Tina Sichrovsky

Long‐Term Outcome Following Successful Pulmonary Vein Isolation: Pattern and Prediction of Very Late Recurrence

Background:u2002Despite encouraging results of pulmonary vein isolation (PVI) ablation for atrial fibrillation (AF), it is unclear whether there is genuine cure or there is an important attrition rate. We sought to determine the long‐term outcome of the initial responders who experienced a prolonged AF‐free complete response.

Cardiac implantable electronic device infections: Incidence, risk factors, and the effect of the AigisRx antibacterial envelope

BACKGROUNDnCardiac implantable electronic device (CIED) infection is associated with morbidity and mortality.nnnOBJECTIVESnTo determine the incidence and risk factors for CIED infection, to develop a scoring index for risk stratification, and to analyze the effect of the AIGISRx envelope on infection rates.nnnMETHODSnConsecutive patients who underwent a CIED procedure were identified and surveyed for 6 months for the development of an infection necessitating removal of all implanted hardware.nnnRESULTSnIn the pre-envelope era, an infection occurred in 25 (1.5%) of 1651 patients. After its availability, an envelope was used in 275 (22%) of 1240 patients; an infection occurred in 8 (0.6%) patients in this era (P = .029 vs pre-envelope). In the overall cohort of 2891 patients, the infection rate was 1.2% and 3.5% in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device, respectively (P = .018); in these patients, 7 independent risk factors predicted infection: early pocket re-exploration, male sex, diabetes, upgrade procedure, heart failure, hypertension, and glomerular filtration rate < 60 mL/min. A composite risk score (0-25; C index 0.72; 95% confidence interval 0.61-0.83) was created by weight, adjusting these 7 factors: 3 groups emerged-low risk (score 0-7; 1% infection), medium risk (score 8-14; 3.4% infection), and high risk (score ≥15; 11.1% infection). The envelope reduced infections by 79% and 100% in the medium- and high-risk groups, respectively.nnnCONCLUSIONSnCIED infection most commonly occurred in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device. A composite score based on clinical variables appeared feasible for infection risk stratification. The AIGISRx envelope significantly lowered the risk of CIED infection. Randomized clinical data are warranted.

Dexmedetomidine Sedation Leading to Refractory Cardiogenic Shock

Dexmedetomidine is frequently used for deep sedation during electrophysiology procedures. We report a case where, presumably, the use of dexmedetomidine resulted in a patients death. The patient developed unexplained and refractory cardiogenic shock and could not be resuscitated. Autopsy failed to demonstrate any abnormality or cause of death. We postulate that, in certain susceptible individuals, dexmedetomidine may lead to terminal complications. We therefore urge caution about using dexmedetomidine in the electrophysiology laboratory.

Long-term ECG monitoring using an implantable loop recorder for the detection of atrial fibrillation after cavotricuspid isthmus ablation in patients with atrial flutter

BACKGROUNDnIn patients with atrial flutter who undergo cavotricuspid isthmus ablation, long-term electrocardiographic (ECG) monitoring may identify new onset of atrial fibrillation (AF).nnnOBJECTIVESnTo ascertain, through the use of an implantable loop recorder (ILR) with a dedicated AF detection algorithm, the incidence, duration, and burden of new AF in these patients and to develop an optimal postablation ECG monitoring strategy.nnnMETHODSnWe enrolled 20 patients with flutter, a CHADS2 score of 2-3, and no prior episode of AF. After cavotricuspid isthmus ablation, we implanted an ILR, which was interrogated routinely; all stored ECGs were adjudicated.nnnRESULTSnDuring a mean follow-up of 382 ± 218 days, 3 patterns were observed. First, in 11 (55%) patients, stored ECGs confirmed AF at 62 ± 38 days after ablation. Second, in 4 (20%) patients, although the ILR suggested AF, episodes actually represented sinus rhythm with frequent premature atrial contractions and/or oversensing. Third, in 5 (25%) patients, no AF was observed. Episodes <4 hours were associated with low AF burden (<1%) or false detections. The 1-year freedom from any episode of AF >4 and >12 hours was 52% and 83%, respectively.nnnCONCLUSIONSnOur data show that many (but not all) patients develop new AF within the first 4 months of flutter ablation. Since external ECG monitoring for this duration is impractical, the ILR has an important role for long-term AF surveillance. Future research should be directed toward identifying the relationship between duration/burden of AF and stroke and improving existing ILR technology.

Very long-term outcome after initially successful catheter ablation of atrial fibrillation

BACKGROUNDnThe ablation of atrial fibrillation (AF) using pulmonary vein isolation is indicated when patients do not respond favorably to medical therapy. Successful procedures are accomplished in the majority of patients, but the outcome after many years of follow-up after ablation is unknown.nnnOBJECTIVEnTo describe the long-term recurrence rate and pattern of AF after successful ablation.nnnMETHODSnA prospectively identified cohort of 445 patients who demonstrated freedom from AF for at least 1 year postablation (single procedure in 391 [87.9%]) was followed for 66.0 ± 34.0 months. Patients were seen at least annually as outpatients and underwent regular electrocardiographic monitoring.nnnRESULTSnAt 40.7 ± 27.0 months postablation, 97 (21.8%) patients experienced at least 1 episode of recurrent AF. The vast majority of events were symptomatic, and no serious clinical events were associated with AF recurrence (eg, stroke). There was a steady attrition rate reaching 16.3% and 29.8% at 5 and 10 years, respectively. In 29 patients (29.5%) of the patients, recurrences were self-limited; the remainder required either medical therapy or repeat ablation. By multivariate analysis, persistent AF (hazard ratio 3.08; P < .0001) and hypertension (hazard ratio 1.08; P = .009) were independent risk factors for the recurrence of AF. The presence of both factors placed the patient at high risk of recurrence: 37.6% at 5 years and 68.8% at 10 years.nnnCONCLUSIONSnOver the decade after a successful ablation of AF, most patients continue to demonstrate freedom from AF. At the highest risk of very late recurrence is the subset of patients with hypertension and prior persistent AF.

Hypertension and Hypertensive Heart Disease Are Associated with Increased Ostial Pulmonary Vein Diameter

Introduction: Atrial fibrillation (AF) is associated with increased ostial pulmonary vein (PV) diameter and commonly with hypertension. We sought to investigate ostial PV anatomy in patients with and without AF with the goal of characterizing the relationship to hypertension and cardiovascular disease.

Comparison of endovascular versus epicardial lead placement for resynchronization therapy.

Cardiac resynchronization therapy (CRT) has been shown to improve survival and symptoms in patients with severe left ventricular (LV) dysfunction, congestive heart failure, and prolonged QRS duration. LV lead placement is achieved by placing the lead in the coronary sinus, an endovascular approach, or by a minimally invasive robotic-assisted thoracoscopic epicardial approach. There are no data directly comparing the 2 methods. Patients eligible for CRT were randomized to the endovascular and epicardial arms. Coronary sinus lead placement was achieved using the standard technique, and epicardial leads were placed using a minimally invasive robotic-assisted thoracoscopic approach. The primary end point was a decrease in LV end-systolic volume index at 6 months. The secondary end points included 30-day mortality rate, measures of clinical improvement, 1-year electrical lead performance, and 1-year survival rate. The relative improvement of LV end-systolic volume index from baseline to 6 months was similar between the arms (28.8% for the transvenous [n = 12] vs 30.5% for the epicardial (n = 9) arm, p = 0.93). There were no significant differences in the secondary end points between the 2 groups. In conclusion, there were no differences in echocardiographic and clinical outcomes comparing a conventional endovascular approach versus robotic-assisted surgical epicardial LV lead placement for CRT in patients with heart failure. Surgical approaches are still a viable alternative when a transvenous procedure has failed or is not technically feasible.

The Efficacy of His Bundle Pacing: Lessons Learned From Implementation for the First Time at an Experienced Electrophysiology Center

OBJECTIVESnThis study sought to evaluate the clinical and procedural characteristics impacting outcomes during implementation of a His bundle pacing (HBP) program in a real-world setting.nnnBACKGROUNDnRight ventricular pacing is associated with an elevated risk of heart failure, but device reprogramming and upgrades have significant challenges. HBP has emerged as an alternative and is reported to be highly successful in the hands of highly experienced centers.nnnMETHODSnAll patients referred for permanent pacemaker implantation at the Valley Hospital (Ridgewood, New Jersey) between October 2015 and October 2017 were evaluated; a subset of 24% was selected for HBP.nnnRESULTSnPermanent HBP was feasible with an acute implant success rate of 75%. HBP in the presence of bundle branch block (64% vs. 85%; pxa0= 0.05) or complete heart block (56% vs. 83%; pxa0= 0.03) was significantly less successful. The pattern of atrioventricular block in combination with bundle branch block (BBB) further affects outcomes. HBP is highly successful across the spectrum of atrioventricular block pattern severity in the absence of BBB. In the presence of BBB, Mobitz II AV block and complete heart block significantly attenuated HBP success compared with Mobitz I atrioventricular block (62% vs. 100%; pxa0= 0.02). A rising threshold was observed in 30%, and 8% required lead intervention.nnnCONCLUSIONSnHBP was feasible and readily learned with a high implant success in the hands of experienced electrophysiologists without prior exposure to the technique. BBB and atrioventricular block pattern appears to affect success. The technique is limited by a high rate of rising thresholds and lead intervention. These data have important implications for patient selection.

Migration of an implantable loop recorder into the pleural space

Introduction Implantable loop recorders (ILRs) are most commonly used in patients with unexplained palpitations or syncope as well as suspected or known atrial fibrillation. The device most commonly being used today is the Medtronic Reveal LINQ (Minneapolis, MN); with a volume of,1.2 cc, it is designed for insertion using a greatly simplified technique. Specifically, the ILR is provided preloaded into an insertion tool that is used to deliver the device subcutaneously through a small incision, which is then closed using surgical glue, surgical tape, sutures, or staples. The LINQUsability study provided first in-human experience in an initial cohort of 30 patients followed for a month. The only remarkable findings were implant site pain in 2 patients and a superficial wound infection in 2 patients. In this case report, we describe a patient in whom the ILR progressively migrated from the subcutaneous into the left pleural space.

Obstacles preventing biventricular pacing mitigated with lead extraction and His bundle pacing to achieve effective cardiac resynchronization

Introduction Cardiac resynchronization therapy (CRT) achieved by implanting a lead via the coronary sinus (CS) system significantly improves well-being, symptoms, morbidity, and mortality in appropriately selected populations with advanced heart failure (HF) or pacing-induced cardiomyopathy. Despite improvements in implant technique, lead design, and pacing algorithms, there still remains a significant nonresponder rate, high implant failure, and higher risk of complications. The options for CRT are generally limited to surgical lead placement if lead delivery via the CS is not feasible. His bundle pacing (HBP) engages and recruits the native His-Purkinje system distal to the level of block allowing for rapid and coordinated electromechanical ventricular activation avoiding dyssynchrony with hemodynamics and remodeling similar or superior to CRT via the CS. Despite the potential for superior CRT and less complex procedures, HBP is underutilized in cases where CRT via the CS is not feasible. We present a case with several obstacles to CRT that was ultimately achieved with HBP.