Successful coronary sinus left ventricular lead extraction 9 years postimplantation using the wire ThRoUgh Snare Twice (wire TRUST) technique.

The newly-proposed tandem approach, Wire ThRoUgh Snare Twice (Wire TRUST) is effective for grasping a lead with inaccessible ends. This case report shows that Wire TRUST can also enable successful extraction of a left ventricular lead by iteratively grasping and repositioning to the distal portion of the lead.

Real-time Ripple technique: A case report on Ripple map for real-time identification of conduction gaps without first-pass pulmonary vein isolation.

This paper presents a novel approach to gap mapping in pulmonary vein isolation (PVI) for atrial fibrillation (AF) treatment, utilizing the real-time Ripple (RR) technique. Radiofrequency (RF) catheter ablation, particularly encircling PVI, is a common intervention for AF. Identifying left atrium-pulmonary vein conduction gaps is crucial for achieving PVI with minimal additional ablation if first-pass PVI is unsuccessful. However, identifying conduction gaps can be relatively challenging, often necessitating manual electrocardiogram reannotation due to the limitations of local activation time (LAT) maps. In the case of a 63-year-old patient with drug-resistant symptomatic persistent AF, the RR technique was utilized to identify conduction gaps during RF ablation. The technique involved pausing fast anatomical mapping (FAM), activating Ripple map (RM) feature on the CARTO 3 system and acquiring points with an ultrahigh-resolution mapping catheter. This approach revealed that the actual site of earliest activation differs from the LAT map indication, enabling successful PVI. The RM feature's capability to reflect actual excitation propagation without reliance on map annotations was crucial for precise conduction gap identification, overcoming inter-operator variability and inaccuracies of conventional methods. The RR technique not only facilitated real-time analysis during gap mapping but also significantly reduced the procedure time, minimizing potential complications. This case report highlights the efficacy of the RR technique in real-time gap mapping, demonstrating its value in cases where first-pass PVI is unsuccessful. The integration of this technique into PVI procedures can enhance both the accuracy and efficiency of catheter ablation for AF.

Improvement in respiratory function and exercise tolerance following video-assisted thoracoscopic diaphragm plication for symptomatic iatrogenic persistent diaphragm paralysis after radiofrequency catheter ablation.

Hemidiaphragm paralysis, a complication of catheter ablation for atrial fibrillation, can severely affect respiratory function and can lead to paradoxical breathing and dyspnea on exertion. A 75-year-old woman with iatrogenic diaphragm paralysis showed improved symptoms, respiratory function, and exercise tolerance after video-assisted thoracoscopic diaphragm plication.

Successful transvenous retrieval of an electrode ring dislodged from a novel visualized steerable sheath by inflation of a balloon inside the ring.

The VIZIGO sheath (Biosense Webster, Irvine, CA, USA) is used for catheter ablation (CA) of atrial arrhythmia. In this case report, we describe a complication associated with the VIZIGO sheath and present a successful bailout method. An 82-year-old woman with paroxysmal atrial fibrillation (AF) and atrial tachycardia (AT) was referred to our hospital after experiencing palpitations for 6 months. She underwent CA using the VIZIGO sheath and a fixed Swartz sheath (St. Jude Inc., St. Paul, MN, USA). Pulmonary vein isolation and left atrial posterior wall isolation were performed to address AF and AT. Following ablation, the Swartz sheath was removed; however, the VIZIGO sheath showed resistance to removal. A wire was inserted into the VIZIGO sheath for removal, but the distal electrode ring detached in the vessel. To retrieve the electrode ring, a Mustang over-the-wire angioplasty balloon was dilated inside the ring and withdrawn with the ring. After venography and confirmation of a hemostatic seal, the ablation procedure was completed. The patient experienced postoperative anemia, which was resolved by erythrocyte transfusion. No further paroxysmal AF or AT occurred during the 1-year follow-up. In conclusion, the VIZIGO sheath's distal electrode ring may become detached during CA, and the detached ring can be successfully retrieved using our original bailout technique. Learning objective: This case report highlights the unique complication of electrode ring detachment associated with the novel visualized steerable sheath (VIZIGO; Biosense Webster, Irvine, CA, USA) during catheter ablation procedures and presents the successful technique as a bailout method for retrieving the dislodged ring. The technique involves dilating a non-compliant over-the-wire angioplasty balloon inside the ring and withdrawing it along with the detached ring.

Oversensing caused by trapped air in the header of subcutaneous cardioverter-defibrillator generator.

In this study, we report two cases with oversensing due to air accumulation in the subcutaneous implantable cardioverter-defibrillator (S-ICD) device generator header. If trapped air in the header of the device is suspected, the re-connection procedure should be considered or the primary vector must be used, which might prevent oversensing.

Lock and dock: Two-step transvenous retrieval of a fractured femoral sheath with a vascular snare via the right internal jugular vein.

An 86-year-old male with progressive palpitations and dyspnea was referred to our hospital for heart failure treatment. Catheter ablation was performed for atrial flutter as we suspected tachycardia-induced cardiomyopathy as the cause of the patient's heart failure. Due to difficulty securing a peripheral venous route, a 6-Fr sheath was inserted via the right common femoral vein prior to administering general anesthesia. While attempting to insert a mapping catheter, the 6-Fr sheath became lodged and subsequently fractured during removal. Percutaneous transvenous retrieval using an 8-Fr sheath was unsuccessful, and a switch to a right internal jugular vein approach with a 16-Fr sheath was necessary for successful retrieval. The following two-step retrieval ("lock and dock") was then performed: 1) lock: a vascular snare was used to catch the remaining wire crossing into the fractured sheath lumen to prevent the risk of sheath migration to the right ventricle or the pulmonary artery, and 2) dock: the same snare was subsequently used to catch the fractured sheath. The planned catheter ablation was then successfully performed, without any complications. Learning objective: Our case presents, "lock and dock," a novel approach for percutaneous transvenous retrieval that involves two steps: a vascular snare is used to catch the wire and subsequently the fractured sheath. This use of a vascular snare and a large-diameter sheath through the right internal jugular vein effectively reduces the possibility of fractured sheath migration.

Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction.

INTRODUCTION: Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named "Wire ThRoUgh Snare Twice" (Wire TRUST), for effectively grasping a lead without a free end during TLE. METHOD: The Wire TRUST technique was applied in a case involving a 49-year-old male patient requiring TLE due to electrical artifact on the right ventricular (RV) lead, replacement of the RV lead, and pacemaker generator exchange. The Wire TRUST technique involved the insertion of a 4-Fr pigtail catheter and a 6-Fr snare catheter through the 14-Fr sheath inserted from the right common femoral vein. The 4-Fr pigtail catheter was hooked to the RV lead under multidirectional fluoroscopic guidance in the right atrium. The 0.014-in. guidewire was advanced through the pigtail catheter, crossing the RV lead until reaching the inferior vena cava. Subsequently, the distal end of the 0.014-in. guidewire was captured using a snare and pulled, facilitating externalization of the guidewire. After externalization, both ends of the 0.014-in. guidewire were passed through the snare outside the body and reinserted into the 14-Fr sheath. By simultaneously advancing and closing the snare while applying tension to the 0.014-in. guidewire, a secure grip on the lead without free ends was achieved. RESULTS: The Wire TRUST technique enabled successful lead extraction and replacement without any complications. The technique facilitated the co-axial alignment of the powered sheath with the RV lead, ensuring safe and efficient extraction. CONCLUSION: The Wire TRUST technique presents a novel and effective approach for grasping leads with inaccessible ends during TLE.

Rocket-shape crossing technique: A combination of lead extraction and modified venoplasty for device upgrade with venous occlusion.

This case discusses an upgrade method to cardiac resynchronization therapy defibrillator for a 54 year old man with superior vena cava occlusion. Right ventricular lead extraction with modified venoplasty, Rocket shape Crossing Technique (RCT), was performed. In RCT the integration of the inflated balloon, halfway inside the laser sheath, and the laser sheath are advanced through the occlusion like a rocket shape crossing.

Predictors of Pacing Capture Threshold Exacerbation After Leadless Pacemaker Implantation.

The predictors of pacing capture threshold (PCT) exacerbation after leadless pacemaker implantation remain unknown. We analyzed the predictors of poor PCT by identifying risk factors using multivariate logistic regression analysis for 211 patients with leadless pacemaker implantation. Twenty patients met the criteria for elevated PCT levels and were categorized in the poor PCT group. Multivariate analyses revealed that PCT (P < 0.0001) and pacing impedance (P = 0.03) were independent predictors of PCT exacerbation. Elevated PCT levels and low pacing impedance during leadless pacemaker implantation were potential risk factors for the replacement of leadless pacemakers after the procedure.