Bilateral Cardiac Sympathetic Denervation for Refractory Multifocal Premature Ventricular Contractions in Patients With Nonischemic Cardiomyopathy.

BACKGROUND: Bilateral cardiac sympathetic denervation (BCSD) for refractory life-threatening ventricular arrhythmias is a neuromodulatory intervention targeting sympathetically driven focal or re-entrant ventricular arrhythmias. OBJECTIVES: This study sought to provide a more complete and successful option for intervention in patients in whom premature ventricular contraction (PVC) ablation is not feasible or has been unsuccessful. METHODS: A total of 43 patients with >5% PVC burden and concomitant nonischemic cardiomyopathy (NICM) who previously failed medical and ablation therapies were referred for BCSD. All patients underwent bilateral video-assisted thoracoscopic surgical approach with T1-T4 sympathectomy. Primary effectiveness endpoints were postprocedural PVC burden resolution, improvement in left ventricular ejection fraction (LVEF), and cessation of antiarrhythmic drugs (AADs). Safety endpoints included peri- and postprocedural complications. Outcomes were assessed over a 1-year follow-up period. RESULTS: Among the 43 patients who underwent BCSD, the mean age was 52.3 ± 14.7 years, 69.8% of whom were male patients. Presenting mean LVEF was 38.7% ± 7.8%, and PVC burden was 23.7% ± 9.9%. There were significant reductions in PVC burden postprocedurally (1.3% ± 1.1% post-BCSD, compared with 23.7% ± 9.9% pre-BCSD, P < 0.001) and improvements in LVEF (46.3% ± 9.5% post-BCSD, compared with 38.7% ± 7.8% pre-BCSD, P < 0.001). The rate of ICD therapies decreased from 81.4% (n = 35) to 11.6% (n = 5) (P < 0.001), leading to a significant reduction in use of AADs (100.0% to 11.6%, P < 0.001) and improvement in mean NYHA functional class (2.5 ± 0.5 to 1.4 ± 0.2, P < 0.001). Major intraoperative complications were seen in 4.7% of patients (hemothorax and chylothorax). Of the patients, 81.4% (n = 35) experienced no mortality or major complications over a 1-year follow-up period, with the remaining still within their first year postprocedure. CONCLUSIONS: BCSD is effective for the management of refractory PVCs and ventricular tachycardia who have failed previous ablation therapy.

Peri-procedural use of direct anticoagulation agents during cardiac device implantation: vitamin K antagonists vs direct oral anticoagulants.

BACKGROUND: Warfarin is deemed safe compared to bridging with heparin in the peri-procedure setting while implanting cardiac devices. The timing of discontinuation and re-initiation of direct anticoagulant agents (DOACs) such as dabigatran, apixaban, and rivaroxaban in the peri-procedural setting in comparison to warfarin is not well studied. OBJECTIVE: We wanted to compare three DOAC agents with warfarin during cardiac device implantation. METHODS: Consecutive patients on treatment with dabigatran, rivaroxaban, or apixaban (group A) undergoing a cardiac device generator change, upgrade, or new implantation procedure were compared to those on warfarin (group B). Incidence of hematoma, infection, effusion, stroke, and other complications were noted at 1 day, 1 week, and 3 months. RESULTS: A total of 311 patients in group A underwent the above procedures with 73 patients on dabigatran, 153 on rivaroxaban, and 85 on apixaban. There were 467 patients on warfarin in group B. Mean age of the total population was 68 ± 12 years with 67% males and > 80% Caucasians. The last dose of the DOAC was the night prior to the procedure and resumed the night of the procedure (single dose interruption for apixaban and dabigatran and no un-interruption for rivaroxaban). There was no difference noted in the incidence of minor or major hematoma (9% vs 8.5%, p = 0.7). No stroke occurred in either group. CONCLUSION: Use of DOAC agents with transient interruption of one dose is as safe as warfarin in the peri-procedural setting during implantation of cardiac devices.

Safety and efficacy of leadless pacemaker for cardioinhibitory vasovagal syncope.

BACKGROUND: Single-chamber leadless pacemakers (LPs) have been shown to be an effective alternative to conventional transvenous pacemakers (CTPs), but their benefit in the context of cardioinhibitory vasovagal syncope (CI-VVS) is unknown. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of LP compared with dual-chamber CTP for CI-VVS. METHODS: We conducted a multicenter, retrospective study comparing patients who received LP or dual-chamber CTP for drug-refractory CI-VVS. CI-VVS was diagnosed clinically and supported by cardiac monitoring and head-up tilt table testing. The primary efficacy endpoint was freedom from syncope during follow-up. Secondary endpoints included device efficacy and safety estimated by device-related major and minor adverse events (AEs). RESULTS: Seventy-two patients (24 LP, 48 CTP; age 32 ± 5.5 years; 90% female; syncope frequency 7.6 ± 3.4 per year) were included. At 1 year, 91% of patients (22/24) in the LP group and 94% of patients (43/48) in the CTP group met the primary efficacy endpoint (P = .7). Device efficacy endpoint was met in 92% of the LP group and 98% of the CTP group (P = .2). Early major AEs occurred in 2 of 24 in the LP group and 3 of 48 in the CTP group (P = .4). Late major AEs occurred in 0 of 24 in the LP group and 2 of 48 in the CTP group (P = 1). CONCLUSION: In patients with CI-VVS, single-chamber LP demonstrated equivalent efficacy in reducing syncopal events compared to dual-chamber CTP, with a similar safety profile.

Differences in Transient Thermal Response of Commercial Esophageal Temperature Probes: Insights From an Experimental Study.

OBJECTIVES: The purpose of this study was to evaluate the differences in transient thermal response (TTR) among various types of commercial esophageal temperature probes (ETPs) in the United States in an experimental model. BACKGROUND: There is little information regarding the variation in TTR among various commercial ETPs that are approved for atrial fibrillation ablation. METHODS: We compared various thermodynamic characteristics including, mean thermal time constant (τ), time to rise 1°C (T1°C), time to peak temperature (Tpeak), and decay time among 22 different ETPs. Each probe was submerged in a constant-temperature water bath maintained at 37 ± 0.5°C and then quickly (<0.5 s) submerged into another water bath at 45 ± 0.5°C. The experiments were repeated 3 times with each probe. TTR properties were compared on the basis of probe size, design, and number of sensors. RESULTS: The τ was significantly higher with the larger 24- and 18-F ETPs compared with the smaller 9-F ETPs. Compared with the 18-F probe, T1°C (11.9 s vs. 5 s), Tpeak (40.3 s vs. 14.4 s), and Tdecay (92.4 s vs. 32.4 s) was shorter with the 9-F ETPs. Solid-shaft ETPs had shorter τ (8.6 s vs. 20.5 s), T1°C (4.4 s vs. 10.1 s) and Tpeak (13.5 s vs. 32.5 s) compared with acoustascopes. Multisensor ETPs had shorter τs (3.9 s vs. 9.1 s), T1°C (2.3 s vs. 5 s), and Tpeak (6.2 s vs. 14.4 s) compared with single-sensor ETPs. CONCLUSIONS: There is a significant variation in TTR among the various commercially available ETPs. The use of certain ETPs might result in underestimation of luminal esophageal temperature, which can potentially lead to adverse events.