Transcatheter closure of atrial septal defect using intracardiac echocardiography: a two-center, retrospective study.

AIMS: We present the experience and long-term results of intracardiac echocardiography (ICE)-guided closure of ostium secundum atrial septal defects (ASDs) in two Italian centers and investigate its systematic applicability as the gold standard in routine clinical practice. METHODS: We retrospectively evaluated all consecutive patients who underwent an ASD percutaneous closure procedure from March 2008 to February 2020. All patients underwent a preprocedural transesophageal echocardiography (TEE) evaluation. The closures were carried out under fluoroscopic and ICE guidance. A follow-up visit was performed at 1, 3 and 12 months, followed by telephone evaluations approximately every 2 years. RESULTS: Sixty-six patients (29% male individuals), mean age 43 ±â€Š16 years, were treated. In 15 cases, the TEE defect diameter was less than 10 mm, and in 8 of these patients, the ICE intraprocedural sizing increased the maximum diameter by more than 5 mm. Sizing balloon of the defect was performed in 51 cases; 2 patients received an ASD 38 mm device. Eight patients had multiple defects; in three of these, it was necessary to apply two devices. Four patients showed nonsignificant residual shunt; no complications related to the use of ICE were observed. One patient presented the migration of the ASD device into the abdominal aorta, percutaneously retrieved with a snare. No major complications were recorded during the entire follow-up period. CONCLUSION: This study confirms that ICE monitoring during ASD percutaneous closure is well tolerated and effective; it might be achievable as a routine gold standard by operators willing to use ICE systematically in all transcatheter closure interventions of interatrial communications.

ECMO-Supported Ablation and Percutaneous Repair of Severe Valvulopathy: A Winning Combination in a Complex Clinical Case.

In this case report, we describe a complex case of a 67-year-old patient who was suffering from acute heart failure with electrical storm. Clinical case management was based on an integrated approach comprising two different procedures that were complementary and synergistic, and that allowed the patient to reach acute stabilization and to demonstrate mid-term clinical improvement. Complex clinical settings, such as electrical and hemodynamic instability, require complex solutions. The use of an integrated approach that allows physiopathological mechanisms to work together may be beneficial for these patients.

Cardiopulmonary Support During Catheter Ablation of Ventricular Arrhythmias With Hemodynamic Instability: The Role of Inducibility.

Background: Catheter ablation is a treatment option for sustained ventricular tachycardias (VTs) that are refractory to pharmacological treatment; however, patients with fast VT and electrical storm (ES) are at risk for cardiogenic shock. We report our experience using cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) during catheter ablation of VT. Methods: Sixty-two patients (mean age 68 ± 9 years; 94% male) were referred to our center for catheter ablation of repeated episodes of hemodynamically unstable ventricular arrhythmias. ES was defined as the occurrence of three or more VT/ventricular fibrillation episodes requiring electrical cardioversion or defibrillation in a 24-h period. All patients had hemodynamically unstable VTs. Results: Thirty-one patients (group 1) performed catheter ablation without ECMO support and 31 patients (group 2) with ECMO support. At the end of the procedure, ventricular inducibility was not performed in 16 patients of group 1 (52%) due to significant hemodynamic instability. Ventricular inducibility was performed in the other 15 patients (48%); polymorphic VTs were inducible in eight patients. In group 2, VTs were not inducible in 29 patients (93%); polymorphic VTs were inducible in two patients. The median follow-up duration was 24 months. Four patients of group 1 (13%) and five patients of group 2 (16%) died due to refractory heart failure. An implantable cardioverter-defibrillator intervention (shock or antitachycardia pacing) was documented in 13 patients of group 1 (42%) and six patients of group 2 (19%). Conclusions: Extracorporeal membrane oxygenation support during catheter ablation for hemodynamically unstable VTs is a useful tool to prevent acute procedural heart failure and to reduce arrhythmic burden.

Stereotactic Ablative radiation therapy (SABR) for cardiac arrhythmia: A new therapeutic option?

AIM: Stereotactic ablative radiation therapy (SABR) is used in non-oncologic indications, recently even for cardiac arrhythmias. Thus, aim of this analysis is to review preclinical, early clinical evidences and future direction of the latter new treatment approach. METHOD: A collection of available data regarding SABR and cardiac arrhythmias was made, by Pubmed research and 2 independent researchers, including preclinical and clinical data. A review of ongoing trials was conducted on ClinicalTrials.gov. RESULTS: Preclinical research conducted in animal models showed that a safe and effective noninvasive treatment approach for cardiac arrhythmias could be represented by SABR with a median time of response around 2-3 months. The treatment dose plays a crucial role: the atrioventricular node would seem more radiosensitive than the other cardiac electric zones. Clinical data, such as published case series, case reports and early prospective studies, have already suggested the feasibility, efficacy and safety of SABR (25 Gy in one session) for refractory ventricular arrhythmias. CONCLUSION: Considering the ongoing trials of SABR and new technological improvements in radiotherapy (e.g. hybrid magnetic resonance) and in arrhythmias noninvasive mapping systems, the future analyses will improve the reliability of those preliminary results.

Electroanatomic guidance versus conventional fluoroscopy during transseptal puncture for atrial fibrillation ablation.

INTRODUCTION: Technological advancement in the setting of atrial fibrillation (AF) ablation has decreased radiation exposure and complications associated with the procedure. Yet, transseptal puncture (TSP) remains a challenging step that necessitates accurate guidance. We describe our experience performing TSP under electroanatomic (EA) guidance. METHODS AND RESULTS: The analysis included 145 consecutive EA-guided ablation procedures performed between June 2018 and April 2019 and 145 consecutive standard ablations performed before June 2018. EA guidance utilized the CARTO 3 three-dimensional mapping system to reconstruct anatomic and electrical characteristics of the right atrium and fossa ovalis. Patients with a history of previous cardiac surgery were excluded. For EA-guided procedures, the mean patient age was 60 ± 10 years, 75.2% were male, and 69.0% had paroxysmal AF. Similarly, the mean age for conventional procedures was 60 ± 11 years, 71.0% were male, and 71.7% had paroxysmal AF. The fossa ovalis was detected as a region of low voltage, <0.75 mV. EA guidance yielded shorter fluoroscopy times (EA vs. conventional, 3.6 ± 2.5 vs. 13.5 ± 10.5 min; p < .001) and a lower dose area product than conventional guidance (13 ± 11 Gy* cm2 vs. 28 ± 27 Gy* cm2 ; p < .001). The total procedure duration was similar between groups (146 ± 48 vs. 148 ± 54 min). There were no significant complications related to TSP. CONCLUSION: During AF ablation, TSP with EA guidance facilitated safe access to the left atrium while reducing radiation risk to both patients and operators.

Catheter ablation of atrial fibrillation with uninterrupted anticoagulation: a meta-analysis of six randomized controlled trials.

AIMS: Uninterrupted anticoagulation is recommended during the ablation of atrial fibrillation. This meta-analysis compared the safety and efficacy of uninterrupted direct oral anticoagulants (DOACs) to uninterrupted vitamin K antagonists (VKAs) during atrial fibrillation ablation. METHODS: The meta-analysis included eligible randomized controlled trials from 2009 to 2019. Odds ratios (ORs) and 95% confidence intervals were pooled using a random effects model and a sensitivity analysis was performed by sequentially removing one study or DOAC at a time. RESULTS: Six studies were included; 1288 received DOAC and 1081 VKA. Pooled ORs indicated a lower nonsignificant incidence in DOACs vs. VKA of composite outcome of major bleeding, stroke, or transient ischemic attack, and mortality (0.69; 0.28-1.71; 31 vs. 45 events), major bleeding alone (0.66; 0.30-1.47; 27 vs. 41 events), and cardiac tamponade (0.56; 0.21-1.45; eight vs. 13 events) with a slightly higher occurrence of minor bleeding (1.17; 0.89-1.56; 139 vs. 106 events) and silent cerebral thromboembolic events (1.12; 0.75-1.66; 72 vs. 58 among 442 and 376 patients performing MRI study). Sensitivity analyses confirmed overall results: pooled ORs ranged from 0.56 to 1.00 for the composite outcome and from 0.54 to 0.92 for major bleedings. CONCLUSION: Uninterrupted DOAC is a safe and effective alternative to uninterrupted VKA during atrial fibrillation ablation.

Cardiopulmonary support in patients undergoing catheter ablation of poorly tolerated ventricular arrhythmias and electrical storm.

INTRODUCTION: Catheter ablation is an important treatment option for sustained ventricular arrhythmias (VA) that are refractory to pharmacological treatment; however, patients with fast VA or electrical storm (ES) are at risk for cardiogenic shock. We report our experience using cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) during catheter ablation of VA. METHODS: Nineteen patients (mean age, 62 ± 10 years; 84% male) were referred to our center for CA of ES between January 2017 and April 2018. ES was defined as the occurrence of ≥3 ventricular tachycardia or ventricular fibrillation episodes requiring electrical cardioversion or defibrillation in a 24-hour period. ECMO support was implemented for all patients. RESULTS: CA of ES was completed in all patients. Activation mapping was performed for all VTs and substrate modification was performed by targeting sites identified by late/fragmented abnormal potentials. VTs were not inducible after ablation in 16 of 19 patients (84%). With regard to procedural complications, two patients underwent percutaneous angioplasty with stenting for a femoral artery dissection and one patient was treated for a dislodged ECMO arterial cannula and subsequent hemorrhagic shock. After a median follow-up of 10 months, three patients died from refractory heart failure and one patient died as a result of ES. Overall, the procedural success rate was 68% and the Kaplan-Meier mortality rate was 21%. CONCLUSIONS: ECMO support may be used for ablation procedures in patients with ES.

Bilateral left lateral ridge ablation increases the long-term success of patients ablated for atrial fibrillation.

AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation in paroxysmal atrial fibrillation (PAF). Studies reported that the PVI single procedure was able to achieve durable sinus rhythm without the need of antiarrhythmic drugs in 60-80% of patients with PAF. In this study, we report data regarding bilateral left lateral ridge ablation for PAF. METHODS: We retrospectively collected data of 120 consecutive patients (mean age 56 ±â€Š10 years; 62% male) referred to our center to perform PVI. In 60 patients we performed PVI (group 1) and in 60 patients performed PVI and bilateral left lateral ridge ablation (group 2). All patients performed a clinical follow-up after 24 months from the ablation procedure. RESULTS: PVI was achieved in all patients. The mean radiofrequency time to perform ablation on the left atrial appendage ostium was 216 ±â€Š49 s. In all patients of group 2 we obtained disappearance of local electrograms and the loss of local capture during pacing on posterior wall of left atrial appendage ridge. No significant differences were found between the two groups regarding mean contact force during ablation (14 ±â€Š4 vs. 15 ±â€Š4 g; groups 1 and 2, respectively, P = 0.34). At 24-month follow-up, single procedure success rate was significantly higher in group 2 compared with group 1 (88 vs. 74%, respectively; P = 0.03). No significant procedural complications were documented. CONCLUSION: Bilateral left lateral ridge ablation is a safe technique able to improve the success rate of PVI in patients with PAF.

Self-expanding stent for spontaneous coronary artery dissection: a rational choice.

: Spontaneous coronary artery dissection (SCAD) is a rare and poorly understood cause of acute coronary syndrome in relatively young patients. Nowadays, the optimal treatment of SCAD is uncertain. A conservative approach seems to be preferable, but in particular conditions, an invasive strategy is necessary. The poor rate of procedural success, the high risk of procedural complications and the uncertain long and mid-term results make the interventional treatment of SCAD a challenge. We report a case of a young male patient presenting with SCAD successfully treated with a sirolimus-eluting self-expanding coronary stent. To our knowledge, the use of self-expanding coronary stent for SCAD has never been described yet and we discuss about the rationale of a possible larger use in clinical practice.

Ablation of atrial fibrillation and esophageal injury: Role of bipolar and unipolar energy using a novel multipolar irrigated ablation catheter.

BACKGROUND: The circular nMARQ ablation catheter is a useful tool for pulmonary vein isolation (PVI). Some studies reported a high incidence of esophageal lesions by using this catheter. OBJECTIVE: The primary aim of this study was to compare the effects on the esophageal wall of bipolar and unipolar energy applied by the nMARQ ablation catheter during AF ablation. METHODS: Forty patients (mean age 53 ± 8 years; 26 [65%] men) were enrolled to perform PVI for symptomatic atrial fibrillation. Thirty patients underwent PVI with the nMARQ catheter (group 1) and 10 patients with the ThermoCool Surround Flow catheter (group 2). The procedures were performed with the CARTO3 system. All patients received an esophageal temperature probe. In group 1, we delivered unipolar energy on the left posterior wall with power between 15 and 18 W or bipolar energy with power at 15 W. In group 2, unipolar energy was delivered on the posterior atrial wall at 20-25 W power. All patients underwent esophagoscopy the day after the procedure. RESULTS: No patients had procedural complications. In group 1, bipolar energy was associated with a lower esophageal temperature increase as compared with unipolar energy (0.6°C [range 0-2.2°C] vs 2.1°C [range 0.8-2.9°C]; P < .001). Unipolar energy was associated with a similar temperature increase in the 2 groups (1.9°C [range 0.8-2.9°C] in group 1 vs 1.7°C [range 0.7-2.9°C] in group 2; P = .49). No patient had esophageal injury. CONCLUSION: The use of the nMARQ catheter for PVI is feasible and safe. The use of 15 W for bipolar energy or 15-18 W for unipolar energy is an optimal strategy to avoid esophageal injury with this new catheter.

Spontaneous coronary artery dissection: One more extrarenal manifestation of autosomal dominant polycystic kidney disease?

Autosomal dominant polycystic kidney disease (ADPKD) may present with a variety of extrarenal manifestations. Only 1 case of spontaneous coronary artery dissection has been reported so far in ADPKD. Here we report a case of coronary artery dissection occurring in a 38-year-old woman with ADPKD and an unremarkable medical history. She was admitted to the intensive care unit with acute chest pain. Anterior myocardial infarction was diagnosed by ECG; the patient was treated with thrombolysis with tenecteplase and aspirin, heparin and carvedilol. Then she was referred to the cardiac catheterization laboratory. Coronary angiography revealed a long linear dissection in the middle left descending coronary artery (DCA) with TIMI 1 distal flow. Complete vessel recanalization was achieved by positioning 2 drug-eluting and overlapped stents in the middle DCA and a further proximal stent due to residual proximal dissection, resulting in a TIMI 3 distal flow. There were no procedural complications, and the patient was discharged on day 8. In conclusion, spontaneous coronary artery dissection is a rare cause of myocardial ischemia and infarction. Myocardial infarction in patients without any risk factors for coronary atherosclerosis or in young patients should prompt a diligent search for a possible spontaneous coronary artery dissection. It is suggested that ADPKD may be a predisposing factor for spontaneous coronary artery dissection.

Optical coherence tomography imaging in complicated acute myocardial infarction treated with primary angioplasty and AngioJet.

We describe the case of a 47-year-old man presenting with inferior acute myocardial infarction complicated by complete atrioventricular block and cardiogenic shock, who underwent primary angioplasty and rheolytic thrombectomy with AngioJet and subsequent evaluation by optical coherence tomography. Optical coherence tomography is a rather novel technique in the management of coronary disease, and as far as we know, this is the first report about optical coherence tomography imaging after AngioJet thrombectomy. Moreover, we provide a brief discussion on advantages and disadvantages of this imaging modality on the basis of current practice.

Ischemic cardiomyopathy, left coronary trunk hypoplasia and subsidiary coronary supply from the descending thoracic aorta.

Clinical symptoms of acute or chronic myocardial ischemia due to congenital coronary anomalies occasionally develop during adult life. While several types of coronary anomalies have been already reported, origin of the coronary arteries outside of the ascending aorta and pulmonary trunk is exceedingly rare, and has indeed been described to date only in a 6-day-old newborn. We hereby report to the best of our knowledge the first and unique case of an adult patient with ischemic cardiomyopathy, in whom coronary angiography and aortography disclosed both left main trunk hypoplasia and subsidiary left coronary supply provided by an ectopic artery arising from the descending thoracic aorta.