Interventional Cardiac Electrophysiology

Development of a novel ablation hood to prevent systemic embolization of microbubbles and particulate emboli Abstract Background Atrial fibrillation ablation results in microbubbles and particulate emboli formation. We aimed to develop and test the early feasibility of a novel ablation hood to contain microbubbles and particulate emboli with the ultimate goal of preventing systemic embolization. Methods In seven canines, we developed, iterated, and tested a novel retractable hood that can cover the catheter-tissue ablation site. The number and volume (nL) of microbubbles formed during ablation with and without the hood was measured using an extracorporeal circulation loop. Wilcoxon’s signed-rank test was used to compare the number of bubbles detected with and without the hood. Results The hood reduced systemic embolization of microbubbles in 21/28 (75%) of ablations. Both atrial and ventricular ablations showed a statistically significant reduction in bubble number (476 ± 811 without hood vs 173 ± 226 with hood, p = 0.02; 2669 ± 1623 without hood vs 1417 ± 970 with hood, p = 0.04, respectively) and bubble volume (3.3 ± 7.6 nL without hood vs 0.2 ± 0.56 nL with hood, p = 0.006; 6.1 ± 5.2 nL without hood vs 1.9 ± 1.4 nL with hood, p = 0.05, respectively). Conclusions Use of a novel hood to cover the ablation catheter at the site of catheter-tissue contact has the potential to provide a means to reduce systematic embolization of microbubbles. Further work is required to examine particulate emboli, but these data show the early feasibility of this design concept.

Ventricular tachycardia sensitive to antitachycardia pacing in a patient with severely symptomatic Brugada syndrome

Identification of precise accessory pathway using ultra-high-resolution three-dimensional mapping system: utility and feasibility in preliminary experience

Viewpoint: Cardiac implantable electronic devices and magnetic resonance compatibility: was it really necessary?

Percutaneous ventricular assist device in ventricular tachycardia ablation: a systematic review and meta-analysis Abstract Background There is a lack of compelling data regarding the benefit of percutaneous ventricular assist devices (PVAD) in patients undergoing ventricular tachycardia (VT) ablation. The study aims to conduct a meta-analysis comparing the safety and efficacy of PVAD versus no-PVAD (N-PVAD) during VT ablation. Methods Studies meeting criteria were systematically reviewed. Baseline characteristics and clinical outcomes were extracted and analyzed. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI). Results The meta-analysis included five retrospective, observational studies consisting of 2026 patients (PVAD group—284 patients versus N-PVAD group—1742 patients). The PVAD group was sicker with significantly higher VT storm, lower LVEF and greater proportion of NYHA class ≥ III than N-PVAD (p < 0.050). The acute procedural success [RR 0.95, 95% CI, (0.89–1.00), p = 0.070], VT recurrence [RR 0.94, 95% CI, (0.66–1.34), p = 0.740] and mortality [RR 1.28, 95% CI, (0.43–3.83), p = 0.660] were similar on follow-up between PVAD versus N-PVAD. PVAD group also had significantly higher complications [RR 1.83, 95% CI (1.21–2.76), p = 0.004] and longer fluoroscopy [MD + 7.31 min, 95% CI (0.91–13.71), p = 0.030] and procedure time [MD + 71.41 min, 95% CI (31.67–111.14), p < 0.001] than N-PVAD. Conclusion Patients receiving PVAD support during VT ablation were sicker with no significant difference in acute procedural success, VT recurrence, and mortality compared with N-PVAD. PVAD support was also associated with higher complications and longer fluoroscopy and procedure time. A prospective randomized controlled trial will identify if using PVAD support in unstable patients undergoing VT ablation will impact clinical outcomes.

Pacemaker implantation in familial amyloid polyneuropathy: when and for whom? Abstract Background Despite the important role of cardiac pacing in preventing syncope and sudden cardiac death in familial amyloid polyneuropathy (FAP), we lack clear guidelines as to the ideal timing and indications for permanent pacemaker implantation. Purpose: The purpose of this study was to evaluate the ideal timing for pacemaker implantation in FAP patients submitted to liver transplantation. Methods Retrospective study of 258 FAP patients submitted to liver transplantation between 1992 and 2012. Comparison of three groups: (A) patients without pacemaker (N = 122); (B) patients submitted to pacemaker implantation after liver transplantation, with documented conduction disorders (N = 73); and (C) patients submitted to “prophylactic” pacemaker implantation before transplantation, (N = 73). Patients were followed up for 12.2 ± 6.7 years. Results The majority of patients (57%) were referred for pacemaker implantation, which occurred before liver transplantation in 50% of cases. Patients who required pacemaker after transplantation presented significantly higher Machado-Joseph Score during pre-transplant evaluation than those who did not require pacemaker (24 ± 10 vs 20 ± 10, p = .025), and also exhibited higher levels of hepatic cytolysis enzymes and hyperbilirubinemia. The most common indication for permanent pacemaker was first degree atrioventricular block, with a mean time between transplantation and pacemaker implantation of 8.7 ± 4.2 years. During long-term follow-up, all-cause mortality was 27% and was lowest in the group submitted to pacemaker implantation only after liver transplantation (p = 0.002). Conclusion The majority of FAP patients submitted to liver transplantation will need a pacemaker at some time of follow-up. However, it seems that there is no benefit in “prophylactic” cardiac pacing before liver transplantation.

Prediction of acute coronary syndrome, ischemic stroke, and mortality in patients with heart failure: a comparison of CHA 2 DS 2 -VASc and AHEAD scores Abstract Purpose To compare the predictive capacity of the CHA2DS2-VASc and AHEAD scores in predicting acute coronary syndrome (ACS), ischemic stroke (IS), and mortality in patients with heart failure (HF). Methods A total of 404,635 patients hospitalized for HF between 2000 and 2011 were recruited from a large national database in Taiwan. The predictive value of both scores was evaluated by analysis of the area under the receiver operating characteristic curve (AUROC), and the difference in their discriminative capacity was assessed using the DeLong test. Results The AUROC for the CHA2DS2-VASc score was significantly higher than that for the AHEAD score in predicting ACS and IS: 0.53 (95% CI = 0.53–0.54) versus 0.51 (95% CI = 0.51–0.52) for ACS, and 0.57 (95% CI = 0.56–0.57) versus 0.52 (95% CI = 0.51–0.52) for IS, respectively (all DeLong tests p < 0.001). By contrast, for mortality risk, the AUROC was significantly lower for the CHA2DS2-VASc score (0.56, 95% CI = 0.55–0.56) than the AHEAD score (0.60, 95% CI = 0.59–0.60; DeLong test p < 0.001). Conclusions The ability of the CHA2DS2-VASc score to predict macrovascular complications (ACS and IS) in HF patients was higher than that of AHEAD.

Vacuum-assisted vegetation removal with percutaneous lead extraction: a systematic review of the literature Abstract Purpose To perform a systematic review of reports in which the AngioVac™ percutaneous vacuum-assisted aspiration system was successfully used to debulk or remove vegetations prior to percutaneous lead extraction. Methods We included all studies and case reports that used a percutaneous aspiration technique for vegetation removal or debulking with percutaneous lead extraction for patients with lead-associated endocarditis. Ten reports and retrospective data from our centers were used, which included a total of 88 patients and 205 leads. Results The percutaneous aspiration procedure was completely or partially successful in 86 patients (97.7%). The lead extraction procedure itself was successful in 87 patients (98.9%). The aspiration procedure and lead extraction were done concomitantly in 81 patients (92.0%). Four patients (4.5%) had major complications (two due to vascular injuries, one due to coronary sinus injury, and one due to tricuspid valve injury). There were no complications from the aspiration procedure, and no cases were associated with procedure-related mortality. Conclusion While patients with large vegetations have historically been referred for surgical lead extraction, data are lacking in its techniques and outcomes. Existing data suggest that percutaneous vacuum-assisted aspiration for vegetation removal or debulking in endocarditis prior to or concurrent with percutaneous lead extraction has a high success rate with a low complication rate across a broad series of patients.

Midrange ejection fraction as a risk factor for deterioration of cardiofunction after permanent pacemaker implantation Abstract Purpose To determine whether the midrange ejection fraction (mrEF) is associated with increased risk of deterioration of cardiac function (DCF) after dual chamber permanent pacemaker (PPM) implantation. Methods We performed a prospective cohort study of relevance in patients with EF ≥ 40% and indications for PPMs. Patient characteristics were recorded at baseline and 1 day, 1 month, 3 months, and 6 months after PPM implantation with leads placed in the right ventricular apex. These included clinical symptoms, signs, biochemical parameters, BNP, echocardiography and ECG parameters, and pacing-related parameter changes. The patients were followed-up for 6 months. Univariate and multivariable Cox regression analyses were performed. Results A total of 879 patients were included, aged 35 to 88 years (mean age 67.2 ± 9.6); a total of 81 patients (9.2%) developed DCF after PPM implantation, including LVEF < 40% (57 cases) and increased NYHA class (24 cases). Cox models demonstrated that age ≥ 75 years (HR 2.273 [95% CI, 1.541–3.626]), OMI (HR 2.078 [95% CI, 1.275–3.604]), mrEF (HR 2.762 [95% CI, 1.558–4.769]), moderate mitral regurgitation (HR 2.819 [95% CI, 1.604–4.153]), and right ventricular pacing ≥ 50% (HR 2.311 [95% CI, 1.478–3.937]) were strong predictors for DCF, and NT-proBNP > 1000 ng/L and paced QRS duration ≥ 180 ms were also the independent predictors of DCF. Conclusions MrEF was associated with increased risk of deterioration of cardiac function after PPM implantation. Moderate mitral regurgitation and increased NT-proBNP levels are also potential independent predictors for deterioration of cardiac function after PPM implantation.

Efficacy of the optimal ablation index–targeted strategy for pulmonary vein isolation in patients with atrial fibrillation: the OPTIMUM study results Abstract Purpose The ablation index (AI) is a recently developed marker for ablation lesion quality that incorporates contact force (CF), time, and power in a weighted formula. There is a paucity of information on whether AI-guided pulmonary vein isolation (PVI) could improve the outcome in patients with atrial fibrillation (AF). We evaluated the optimal AI threshold for avoiding acute pulmonary vein reconnection (PVR), and to compare the efficacy of optimal AI-targeted PVI with that of conventional CF-guided PVI. Methods Seventy patients with AF (paroxysmal, 67%) were enrolled. In a phase 1 study, the patients underwent conventional CF-guided PVI (CON group), and the optimal AI threshold for avoiding acute PVR was identified. In phase 2, the patients underwent AI-guided PVI (OAI group). We compared the acute PVR rate between the CON group and the OAI group to demonstrate the efficacy of AI-guided PVI. Results In phase 1 (n = 38), acute PVR was observed in 57 of 532 (10.7%) segments. AI values of ≥ 450 at the anterior/roof segments and of ≥ 350 at the posterior/inferior/carina segments were identified as the optimal AI thresholds for avoiding acute PVR. In the phase 2 study targeting those AI values, the OAI group (n = 32) showed a significantly lower acute PVR rate than the CON group (4.2% vs. 10.7%, p < 0.001). The OAI group showed a higher minimum AI and smaller variations in AI values than the CON group. Conclusions Optimal AI-targeted PVI is feasible and could improve the acute outcome in patients with AF. Trial registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT03389074.