Sequential hybrid ablation vs. surgical CryoMaze alone for treatment of atrial fibrillation: results of multicentre randomized controlled trial.

AIMS: Data on the hybrid atrial fibrillation (AF) treatment are lacking in patients with structural heart disease undergoing concomitant CryoMaze procedures. The aim was to assess whether the timely pre-emptive catheter ablation would achieve higher freedom from AF or atrial tachycardia (AT) and be associated with better clinical outcomes than surgical ablation alone. METHODS AND RESULTS: The trial investigated patients with non-paroxysmal AF undergoing coronary artery bypass grafting and/or valve repair/replacement with mandatory concomitant CryoMaze procedure who were randomly assigned to undergo either radiofrequency catheter ablation [Hybrid Group (HG)] or no further treatment (Surgery Group). The primary efficacy endpoint was the first recurrence of AF/AT without class I or III antiarrhythmic drugs as assessed by implantable cardiac monitors. The primary clinical endpoint was a composite of hospitalization for arrhythmia recurrence, worsening of heart failure, cardioembolic event, or major bleeding. We analysed 113 and 116 patients in the Hybrid and Surgery Groups, respectively, with a median follow-up of 715 (IQR: 528-1072) days. The primary efficacy endpoint was significantly reduced in the HG [41.1% vs. 67.4%, hazard ratio (HR) = 0.38, 95% confidence interval (CI): 0.26-0.57, P < 0.001] as well as the primary clinical endpoint (19.9% vs. 40.1%, HR = 0.51, 95% CI: 0.29-0.86, P = 0.012). The trial groups did not differ in all-cause mortality (10.6% vs. 8.6%, HR = 1.17, 95%CI: 0.51-2.71, P = 0.71). The major complications of catheter ablation were infrequent (1.9%). CONCLUSION: Pre-emptively performed catheter ablation after the CryoMaze procedure was safe and associated with higher freedom from AF/AT and improved clinical outcomes.

Image-guided left ventricular lead placement in cardiac resynchronization therapy: focused on image fusion methods.

Cardiac resynchronization therapy is an effective and widely accessible treatment for patients with advanced, drug-refractory heart failure. It has been shown to reverse maladaptive ventricular remodeling, increase exercise capacity, and lower hospitalization and mortality rates. However, there still exists a considerable proportion of patients who do not respond favorably to the therapy. Tailored left ventricular (LV) lead positioning instead of empiric implantation is thought to have the greatest potential to increase response rates. In our paper, we focus on the rationale for guided LV lead implantation and provide a review of the non-invasive imaging modalities applicable for navigation during LV lead implantation, with special attention to the latest achievements in the field of multimodality imaging and image fusion techniques. Current limitations and future perspectives of the concept are discussed as well.

Lesion durability found during mandated percutaneous catheter ablation after surgical cryo-ablation for treatment of non-paroxysmal atrial fibrillation.

OBJECTIVES: Current recommendations support surgical treatment of atrial fibrillation (AF) in patients indicated for cardiac surgery. These procedures are referred to as concomitant and may be carried out using radiofrequency energy or cryo-ablation. This study aimed to assess the electrophysiological findings in patients undergoing concomitant cryo-ablation. METHODS: Patients with non-paroxysmal AF undergoing coronary artery bypass grafting and/or valve repair/replacement were included in the trial if concomitant cryo-ablation was part of the treatment plan according to current guidelines. The patients reported in this study were assigned to undergo staged percutaneous radiofrequency catheter ablation (PRFCA), i.e., hybrid treatment, as a part of the SURHYB trial protocol. RESULTS: We analyzed 103 patients who underwent PRFCA 105 ± 35 days after surgery. Left and right pulmonary veins (PVs) were found isolated in 65 (63.1%) and 63 (61.2%) patients, respectively. The LA posterior wall isolation and mitral isthmus conduction block were found in 38 (36.9%) and 18 (20.0%) patients, respectively. Electrical reconnections (gaps) in the left PVs were more often localized superiorly than inferiorly (57.9% vs. 26.3%, P = 0.005) and anteriorly than posteriorly (65.8% vs. 31.6%, P = 0.003). Gaps in the right PVs were more equally distributed anteroposteriorly but dominated in superior segments (72.5% vs. 40.0%, P = 0.003). There was a higher number of gaps on the roof line compared to the inferior line (131 (67.2%) vs. 67 (42.2%), P < 0.001). Compared to epicardial cryo-ablation, endocardial was more effective in creating PVs and LA posterior wall isolation (P < 0.05). Cryo-ablation using nitrous oxide (N20) or argon (Ar) gas as cooling agents was similarly effective (P = NS). CONCLUSIONS: The effectiveness of surgical cryo-ablation in achieving transmural and durable lesions in the left atrium is surprisingly low. Gaps are located predominantly in the superior and anterior portions of the PVs and on the roof line. Endocardial cryo-ablation is more effective than epicardial ablation, irrespective of the cooling agent used.

Remote monitoring of implantable cardioverters defibrillators: a comparison of acceptance between octogenarians and younger patients.

BACKGROUND: Remote monitoring (RM) is increasingly employed for all types of cardiac implantable devices (CIED). However, there are only limited data on the acceptance of RM by the elderly. The aim of our study was to ascertain how octogenarians assess RM technologies compared to younger, presumably technically more literate patients, and what concerns or technical problems the system presents to both groups of patients. METHODS: The trial was designed as a descriptive, register-based single-center study. The study population consisted of all consecutive patients ≥ 80 years of age (group A, n = 94) and all consecutive patients aged ≤ 40 years (group B, n = 71), who had undergone implantation of an implantable cardioverter-defibrillator (ICD) between the years of 2009 and 2018 and were using a Home MonitoringTM (HM, Biotronik, Berlin, Germany) system. All patients fulfilling entry criteria were approached with a request to participate in the survey. RESULTS: A total of 85 (90.4%) and 65 (91.5%) valid surveys were obtained for groups A and B, respectively. Ninety-two percent of patients in both groups (P = 0.903) were satisfied with the limited number of planned ambulatory follow-ups (i.e., once a year). All patients in both groups (100%) reported that they were satisfied with the HM system, and 97% and 94% of patients in Groups A and B, respectively, ranked it highly beneficial (P = 0.68). A significant proportion of patients in both groups were completely unaware of any health-related benefits associated with the use of the HM system (42% in Group A vs. 49% in Group B, P = 0.4). Among the most frequently reported personal benefits of HM were a sense of safety and security and savings on travel expenses and time. 5% and 9% of patients in Groups A and B, respectively, reported that usage of HM caused them some degree of psychological stress (P = 0.27). Nearly all patients in both groups reported receiving information on HM from their doctor after ICD implantation. None of Group A reported receiving information from a nurse either before or after ICD implantation, while 14% of Group B patients reported receiving information from a nurse after, but not before ICD implantation. Seven and 51% (P < 0.0001) of patients in Group A and B, respectively, sought additional information about HM post-discharge. CONCLUSIONS: The HM system received good marks and was much appreciated, even in patients over 80 years of age. The level of acceptance and potential psychological stress resulting from RM technology appears to be about the same in older patients as in younger patients. The majority of octogenarians either did not fully understand the clinical benefits of the system or mistakenly thought that the HM system was a substitute for emergency 24-h surveillance. These results highlight the need for better patient education relative to RM technology, with one option being to delegate more of this educational process to specially trained nurses.