Yong-Mei Cha

Success of Ablation for Atrial Fibrillation in Isolated Left Ventricular Diastolic Dysfunction: A Comparison to Systolic Dysfunction and Normal Ventricular Function

Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ≤40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls ( P =0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls ( P =0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P =0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P =0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.Background— The efficacy of radiofrequency ablation for atrial fibrillation (AF) in patients with left ventricular (LV) systolic dysfunction and isolated diastolic dysfunction is uncertain. Methods and Results— A prospective cohort of patients with normal and abnormal LV function underwent ablation for antiarrhythmic drug (AAD)-refractory AF. Three groups were compared: 111 patients with systolic dysfunction, defined as LV ejection fraction (LVEF) ⩽40%; 157 patients with isolated diastolic dysfunction but preserved LVEF ≥50%; and 100 patients with normal LV function. The primary end point was AAD-free AF elimination at 1 year after ablation. This end point was achieved in 62% of patients with systolic dysfunction, 75% of those with diastolic dysfunction, and 84% of controls (P=0.007). AF control on or off AADs was achieved in 76% of patients with systolic dysfunction, 85% of those with diastolic dysfunction, and 89% of controls (P=0.08). In the systolic dysfunction group, 49% experienced an increase in LVEF by ≥5% after ablation, of which 64% achieved normal LVEF. In the diastolic dysfunction group, 30% of patients demonstrated at least 1 grade improvement in diastolic dysfunction. Multivariable analysis demonstrated an increased relative risk of arrhythmia recurrence of 1.8 (95% CI, 1.1 to 3.1; P=0.02) in systolic dysfunction and 1.7 (1.0 to 2.7; P=0.04) in isolated diastolic dysfunction compared with normal function. Conclusions— Although an ablative approach for AF in patients with systolic or diastolic dysfunction is associated with an increased long-term recurrence risk, there is potential for substantial quality-of-life improvement and LV functional benefit.

Bioprosthetic Tricuspid Valve Regurgitation Associated With Pacemaker or Defibrillator Lead Implantation

OBJECTIVES The goal of this study was to determine the impact of transvenous pacemaker and defibrillator leads on the incidence of bioprosthetic tricuspid valve (BTV) regurgitation compared with BTV patients without a transvalvular lead. BACKGROUND Although concern has been raised regarding the potential deleterious effect of permanent transvenous device leads on BTV function, little is known about the incidence of prosthetic tricuspid regurgitation (TR) after lead placement. METHODS A retrospective review of 58 patients who underwent BTV implantation and subsequently required endocardial pacemaker (n = 52) or defibrillator (n = 6) lead implantation across the BTV was conducted. Patient and prosthesis characteristics, lead type, and clinical events were collected. The incidence and severity of prosthetic TR, determined by Doppler echocardiography, was compared with 265 consecutive patients who underwent BTV implantation without undergoing subsequent transvalvular device lead implantation. RESULTS Over a mean follow-up of 25 months, in 5 patients (9%) with a transvalvular lead significant (moderate or greater) prosthetic TR developed compared with 12 patients (5%) in the control group (p = 0.20). Kaplan-Meier analysis revealed no significant difference in the incidence of TR in BTV patients with and without transvalvular leads (p = 0.45). Significant prosthetic TR in patients with and without a transvalvular lead more commonly occurred 2 years or later after lead or BTV implantation (4 of 5, 80% and 10 of 12, 83%, respectively). CONCLUSIONS Transvalvular device lead implantation in BTV patients was not associated with an increased incidence of significant prosthetic TR (p = 0.45). Based on these data, transvalvular lead implantation appears to be an acceptable approach for patients with a BTV who require permanent pacemaker or defibrillator placement.

Outcomes and Complications of Lead Removal

Removal of an entire cardiovascular implantable electronic device is associated with morbidity and mortality. We sought to establish a risk classification scheme according to the outcomes of transvenous lead removal in a single center, with the goal of using that scheme to guide electrophysiology lab versus operating room extraction.

Outcomes of cardiac resynchronization therapy using left ventricular quadripolar leads

Quadripolar left ventricular (LV) leads provide a more optimal pacing configuration for cardiac resynchronization therapy (CRT) than conventional bipolar leads. The objective of this study is to determine the clinical outcomes of CRT using quadripolar leads.

MULTICENTER STUDY OF THE SAFETY AND EFFECTS OF MAGNETIC RESONANCE IMAGING IN PATIENTS WITH CORONARY SINUS LEFT VENTRICULAR PACING LEADS

Magnetic resonance imaging (MRI) in patients with left ventricular (LV) leads may cause tissue or lead heating, dislodgement, venous damage, or lead dysfunction. MRI conditional LV leads are not available. We therefore investigated the safety of MRI in patients with LV pacing leads. Prospective

Prevention of Thromboembolic Stroke in Patients Undergoing Catheter-Based Ablation for Atrial Fibrillation: Has It Been Optimized?

Over the past decade, catheter-based ablation of atrial fibrillation (AF) has been widely accepted as standard therapy for patients with symptomatic AF refractory to antiarrhythmic drugs. The outcome of restoring and maintaining sinus rhythm by an ablative approach without the need for antiarrhythmic drug therapy attracts not only electrophysiologists but also referral physicians and patients dealing with symptomatic atrial fibrillation. Despite the evolving technology for AF ablation and the enthusiasm for this clinical approach, devastating complications may still occur. Periprocedural cerebrovascular accident (CVA) due to thrombus or air embolism remains one of the most serious complications of AF ablation. In spite of precautions taken before, during, and after the ablation to minimize the risk of CVA, the reported event rate remains 0.5–2.8%.1-3 Fatal CVA occurs in one of 10,000 patients according to a worldwide survey of prevalence and causes of fatal outcome in catheter ablation of AF.4 Prevention of periprocedural CVA will continue to be an area of challenge to interventional electrophysiologists in view of the rapidly growing patient population choosing to undergo AF ablation. The excellent study by Scherr and associates5 in this issue of the journal investigated the incidence and predictors of periprocedural CVA in 721 consecutive AF ablations (579 patients) at a single center. Periprocedural CVA was defined as the new onset of a neurologic deficit that occurred within 30 days after the AF ablation. The diagnosis was confirmed by cranial CT, and/or MRI, and a neurologist. All patients had standard periprocedural care including preprocedure therapeutic anticoagulation with warfarin for a minimum of 4 weeks, preprocedure transesophageal echocardiography to exclude thrombus, warfarin reinitiation immediately postprocedure, and bridging with enoxaparin until the INR was therapeutic. Heparin was given throughout the procedure to maintain activated clotting time (ACT) between 300 and 400 seconds. The authors reported a 1.4% (10 of 721 cases) incidence of periprocedural CVA (all thromboembolic strokes); nine of these events occurred within 48 hours after AF ablation. The risk of periprocedural CVA did not vary significantly during the course of the study from 2001 to 2008. The event rates were 0.3%, 1.0%, and 4.7% in patients with CHADS2 scores of 0, 1, and ≥2, respectively (P <

Cardiomyopathy induced by pulmonary vein tachycardia cured by catheter ablation

Background A 51-year-old male was referred for consideration for heart transplantation because of recently diagnosed congestive heart failure refractory to medical therapy. Previous echocardiography demonstrated a left ventricular ejection fraction of approximately 15% with global hypokinesia. Coronary angiography did not reveal any clinically significant obstructive coronary artery disease and an electrocardiogram documented atrial fibrillation with a rapid ventricular rate of 130 beats/min. Other laboratory tests including thyroid function test were unremarkable. The patients main complaints were dyspnea on exertion, and orthopnea with minimal palpitations.Investigations Physical examination, laboratory testing, electrocardiography, Holter monitoring, chest radiography, transthoracic echocardiography, transesophageal echocardiography, coronary angiogram, and electrophysiologic study with catheter ablation.Diagnosis Cardiomyopathy resulting from pulmonary vein tachycardia.Management Catheter-based radiofrequency ablation of the focus of pulmonary vein tachycardia.

Outcomes of repeated transvenous lead extraction

The outcomes of repeated cardiovascular implantable electronic device (CIED) lead extraction have not been well studied. We sought to determine the indications, outcomes, and safety of repeated lead extraction procedures.

Diagnostic and therapeutic value of implantable loop recorder: A tertiary care center experience

Implantable loop recorders (ILRs) are effective in achieving symptom‐rhythm correlation. However, diagnostic yield in routine clinical practice is not well established.

Multicenter Experience of Concomitant Use of Left Ventricular Assist Devices and Subcutaneous Implantable Cardioverter-Defibrillators

The subcutaneous implantable-cardioverter defibrillator (S-ICD) is an important development in defibrillation therapy for sudden cardiac death. The extravascular presence of S-ICDs can be advantageous in patients with an increased risk of intravascular infections, such as patients with left