Three-dimensional-guided and ICE-guided transseptal puncture for cardiac ablations: A propensity score match study.

INTRODUCTION: Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-guided TSP techniques. METHODS: We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D-guided TSP with patients undergoing ICE-guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate, and complications between the groups. RESULTS: Sixty-five patients underwent 3D-guided TSP, and 151 propensity score-matched patients underwent ICE-guided TSP. The TSP success rate was 100% in both the 3D-guided and ICE-guided groups. Median needle time was 4.00 min (interquartile range [IQR]: 2.57-5.08) in patients with 3D-guided TSP compared to 4.02 min (IQR: 2.83-6.95) in those with ICE-guided TSP (p = .22). Mean fluoroscopy time was 0.2 min (IQR: 0.1-0.4) in patients with 3D-guided TSP compared to 1.2 min (IQR: 0.7-2.2) in those with ICE-guided TSP (p < .001). There were no complications related to TSP in both group. CONCLUSIONS: Three-dimensional mapping-guided TSP is as safe and effective as ICE-guided TSP without additional cost.

A comparison of clinical outcomes and cost of radiofrequency catheter ablation for atrial fibrillation with monitored anesthesia care versus general anesthesia.

INTRODUCTION: Monitored anesthesia care (MAC) or general anesthesia (GA) can be used during catheter ablation (CA) of atrial fibrillation (AF). However, each approach may have advantages and disadvantages with variability in operator preferences. The optimal approach has not been well established. The purpose of this study was to compare procedural efficacy, safety, clinical outcomes, and cost of CA for AF performed with MAC versus GA. METHODS: The study population consisted of 810 consecutive patients (mean age: 63 ± 10 years, paroxysmal AF: 48%) who underwent a first CA for AF. All patients completed a preprocedural evaluation by the anesthesiologists. Among the 810 patients, MAC was used in 534 (66%) and GA in 276 (34%). Ten patients (1.5%) had to convert to GA during the CA. RESULTS: Although the total anesthesia care was longer with GA particularly in patients with persistent AF, CA was shorter by 5 min with GA than MAC (p < 0.01). Prevalence of perioperative complications was similar between the two groups (4% vs. 4%, p = 0.89). There was no atrioesophageal fistula with either approach. GA was associated with a small, ~7% increase in total charges due to longer anesthesia care. During 43 ± 17 months of follow-up after a single ablation procedure, 271/534 patients (51%) in the MAC and 129/276 (47%) patients in the GA groups were in sinus rhythm without concomitant antiarrhythmic drug therapy (p = 0.28). CONCLUSION: With the participation of an anesthesiologist, and proper preoperative assessment, CA of AF using GA or MAC has similar efficacy and safety.

Clinical characteristics and long-term outcomes of catheter ablation in young adults with atrial fibrillation.

PURPOSE: We aim to describe the long-term safety and efficacy of catheter ablation (CA) in young patients (<30 years) with atrial fibrillation (AF). METHODS: This was a retrospective study of patients aged 18-30 who underwent CA for AF, and clinical characteristics and long-term outcomes are reported. Survival analyses were performed between the study group and a propensity-matched older cohort (>30 years, mean age: 58±10 years). RESULTS: From January 2000 to January 2019, a 1st CA (radiofrequency energy n=72, cryoballoon n=10), was performed in 82 patients (mean age 26±4 years, paroxysmal n=61, persistent n=14, longstanding persistent n=7), among 6336 consecutive patients with AF. During a follow-up of 5±5 years, 56% and 30% of the patients with paroxysmal and non-paroxysmal AF were arrhythmia free without antiarrhythmic drug (AAD) therapy after a single CA (P=0.02). After 1.5±0.8 CA procedures, 76% and 75% of the patients with paroxysmal AF and non-paroxysmal AF were arrhythmia free without AADs (P=0.54). Compared to a propensity-matched group of older patients, young patients were as likely to remain in sinus rhythm after CA (P=0.47), however after fewer repeat CAs (1.5±0.8 vs 1.9±0.9, P<0.009). There were no long-term adverse outcomes associated with CA. CONCLUSIONS: CA is a safe and effective treatment of AF in young patients with comparable outcomes to the older patients, however after fewer procedures.

Efficacy and tolerability of quinidine as salvage therapy for monomorphic ventricular tachycardia in patients with structural heart disease.

INTRODUCTION: Quinidine is an effective therapy for a subset of polymorphic ventricular tachycardia and ventricular fibrillation (VF) syndromes; however, the efficacy of quinidine in scar-related monomorphic ventricular tachycardia (MMVT) is unclear. METHODS AND RESULTS: Between 2009 and 2020 a single VT referral center, a total of 23 patients with MMVT and structural heart disease (age 66.7 ± 10.9, 20 males, 15 with ischemic cardiomyopathy, mean LVEF 22.2 ± 12.3%, 9 with left ventricular assist device [LVAD]) were treated with quinidine (14 quinidine gluconate; 996 ± 321 mg, 8 quinidine sulfate; 1062 ± 588 mg). Quinidine was used in combination with other antiarrhythmics (AAD) in 19 (13 also on amiodarone). All patients previously failed >1 AAD (amiodarone 100%, mexiletine 73%, sotalol 32%, other 32%) and eight had prior ablations (median of 1.5). Quinidine was initiated in the setting of VT storm despite AADs (6), inability to tolerate other AADs (4), or recurrent VT(12). Ventricular arrhythmias recurred despite quinidine in 13 (59%) patients at a median of 26 (4-240) days after quinidine initiation. In patients with recurrent MMVT, VT cycle length increased from 359 to 434 ms (p = .02). Six (27.3%) patients remained on quinidine at 1 year with recurrence of ventricular arrhythmias in all. The following adverse effects were seen: gastrointestinal side effects (6), QT prolongation (2), rash (1), thrombocytopenia (1), neurologic side effects (1). One patient discontinued due to cost. CONCLUSION: Quinidine therapy has limited tolerability and long-term efficacy when used in the management of amiodarone-refractory scar-related MMVT.

Comparative Efficacy of Dofetilide Versus Amiodarone in Patients With Atrial Fibrillation.

OBJECTIVES: The study's goal was to compare the efficacy and safety of dofetilide (DOF) versus amiodarone (AMIO) in patients with atrial fibrillation (AF). BACKGROUND: Comparative efficacy of DOF versus AMIO in patients with AF has not been well established. In addition, proarrhythmia has been a concern with DOF therapy. METHODS: Rhythm control was attempted by using DOF in 657 consecutive patients (mean age 72 ± 9 years; 35% women) with AF (n = 528) or atrial flutter and AF (n = 129) between January 2014 and December 2018. RESULTS: DOF was successfully initiated in 573 (87%) of 657 patients, including 510 (89%) with persistent AF and 63 (11%) with paroxysmal AF. During a mean follow-up of 19 ± 7 months, sinus rhythm was maintained in 361 (63%) of the 573 DOF-treated patients. At 12 months, patients on DOF had a similar likelihood of experiencing recurrent atrial arrhythmias compared with the 2,476 consecutive patients treated with AMIO for rhythm control during the study period (37% vs. 39%; p = 0.56). The efficacy of DOF and AMIO was also similar in specific subgroups of patients, including patients >75 years of age, with a low left ventricular ejection fraction, obesity, renal insufficiency, and prior catheter ablation for AF. Among patients with atypical atrial flutter, likelihood of recurrent atrial flutter was similar between the DOF (43 of 108 [40%]) and AMIO (211 of 555 [38%]; p = 0.69) groups. CONCLUSIONS: When properly initiated and monitored, DOF has efficacy comparable to that of amiodarone for rhythm control in patients with AF.

Lead damage after cardiac implantable device replacement procedure: Comparison between electrical plasma tool and electrocautery.

BACKGROUND: Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk. OBJECTIVES: This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures. METHODS: We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups. RESULTS: Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p < .01) with average percent changes of 6.7% and 4.0% (p < .01), respectively. Lead impedance decreased in 438 leads (52.1%) in the EC group versus 507 leads (61.5%) in the PlasmaBlade group (p < .01) with average percent changes of -5.7% and -7.1% (p < .01), respectively. Lead damage requiring lead revision occurred in five leads (0.6%) or after five procedures (1.2%) in the EC group compared to three leads (0.4%, p = .50) or after three procedures (0.7%, p = .48) in the PlasmaBlade group. There were no significant differences in the procedural-related complications between the EC group (nine patients, 2.2%) and the PlasmaBlade group (five patients, 1.2%, p = .28). CONCLUSION: Conventional electrocautery can potentially damage lead insulations. However, this study shows that when used carefully electrocautery is as safe as the PEAK PlasmaBlade™.

Effect of metformin on outcomes of catheter ablation for atrial fibrillation.

BACKGROUND: Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) has not been well described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF. METHODS AND RESULTS: A first CA was performed in 271 consecutive patients with DM and AF (age: 65 ± 9 years, women: 34%; and paroxysmal AF: 51%). At a median of 13 months after CA (interquartile range: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared with 36/89 patients (40%) not receiving metformin (p = .03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (hazard ratio [HR]: 0.66; ±95% confidence interval [CI]: 0.44-0.98; p = .04) that adjusted for age, sex, body mass index, AF type (paroxysmal vs. nonparoxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96; p = .03). CONCLUSIONS: In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined.

Baseline and decline in device-derived activity level predict risk of death and heart failure in patients with an ICD for primary prevention.

BACKGROUND: Implanted defibrillators are capable of recording activity data based on company-specific proprietary algorithms. This study aimed to determine the prognostic significance of baseline and decline in device-derived activity level across different device companies in the real world. METHODS: We performed a retrospective cohort study of patients (n = 280) who underwent a defibrillator implantation (Boston, Medtronic, St. Jude, and Biotronik) for primary prevention at the University of Michigan from 2014 to 2016. Graphical data obtained from device interrogations were retrospectively converted to numerical data. The activity level averaged over a month from a week postimplantation was used as baseline. Subsequent weekly average activity levels (SALs) were standardized to this baseline. SAL below 59.4% was used as a threshold to group patients. All-cause mortality and death/heart failure were the primary end-points of this study. RESULTS: Fifty-six patients died in this study. On average, they experienced a 50% decline in SAL prior to death. Patients (n = 129) who dropped their SAL below threshold were more likely to be older, male, diabetic, and have more symptomatic heart failure. They also had a significantly increased risk of heart failure/death (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 2.3-5.8, P < .0001) or death (HR 4.2, 95% CI 2.2-7.7, P < .0001) compared to those who had sustained activity levels. Lower baseline activity level was also associated with significantly increased risk of heart failure/death and death. CONCLUSION: Significant decline in device-derived activity level and low baseline activity level are associated with increased mortality and heart failure in patients with an ICD for primary prevention.

Relationship Between Obstructive Sleep Apnoea and AF.

With the growing obesity epidemic, the global burden of AF and obstructive sleep apnoea (OSA) is increasing at an alarming rate. Obesity, age, male gender, alcohol consumption, smoking and heart failure are common risk factors for both AF and OSA and they are independently associated with adverse cardiovascular outcomes. Weak evidence from observational studies link OSA to the development of AF. Hypoxia/hypercapnia, systemic inflammation and autonomic nervous system modulation are biological mechanisms that link OSA to AF. Patients with OSA have a poor response to catheter ablation of AF and often suffer recurrences. Observational data shows that continuous positive airway pressure is associated with a reduction in AF burden and a better response to catheter ablation of AF. However, prospective randomised studies are needed to confirm the usefulness of continuous positive airway pressure in the treatment of AF in patients with OSA.

Temporal trends and factors associated with increased mortality among atrial fibrillation weekend hospitalizations: an insight from National Inpatient Sample 2005-2014.

OBJECTIVE: Atrial fibrillation (AF) weekend hospitalizations were reported to have poor outcomes compared to weekday hospitalizations. The relatively poor outcomes on the weekends are usually referred to as 'weekend effect'. We aim to understand trends and outcomes among weekend AF hospitalizations. The primary purpose of this study is to evaluate the trends for weekend AF hospitalizations using Nationwide Inpatient Sample 2005-2014. Hospitalizations with AF as the primary diagnosis, in-hospital mortality, length of stay, co-morbidities and cardioversion procedures have been identified using the international classification of diseases 9 codes. RESULTS: Since 2005, the weekend AF hospitalizations increased by 27% (72,216 in 2005 to 92,220 in 2014), mortality decreased by 29% (1.32% in 2005 to 0.94% in 2014), increase in urban teaching hospitalizations by 72% (33.32% in 2005 to 57.64% in 2014), twofold increase in depression and a threefold increase in the prevalence of renal failure were noted over the period of 10 years. After adjusting for significant covariates, weekend hospitalizations were observed to have higher odds of in-hospital mortality OR 1.17 (95% CI 1.108-1.235, P < 0.0001). Weekend AF hospitalizations appear to be associated with higher in-hospital mortality. Opportunities to improve care in weekend AF hospitalizations need to be explored.

Antiarrhythmic drug therapy and all-cause mortality after catheter ablation of atrial fibrillation: A propensity-matched analysis.

BACKGROUND: It is not clear if antiarrhythmic drug therapy (AAD) after catheter ablation (CA) of atrial fibrillation (AF) increases mortality. OBJECTIVE: To determine whether there is an association between AAD therapy and mortality after CA of AF. METHODS: There were 3624 consecutive patients with AF (mean age: 59 ± 11 years, women: 27%, paroxysmal AF: 58%). An AAD was used in 2253 patients (62%, AAD group) for a mean duration of 1.3 ± 0.8 years, during a mean follow-up of 6.7 ± 2.2 years after CA of AF. Using propensity score matching, with every 2 patients using an AAD matched to 1 patient who did not use AAD (NO-AAD group), Cox regression models were utilized to assess the association between AAD use (as a time-variable covariate) and all-cause mortality. RESULTS: There were a total of 50 deaths (2.2%) in the AAD and 62 deaths (4.5%) in the NO-AAD groups, respectively (P = .02). At the time of death, 46 of 50 patients (92%) who died in the AAD cohort were still using an AAD (P = .21, compared to baseline use). On multivariate analysis, although the risk of death was not statistically significant between the AAD and NO-AAD cohorts, there was a trend towards mortality benefit with AAD therapy (hazard ratio [HR]: 0.66, 95% confidence interval [CI]: 0.43-1.00, P = .05), regardless of the rhythm or anticoagulation status. CONCLUSION: AAD use after CA of AF is not associated with an increased risk of mortality, suggesting that when carefully chosen and monitored, AADs appear to be safe after CA of AF.

Atrioventricular conduction in patients undergoing pacemaker implant following self-expandable transcatheter aortic valve replacement.

BACKGROUND: Heart block requiring a pacemaker is common after self-expandable transcatheter aortic valve replacement (SE-TAVR); however, conduction abnormalities may improve over time. Optimal device management in these patients is unknown. OBJECTIVE: To evaluate the long-term, natural history of conduction disturbances in patients undergoing pacemaker implantation following SE-TAVR. METHODS: All patients who underwent new cardiac implantable electronic device (CIED) implantation at Michigan Medicine following SE-TAVR placement between January 1, 2012 and September 25, 2017 were identified. Electrocardiogram and device interrogation data were examined during follow-up to identify patients with recovery of conduction. Logistic regression analysis was used to compare clinical and procedural variables to predict conduction recovery. RESULTS: Following SE-TAVR, 17.5% of patients underwent device placement for new atrioventricular (AV) block. Among 40 patients with an average follow-up time of 17.1 ± 8.1 months, 20 (50%) patients had durable recovery of AV conduction. Among 20 patients without long-term recovery, four (20%) had transient recovery. The time to transient conduction recovery was 2.2 ± 0.2 months with repeat loss of conduction at 8.2 ± 0.9 months. On multivariate analysis, larger aortic annular size (odds ratio: 0.53 [0.28-0.86]/mm, P = 0.02) predicted lack of conduction recovery. CONCLUSIONS: Half of the patients undergoing CIED placement for heart block following SE-TAVR recovered AV conduction within several months and maintained this over an extended follow-up period. Some patients demonstrated transient recovery of conduction before recurrence of conduction loss. Larger aortic annulus diameter was negatively associated with conduction recovery.