A novel robotic radiation shielding device for electrophysiologic procedures: A prospective study.

BACKGROUND: A robotic Radiaction Shielding System (RSS) was developed to provide a full-body protection to all medical personnel during fluoroscopy-guided procedures, by encapsulating the imaging beam and blocking scattered radiation. OBJECTIVES: We aimed to evaluate its efficacy in real-world electrophysiologic (EP) laboratory- both during ablations and cardiovascular implantable electronic devices (CIED) procedures. METHODS: A prospective controlled study comparing consecutive real-life EP procedures with and without RSS using highly sensitive sensors in different locations. RESULTS: Thirty-five ablations and 19 CIED procedures were done without RSS installed and 31 ablations and 24 CIED procedures (17 with usage levels ≥70%) were done with RSS. Overall, there was 95% average usage level for ablations and 88% for CIEDs. For all procedures with ≥70% usage level and for all sensors, the radiation with RSS was significantly lower than radiation without RSS. For ablations, there was 87% reduction in radiation with RSS (76%-97% for different sensors). For CIEDs, there was 83% reduction in radiation with RSS (59%-92%). RSS usage did not increase procedure time and radiation time. User feedback showed a high-level of integration in the clinical workflow and safety profile for all types of EP procedures. CONCLUSIONS: For both CIED and ablation procedures the radiation with RSS was significantly lower than without RSS. Higher usage level brings higher reduction rates. Thus, RSS may have an important role in full-body protection to all medical personnel from scattered radiation during EP and CIED procedures. Until more data is available, it is recommended to maintain existing standard shielding.

The Prevalence of Cannabis-related Arrhythmias in Patients with Cancer: Real-world Data Evidence of Patient-reported Outcomes.

BACKGROUND: Cannabis consumption is suspected of causing arrhythmias and potentially sudden death. OBJECTIVES: To investigate prevalence and temporal relationships between cannabis use and onset of symptomatic arrhythmias among cancer patients using Belong.life, a digital patient powered network application. METHODS: Real-world data (RWD) were obtained through Belong.Life, a mobile application for cancer patients who use cannabis routinely. Patients replied anonymously and voluntarily to a survey describing their demographics, medical history, and cannabis use. RESULTS: In total, 354 cancer patients (77% female, 71% 50-69 years of age) replied: 33% were smokers and 49% had no co-morbidities. Fifteen had history of arrhythmias and two had a pacemaker; 64% started cannabis before or during chemotherapy and 18% had no chemotherapy. Cannabis indication was symptom relief in most patients. The mode of administration included oil, smoking, or edibles; only 35% were prescribed by a doctor. Cannabis type was delta 9-tetrahydrocannabinol > 15% in 43% and cannabidiol in 31%. After starting cannabis, 24 patients (7%) experienced palpitations; 13 received anti-arrhythmic drugs and 6 received anticoagulation. Eleven needed further medical investigation. Three were hospitalized. One had an ablation after starting cannabis and one stopped cannabis due to palpitations. Seven patients (2%) reported brady-arrhythmias after starting cannabis, but none needed pacemaker implantation. CONCLUSIONS: RWD showed that in cancer patients using cannabis, the rate of reported symptomatic tachy- and brady-arrhythmias was significant (9%) but rarely led to invasive treatments. Although direct causality cannot be proven, temporal relationship between drug use and onset of symptoms suggests a strong association.

Left Atrial Strain: Clinical Use and Future Applications-A Focused Review Article.

Atrial cardiomyopathy represents a process of structural and functional changes affecting the atria and leading eventually to clinical manifestation of atrial fibrillation and risk of stroke. Multimodality imaging provides a comprehensive evaluation of atrial remodeling and plays a crucial role in the decision-making process in treatment strategy. This paper summarizes the current state of knowledge on the topic of left atrial strain imaging using two-dimensional speckle tracking echocardiography (2D-STE). We focus on our recently published data on left atrial remodeling assessed by 2D-STE versus high-density voltage mapping in patients with atrial fibrillation (AF).

Polymorphic ventricular tachycardia, ischaemic ventricular fibrillation, and torsade de pointes: importance of the QT and the coupling interval in the differential diagnosis.

AIMS: Distinctive types of polymorphic ventricular tachycardia (VT) respond differently to different forms of therapy. We therefore performed the present study to define the electrocardiographic characteristics of different forms of polymorphic VT. METHODS AND RESULTS: We studied 190 patients for whom the onset of 305 polymorphic VT events was available. The study group included 87 patients with coronary artery disease who had spontaneous polymorphic VT triggered by short-coupled extrasystoles in the absence of myocardial ischaemia. This group included 32 patients who had a long QT interval but nevertheless had their polymorphic VT triggered by ectopic beats with short coupling interval, a subcategory termed 'pseudo-torsade de pointes] (TdP). For comparison, we included 50 patients who had ventricular fibrillation (VF) during acute myocardial infarction ('ischaemic VF' group) and 53 patients with drug-induced TdP ('true TdP' group). The QT of patients with pseudo-TdP was (by definition) longer than that of patients with polymorphic VT and normal QT (QTc 491.4 ± 25.2 ms vs. 447.3 ± 55.6 ms, P < 0.001). However, their QT was significantly shorter than that of patients with true TdP (QTc 564.6 ± 75.6 ms, P < 0.001). Importantly, the coupling interval of the ectopic beat triggering the arrhythmia was just as short during pseudo-TdP as during polymorphic VT with normal QT (359.1 ± 38.1 ms vs. 356.6 ± 39.4 ms, P = 0.467) but was much shorter than during true TdP (581.2 ± 95.3 ms, P < 0.001). CONCLUSIONS: The coupling interval helps discriminate between polymorphic VT that occurs despite a long QT interval (pseudo-TdP) and polymorphic arrhythmias striking because of a long QT (true TdP).

Echocardiography-guided Cardiac Implantable Electronic Device Implantation to Reduce Device Related Tricuspid Regurgitation: A Prospective Controlled Study.

BACKGROUND: Endocardial leads of permanent pacemakers (PPM) and implantable defibrillators (ICD) across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR) or can worsen existing TR with subsequent severe morbidity and mortality. OBJECTIVES: To evaluate prospectively the efficacy of intraprocedural 2-dimentional-transthoracic echocardiography (2DTTE) in reducing/preventing lead-associated TR. METHODS: We conducted a prospective randomized controlled study comparing echocardiographic results in patients undergoing de-novo PPM/ICD implantation with intraprocedural echo-guided right ventricular (RV) lead placement (Group 1, n=56) versus non-echo guided implantation (Group 2, n=55). Lead position was changed if TR grade was more than baseline in Group 1. Cohort patients underwent 2DTTE at baseline and 3 and/or 6 months after implantation. Excluded were patients with baseline TR > moderate or baseline ≥ moderate RV dysfunction. RESULTS: The study comprised 111 patients (74.14 ± 11 years of age, 58.6% male, 19% ICD, 42% active leads). In 98 patients there was at least one follow-up echo. Two patients from Group 1 (3.6%) needed intraprocedural RV electrode repositioning. Four patients (3.5%, 2 from each group, all dual chamber PPM, 3 atrial fibrillation, 2 RV pacing > 40%, none with intraprocedural reposition) had TR deterioration during 6 months follow-up. One patient from Group 2 with baseline mild-moderate aortic regurgitation (AR) had worsening TR and AR within 3 months and underwent aortic valve replacement and TV repair. CONCLUSIONS: The rate of mechanically induced lead-associated TR is low; thus, a routine intraprocedural 2DTTE does not have a significant role in reducing/preventing it.

Comparison of Factors Associated with Inflammation, Thrombosis, and Platelet Reactivity as well as Turnover between Patients with High versus Low CHA2DS2-VASc without Atrial Fibrillation.

BACKGROUND: The CHA2DS2-VASc score has been shown to predict systemic thromboembolism and mortality in certain groups in sinus rhythm (SR), similar to its predictive value with atrial fibrillation (AF). OBJECTIVES: To compare factors of inflammation, thrombosis, platelet reactivity, and turnover in patients with high versus low CHA2DS2-VASc score in SR. METHODS: We enrolled consecutive patients in SR and no history of AF. Blood samples were collected for neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), immature platelet fraction (IPF%) and count (IPC), CD40 ligand, soluble P-selectin (sP-selectin) and E-selectin. IPF was measured by autoanalyzer and the other factors by ELISA. RESULTS: The study comprised 108 patients (age 58 ± 18 years, 63 women (58%), 28 (26%) with diabetes), In addition, 52 had high CHA2DS2-VASc score (³ 2 for male and ³ 3 for female) and 56 had low score. Patients with low scores were younger, with fewer co-morbidities, and smaller left atrial size. sP-selectin was higher in the high CHA2DS2-VASc group (45, interquartile ratio [IQR] 36-49) vs. 37 (IQR 28-46) ng/ml, P = 0.041]. Inflammatory markers were also elevated, CRP 3.1 mg/L (IQR 1.7-9.3) vs. 1.6 (IQR 0.78-5.4), P < 0.001; NLR 2.7 (IQR 2.1-3.8) vs. 2.1 (IQR 1.6-2.5), P = 0.001, respectively. There was no difference in E-selectin, CD40 ligand, IPC, or IPF% between the groups. CONCLUSIONS: Patients in SR with high CHA2DS2-VASc score have higher inflammatory markers and sP-selectin. These findings may explain the higher rate of adverse cardiovascular events associated with elevated CHA2DS2-VASc score.

[COMPLETE ATRIOVENTRICULAR BLOCK DUE TO PULMONARY EMBOLISM].

INTRODUCTION: Pulmonary embolism, a common and potentially fatal clinical condition, occurs when a blood thrombus becomes lodged in the pulmonary vasculature and creates an acute increment in the pulmonary vascular resistance, which, in turn, creates a right ventricular strain. Among the more familiar electrocardiographic manifestations in acute pulmonary embolism is sinus tachycardia, right bundle branch block and ST-T abnormalities in the right precordium leads. Complete heart block or any type of bradycardia is uncommon. In our case report we present an 81 years old woman who was admitted to our institution with acute pulmonary embolism and complete atrioventricular block, which later resolved with appropriate anticoagulation therapy.

Evaluation of left atrial remodeling by 2D-speckle-tracking echocardiography versus by high-density voltage mapping in patients with atrial fibrillation.

BACKGROUND: Strain imaging during left atrial (LA) reservoir phase (LASr) is used as a surrogate for LA structural remodeling and fibrosis. Atrial fibrillation (AF) patients with >5% low-voltage zones (LVZs) obtained by 3D-electro-anatomical-mapping have higher recurrence rate post-ablation. We investigated the relationship between LA remodeling using two-dimensional-speckle-tracking echocardiography (2D-STE) and high-density voltage mapping in AF patients. METHODS: A prospective study of 42 consecutive patients undergoing AF ablation. 2D-echo, 2D-STE, and high-density contact LA bipolar voltage maps were constructed before ablation. LVZs were determined with different bipolar amplitudes and their ratio per patient's LA area were investigated for correlation with LASr. We compared 2D-LASr results in patients with LVZs ≥ 5% (LVZs group) versus those with LVZ < 5% (non-LVZs group). RESULTS: Compared with non-LVZs group (n = 15), LVZs group (n = 27) included significantly older patients, more women, more persistent AF, higher CHA2 DS2 -VASc score, higher E/A ratio and higher LA volume index (p < .05). LVZs group had lower %LASr values (12.4 ± 5.9% vs. 21.1 ± 6.3, respectively; p<.001). LVZs% in different amplitudes (<0.1 mV, <0.2 mV, and <0.5 mV) were negatively correlated with %LASr (r = -.63, r = -.68, and r = -.72, respectively; p< .001). Atrial strain thresholds for LVZs ≥ 5% in amplitudes <0.1 mV, <0.2 mV, and <0.5 mV were associated with %LASr 12.98, 16.16 and 19.55, respectively; p< .05). In a multivariate analysis, %LASr was the only independent indicator of LVZs (OR, 0.8; 95% CI, 0.6-0.9; p= .04). CONCLUSIONS: LVZs ≥ 5% has a negative association with atrial %LASr. Thus, a simple 2D-STE measurement of %LASr can be used as a noninvasive method to evaluate significant LA remodeling and fibrosis in AF patients.

Immature platelets in patients hospitalized with Covid-19.

Coronavirus disease 2019 (Covid-19) is associated with high incidence of venous and arterial thromboembolic events. Currently, there are no markers to guide antithrombotic therapy in Covid-19. Immature platelets represent a population of hyper-reactive platelets associated with arterial events. This prospective study compared consecutive Covid-19 patients (n = 47, median age = 56 years) to patients with acute myocardial infarction (AMI, n = 100, median age = 59 years) and a group of stable patients with cardiovascular risk factors (n = 64, median age = 68 years). Immature platelet fraction (IPF) and immature platelet count (IPC) were determined by the Sysmex XN-3000 auto-analyzer on admission and at subsequent time-points. IPF% on admission was higher in Covid-19 than the stable group and similar to the AMI group (4.8% [IQR 3.4-6.9], 3.5% [2.7-5.1], 4.55% [3.0-6.75], respectively, p = 0.0053). IPC on admission was also higher in Covid-19 than the stable group and similar to the AMI group (10.8 × 109/L [8.3-18.1], 7.35 × 109/L [5.3-10.5], 10.7 × 109/L [7.7-16.8], respectively, P < 0.0001). The maximal IPF% among the Covid-19 group was higher than the stable group and similar to the AMI group. The maximal IPC in Covid-19 was higher than the maximal IPC in both the stable and AMI groups (COVID-19: 14.4 × 109/L [9.4-20.9], AMI: 10.9 × 109/L [7.6-15.2], P = 0.0035, Stable: 7.55 × 109/L [5.55-10.5], P < 0.0001). Patients with Covid-19 have increased immature platelets indices compared to stable patients with cardiovascular risk factors, and as the disease progresses also compared to AMI patients. The enhanced platelet turnover and reactivity may have a role in the development of thrombotic events in Covid-19 patients.

Temporal trends in prognosis of patients with acute coronary syndrome complicated by ventricular tachyarrhythmia.

OBJECTIVES: To evaluate clinical characteristics and prognosis of patients presented with acute coronary syndrome (ACS) that developed ventricular tachyarrhythmia VTA and to analyse it according to the period of presentation. BACKGROUND: VTA is an infrequent yet serious complication of ACS. There is limited data regarding the incidence and prognostic implications of VTA in the last decade as compared with the previous decade. METHODS: We evaluated clinical characteristics, major adverse cardiovascular events, short and long- term mortality of patients hospitalised with ACS who were enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) during the years 2000-2016. Patients were classified into three groups: no VTA, early VTA (≤48 hours of onset) and late VTA (>48 hours of onset). Data were analysed according to the period of presentation: early vs late period (years 2000-2006 and 2008-2016 accordingly). RESULTS: The study population comprised 15,200 patients. VTA occurred in 487 (3.2%) patients. Early VTA presented in 373/487 (77%) patients and late VTA in 114/487 (23%) patients. VTA's, occurring in ACS patients were associated with increased risk of in-hospital, 30-days, 1-year and 5-year mortality rates during both early and late periods compared with no VTA. Moreover, late VTA was associated with the highest mortality rate with up to 65% in 5-year follow up (P < .001). Nevertheless, late VTA was associated with a lower mortality rate in the late period compared with the early period. CONCLUSIONS: Any VTA following ACS was associated with high short- and long-term mortality rate. However, over the late period, there has been a significant improvement in survival rates, especially in patients with late VTA. This may be attributed to early and invasive reperfusion therapy, implantable cardioverter-defibrillator implantation and better medical treatment.

Quinidine-Responsive Polymorphic Ventricular Tachycardia in Patients With Coronary Heart Disease.

BACKGROUND: Polymorphic ventricular tachycardia (VT) without QT prolongation is well described in patients without structural heart disease (mainly idiopathic ventricular fibrillation and Brugada syndrome) and in patients with acute ST-elevation myocardial infarction. METHODS: Retrospective study of patients with polymorphic VT related to coronary artery disease, but without evidence of acute myocardial ischemia. RESULTS: The authors identified 43 patients in whom polymorphic VT developed within days of an otherwise uncomplicated myocardial infarction or coronary revascularization procedure. The polymorphic VT events were invariably triggered by extrasystoles with short (364±36 ms) coupling interval. Arrhythmic storms (4-16 events of polymorphic VT deteriorating to ventricular fibrillation) occurred in 23 (53%) patients. These arrhythmic storms were always refractory to conventional antiarrhythmic therapy, including intravenous amiodarone, but invariably responded to quinidine therapy. In-hospital mortality was 17% for patients with arrhythmic storm. Patients treated with quinidine invariably survived to hospital discharge. During long-term follow-up (of 5.6±6 years; range, 1 month to 18 years), 3 (16%) of patients discharged without quinidine developed recurrent polymorphic VT. There were no recurrent arrhythmias during quinidine therapy Conclusions: Arrhythmic storm with recurrent polymorphic VT in patients with coronary disease responds to quinidine therapy when other antiarrhythmic drugs (including intravenous amiodarone) fail.

Safety of nifedipine in threatened preterm labor: Investigation by three-dimensional echocardiography.

OBJECTIVE: To evaluate atrial and ventricular parameters using real time three-dimensional transthoracic echocardiography (RT3DTTE) in women treated with nifedipine in the early third trimester (III-T) of pregnancy. METHODS: A prospective single-subject design study in a university-affiliated hospital, where each participant served as her own control. We studied 25 pregnant women at a gestational age of 25-33 weeks with TPTL prior to vs 48 hours postnifedipine treatment. Two-dimensional transthoracic echocardiography (2DTTE) and RT3DTTE were used to study 3D left atrial (LA) volumes and indexes, emptying fraction, left ventricular and LA cavities, and total vascular resistance (TVR). RESULTS: Two-dimensional transthoracic echocardiography showed a significant increase in LA area (from 15.2 ± 2.62 to 16.16 ± 2.21 mm2 , P = .02) before vs after nifedipine; RT3DTTE showed a significant change in LA end-diastolic volume index (from 23.7 ± 4.2 to 26.75 ± 3.8 mL/m2 , P = .008). LA end-systolic volume and index were not significantly different before vs after nifedipine (from 24.56 ± 8 to 25.3 ± 5.5 mL, from 13.6 ± 5.3 to 14.8 ± 3.4 mL/m2 ); P > .05, respectively. E/a ratio, E-tdi, and E/E-tdi did not change significantly ([from 2.54 ± 4.46 to 2.54 ± 4.1], [from 11.9 ± 1.9 to 11.9 ± 2], [from 7.8 ± 1.4 to 7.6 ± 1.1], respectively, P > .05). Tricuspid annular plane systolic excursion (TAPSE) did not change significantly from 23.77 ± 4.2 to 23.9 ± 3.3, P = .1. There was a significant decrease in pulmonary pressure (from 25.4 ± 4.2 to 23 ± 2.5 mm Hg, P = .02), in mean arterial pressure (from 80 ± 4 to 76 ± 3 mm Hg, P < .001) and in TVR (from 1160 ± 260 to 1050 ± 206 dyne s/cm-5 , P = .04). CONCLUSIONS: According to RT3DTTE measurements, in pregnant women treated with nifedipine for tocolysis, there were no detrimental cardiovascular effects detected 48 hours postnifedipine treatment. RT3DTTE could show accurately the compensatory response of the left heart to the cardiovascular changes induced by treatment with nifedipine.

Ablation-Induced Change in the Course of Fascicular Tachycardia.

BACKGROUND: Multiform fascicular tachycardia (FT) was recently described as a ventricular tachycardia (VT) that has a reentrant mechanism using multiple fascicular branches and produces alternate fascicular VT forms. Ablating the respective fascicle may cause a change in the reentrant circuit resulting in a change in morphology. Ablation of the septal fascicle is crucial for successful treatment. OBJECTIVES: To describe four cases of FT in which ablation induced a change in QRS morphologies and aggravated clinical course. METHODS: Four out of 57 consecutive FT cases at three institutions were retrospectively analyzed and found to involve multiform FT. These cases underwent electrophysiological study, fascicular potential mapping, and electroanatomical mapping. All patients initially had FT with right bundle branch block (RBBB) and superior axis morphology. RESULTS: Radiofrequency catheter ablation (RFCA) targeting the distal left posterior fascicle (LPF) resulted in a second VT with an RBBB-inferior axis morphology that sometimes became faster and/or incessant and/or verapamil-refractory in characteristics. RFCA in the upper septum abolished the second VT with no complications and uneventful long-term follow-up. CONCLUSIONS: The change in FT morphology during ablation may be associated with a change in clinical course when shifting from one route to another and may aggravate symptoms. Targeting of the proximal conduction system (such as bifurcation, LPF, left anterior fascicle, high septal/auxiliary pathway) may serve to solve this problem.

Arrhythmic Events in Brugada Syndrome: A Nationwide Israeli Survey of the Clinical Characteristics, Treatment; and Long-Term Follow-up (ISRABRU-VF).

BACKGROUND: Limited information exists about detailed clinical characteristics and management of the small subset of Brugada syndrome (BrS) patients who had an arrhythmic event (AE). OBJECTIVES: To conduct the first nationwide survey focused on BrS patients with documented AE. METHODS: Israeli electrophysiology units participated if they had treated BrS patients who had cardiac arrest (CA) (lethal/aborted; group 1) or experienced appropriate therapy for tachyarrhythmias after prophylactic implantable cardioverter defibrillator (ICD) implantation (group 2). RESULTS: The cohort comprised 31 patients: 25 in group 1, 6 in group 2. Group 1: 96% male, mean CA age 38 years (range 13-84). Nine patients (36%) presented with arrhythmic storm and three had a lethal outcome; 17 (68%) had spontaneous type 1 Brugada electrocardiography (ECG). An electrophysiology study (EPS) was performed on 11 patients with inducible ventricular fibrillation (VF) in 10, which was prevented by quinidine in 9/10 patients. During follow-up (143 ± 119 months) eight patients experienced appropriate shocks, none while on quinidine. Group 2: all male, age 30-53 years; 4/6 patients had familial history of sudden death age < 50 years. Five patients had spontaneous type 1 Brugada ECG and four were asymptomatic at ICD implantation. EPS was performed in four patients with inducible VF in three. During long-term follow-up, five patients received ≥ 1 appropriate shocks, one had ATP for sustained VT (none taking quinidine). No AE recurred in patients subsequently treated with quinidine. CONCLUSIONS: CA from BrS is apparently a rare occurrence on a national scale and no AE occurred in any patient treated with quinidine.

Contemporary rates and outcomes of single- vs. dual-coil implantable cardioverter defibrillator lead implantation: data from the Israeli ICD Registry.

AIMS: Dual-coil leads were traditionally considered standard of care due to lower defibrillation thresholds (DFT). Higher complication rates during extraction with parallel progression in implantable cardioverter defibrillator (ICD) technology raised questions on dual coil necessity. Prior substudies found no significant outcome difference between dual and single coils, although using higher rates of DFT testing then currently practiced. We evaluated the temporal trends in implantation rates of single- vs. dual-coil leads and determined the associated adverse clinical outcomes, using a contemporary nation-wide ICD registry. METHODS AND RESULTS: Between July 2010 and March 2015, 6343 consecutive ICD (n = 3998) or CRT-D (n = 2345) implantation patients were prospectively enrolled in the Israeli ICD Registry. A follow-up of at least 1 year of 2285 patients was available for outcome analysis. The primary endpoint was all-cause mortality. Single-coil leads were implanted in 32% of our cohort, 36% among ICD recipients, and 26% among CRT-D recipients. Secondary prevention indication was associated with an increased rate of dual-coil implantation. A significant decline in dual-coil leads with reciprocal incline of single coils was observed, despite low rates of DFT testing (11.6%) during implantation, which also declined from 31 to 2%. In the multivariate Cox model analysis, dual- vs. single-coil lead implantation was not associated with an increased risk of mortality [hazard ratio (HR) = 1.23; P= 0.33], heart failure hospitalization (HR = 1.34; P=0.13), appropriate (HR = 1.25; P= 0.33), or inappropriate ICD therapy (HR = 2.07; P= 0.12). CONCLUSION: Real-life rates of single-coil lead implantation are rising while adding no additional risk. These results of single-coil safety are reassuring and obtained, despite low and contemporary rates of DFT testing.

Morbidity and mortality with cardiac resynchronization therapy with pacing vs. with defibrillation in octogenarian patients in a real-world setting.

AIMS: Cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) has downsides of high cost and inappropriate shocks compared to CRT without a defibrillator (CRT-P). Recent data suggest that the survival benefit of implantable cardioverter defibrillator (ICD) therapy is attenuated in the older age group. We hypothesized that, among octogenarians eligible for cardiac resynchronization therapy, CRT-P confers similar morbidity and mortality benefits as CRT-D. METHODS AND RESULTS: We compared morbidity and mortality outcomes between consecutive octogenarian patients eligible for CRT therapy who underwent CRT-P implantation at Barzilai MC (n = 142) vs. those implanted with CRT-D for primary prevention indication who were prospectively enrolled in the Israeli ICD Registry (n = 104). Among the 246 study patients, mean age was 84 ± 3 years, 74% were males, and 66% had ischaemic cardiomyopathy. Kaplan-Meier survival analysis showed that at 5 years of follow-up the rate of all-cause mortality was 43% in CRT-P vs. 57% in the CRT-D group [log-rank P = 0.13; adjusted hazard ratio (HR) = 0.79, 95% CI 0.46-1.35, P = 0.37]. Kaplan-Meier analysis also showed no significant difference in the rates of the combined endpoint of heart failure or death (46 vs. 60%, respectively, log-rank P = 0.36; adjusted HR was 0.85, 95% CI 0.51-1.44, P = 0.55). A Cox proportional hazard with competing risk model showed that re-hospitalizations for cardiac cause were not different for the two groups (adjusted HR 1.35, 95% CI 0.7-2.6, P = 0.37). CONCLUSION: Our data suggest that, in octogenarians with systolic heart failure, CRT-P therapy is associated with similar morbidity and mortality outcomes as CRT-D therapy.

Safety, efficacy, and clinical applicability of pulmonary vein isolation with circular multi-electrode ablation systems: PVAC® vs. nMARQ™ for atrial fibrillation ablation.

AIMS: We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC(®), a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. METHODS AND RESULTS: Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC(®) (n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ (n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC(®) and 81 ± 18 and 30 ± 8.5 for nMARQ™ (P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC(®) and 16 ± 5.6 and 11 ± 4 for nMARQ™ (P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC(®) patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC(®) and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC(®) vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. CONCLUSION: Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.

Rotational method simplifies 3-dimensional measurement of left atrial appendage dimensions during transesophageal echocardiography.

BACKGROUND: Not all echo laboratories have the capability of measuring direct online 3D images, but do have the capability of turning 3D images into 2D ones "online" for bedside measurements. Thus, we hypothesized that a simple and rapid rotation of the sagittal view (green box, x-plane) that shows all needed left atrial appendage (LAA) number of lobes, orifice area, maximal and minimal diameters and depth parameters on the 3D transesophageal echocardiography (3DTEE) image and LAA measurements after turning the images into 2D (Rotational 3DTEE/"Yosefy Rotation") is as accurate as the direct measurement on real-time-3D image (RT3DTEE). METHODS: We prospectively studied 41 consecutive patients who underwent a routine TEE exam, using QLAB 10 Application on EPIQ7 and IE33 3D-Echo machine (BORTHEL Phillips) between 01/2013 and 12/2015. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between RT3DTEE and Rotational 3DTEE versus CT. RESULTS: Rotational 3DTEE measurements of LAA were not statistically different from RT3DTEE and from CT regarding: number of lobes (1.6 ± 0.7, 1.6 ± 0.6, and 1.4 ± 0.6, respectively, p = NS for all); internal area of orifice (3.1 ± 0.6, 3.0 ± 0.7, and 3.3 ± 1.5 cm(2), respectively, p = NS for all); maximal LAA diameter (24.8 ± 4.5, 24.6 ± 5.0, and 24.9 ± 5.8 mm, respectively, p = NS for all); minimal LAA diameter (16.4 ± 3.4, 16.7 ± 3.3, and 17.0 ± 4.4 mm, respectively, p = NS for all), and LAA depth (20.0 ± 2.1, 19.8 ± 2.2, and 21.7 ± 6.9 mm, respectively, p = NS for all). CONCLUSION: Rotational 3DTEE method for assessing LAA is a simple, rapid and feasible method that has accuracy similar to that of RT3DTEE and CT. Thus, rotational 3DTEE ("Yosefy rotation") may facilitate LAA closure procedure by choosing the appropriate device size.

A New Method for Direct Three-Dimensional Measurement of Left Atrial Appendage Dimensions during Transesophageal Echocardiography.

AIMS: Currently, two-dimensional transesophageal echocardiography (2DTEE) at a cut-plane angulation of 135° is the recommended method to size maximal left atrial appendage (LAA) orifice diameter before introducing a percutaneous LAA closure device. We compared real time three-dimensional TEE (RT3DTEE) and 2DTEE for measuring LAA dimensions versus computed tomography (CT) as gold standard. METHODS AND RESULTS: We prospectively studied 30 consecutive patients who underwent a routine TEE examination, using QLAB 10.0 Application on EPIQ7 iE33 3D echo machine between December 2012 and December 2013. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between 135 2DTEE and RT3DTEE. Results were compared with CT measurements. Using RT3DTEE, larger LAA diameters were measured versus 2DTEE (23.5 ± 3.9 vs. 24.5 ± 4.7 mm). In seven patients (23.3%), the measurements in 135° 2DTEE were smaller than the cut-plane angulation with maximal orifice diameter. RT3DTEE measurements of LAA were not different from CT regarding number of lobes, area of orifice, and maximal diameter. LAA volume could not be measured directly using RT3DTEE. No difference was found between LAA depth using RT3DTEE (19.5 ± 2.3 mm) vs. CT (19.6 ± 2.3, P = NS) and 2DTEE (19.4 ± 2.2 mm) vs. CT (P = NS). However, RT3DTEE (24.5 ± 4.7 mm) vs. CT (24.6 ± 5, P = NS) was more accurate in measuring maximal LAA diameter compared to 2DTEE (23.5 ± 3.9 mm) vs. CT (P < 0.01). CONCLUSION: RT3DTEE method is more accurate than 2DTEE for assessment of maximal LAA orifice diameter. Bedsides, RT3DTEE LAA measurements are not statistically different from CT. Thus, RT3DTEE may facilitate LAA closure procedure by choosing the appropriate device size.