardioverter defibrillator patients experience painful and distressing shocks in their last phase of life.

A step towards a faster and easier cryoballoon ablation.

The general euphoria on the outcome of catheter ablation seems to have received a blow with the publication of several series with an almost similar outcome, showing that the 5-year results of catheter ablation are less than 50%.1–4 For more experienced electrophysiologists (all this work was published by top referral centers) this does not come as a surprise. Point-by-point radiofrequency (RF) ablation to isolate the four pulmonary veins is a time-consuming art, is very operator-dependent, and is unlikely to become the standard of care, unless new ways of monitoring the delivery (e.g., with reliable robotics and contact information) become more effective in combination with mapping tools in achieving permanent conduction block. A recent comparison with surgery favored minimal invasive procedures, performed from the pericardial side.5 Therefore, it is not surprising that new technologies blossom and become omnipresent. Semi-circular or annular tools delivering modified RF, balloons with innovative or older forms of energy sources (high intensityfocused ultrasound, laser, RF, and freezing gasses) have been tested in humans, with variable outcomes. Most tools made it clear that thermal energy is very effective and is also able to create irreversible side effects (phrenic nerve palsy, esophageal perforation, etc.).6 The advantage of cryoenergy is that it is reversible until a certain moment, so that timely interruption of energy delivery prevents long-lasting side effects.7 This does not mean that cryoballoon ablation is without problems, but most of the side effects are related to the catheterization and the introduction of the sheath.8 Back to the energy delivery: this should be titrated until there is an effect on the targeted