Feasibility and safety of outpatient radiofrequency catheter ablation procedures for atrial fibrillation.

INTRODUCTION: Percutaneous catheter ablation for atrial fibrillation (AF) is a procedure performed typically in an inpatient setting. The feasibility and safety of catheter ablation in patients with paroxysmal and persistent AF were evaluated on an outpatient basis. METHODS: 230 AF ablation procedures were performed in 206 patients (74% male; mean age 56+/-9 years). Patients were admitted to the hospital outpatient facility in the morning for the AF ablation procedure on the same day. The ablation strategy consisted of wide area circumferential lines around both ipsilateral pulmonary veins. After monitoring in the outpatient service, patients were discharged on the same day, if they were clinically stable. RESULTS: Mean procedure time was 201+/-31 min. Major complications occurred in seven patients (3%). One patient (0.4%) suffered a minor stroke and six patients had pericardial tamponade requiring percutaneous drainage. Patients could be discharged on the same day following 205 (89%) procedures. Among the 148 patients whose clinical outcome was assessed at 6 months, 127 (86%) had a reduction of the total symptomatic AF episodes, compared to pre-ablation, with a complete lack of symptoms in 101 patients (68%). CONCLUSION: Catheter ablation of AF on the day of admission is feasible and safe with a low risk of complications. The vast majority of the patients can be discharged on the same day.

A Randomized Trial of Video-based Education in Patients With Heart Failure: The Congestive Heart Failure Outreach Program of Education (COPE).

BACKGROUND: Heart failure (HF) exacerbations often relate to poor self-care. Education programs improve outcomes, but are resource-intensive. We developed a video-based educational intervention and evaluated it in patients with HF. METHODS: Congestive Heart Failure Outreach Program of Education was a pragmatic multicenter randomized trial. We included subjects with HF if they were hospitalized, seen in the emergency department (ED), or high-risk outpatients, and randomized them to intervention or control. Intervention included a 20-minute video, supplementary booklet, and 3 bimonthly newsletters focusing on salt and fluid restriction, daily weights, and medications. Subjects watched the video and were encouraged to review it at home, along with the booklet/newsletters. Control subjects received the booklet only. The primary outcome was the difference in cardiovascular hospitalizations or ED visits between groups at 6 months. Secondary outcomes included clinical events and in-hospital days. RESULTS: We recruited 539 subjects from 22 centers in Canada and the United States. Baseline characteristics were similar in both groups: 64% were male and had a mean age of 66 (± 13) years, mean ejection fraction 31% (± 13.5), and 65% New York Heart Association Functional Classification III/IV. The primary outcome occurred in 57 subjects (21%) in the intervention group compared with 61 subjects (23%) in the control group (P = 0.66). There were no significant differences in prespecified secondary outcomes; however, death occurred in 18 subjects (7%) in the intervention group and 33 subjects (12%) in the control group (P = 0.03). CONCLUSION: Video education on self-care did not reduce hospitalizations or ED visits in patients with HF. Of note, mortality was lower in the intervention group.

INTRODUCTION: L'exacerbation de l'insuffisance cardiaque (IC) est souvent liée à une mauvaise prise en charge autonome des soins. Les programmes d'enseignement améliorent les résultats cliniques, mais exigent beaucoup de ressources. Nous avons conçu une intervention éducative par vidéo et l'avons évaluée auprès de patients atteints d'IC. MÉTHODES: Le Congestive Heart Failure Outreach Program of Education était une étude pragmatique multicentrique à répartition aléatoire. Nous avons sélectionné les sujets atteints d'IC s'ils étaient hospitalisés, vus au service des urgences (SU) ou patients en consultation externe exposés à un risque élevé, et les avons répartis de manière aléatoire au groupe d'intervention ou au groupe témoin. L'intervention a consisté en une vidéo de 20 minutes, un livret supplémentaire et 3 bulletins bimensuels portant sur la restriction du sel et des liquides, les mesures quotidiennes du poids et les médicaments. Après que les sujets eurent regardé la vidéo, nous les avons encouragés à la revoir à la maison, en plus de lire le livret et les bulletins. Les sujets témoins ont reçu seulement le livret. Le critère de jugement principal était la différence dans les hospitalisations en raison d'une maladie cardiovasculaire ou les visites au SU entre les groupes après 6 mois. Les critères de jugement secondaires étaient les événements cliniques et les jours d'hospitalisation. RÉSULTATS: Nous avons recruté 539 sujets de 22 centres au Canada et aux États-Unis. Les caractéristiques initiales étaient similaires dans les 2 groupes : 64 % étaient des hommes et avaient un âge moyen de 66 ans (± 13), une fraction d'éjection moyenne de 31 % (± 13,5), et 65 % avaient une classification fonctionnelle III/IV de la New York Heart Association. Le critère de jugement principal est survenu chez 57 sujets (21 %) dans le groupe d'intervention et chez 61 sujets (23 %) dans le groupe témoin (P = 0,66). Il n'y a eu aucune différence significative dans les critères secondaires prédéfinis. Toutefois, 18 sujets (7 %) du groupe d'intervention et 33 sujets (12 %) du groupe témoin sont morts (P = 0,03). CONCLUSION: L'enseignement sur les autosoins par vidéo n'a pas réduit les hospitalisations ou les visites au SU des patients atteints d'IC. Notamment, la mortalité a été plus faible dans le groupe d'intervention.

Cardiac injury after percutaneous catheter ablation for atrial fibrillation.

AIMS: Small elevations in troponin T levels have been shown with limited radiofrequency (RF) ablation procedures for supraventricular tachycardia, usually to levels below the threshold for ischaemia or infarction. Left atrial catheter ablation for atrial fibrillation (AF) requires far more RF energy, therefore could be expected to have greater elevation in troponin T. We determined troponin T levels before and after ablation in these patients to evaluate the amount of rise with this ablation. METHODS: All patients undergoing pulmonary vein isolation (PVI) from May 2004 to October 2004 had troponin T levels measured 4 h following completion of the procedure. The first 30 patients also had a troponin T level measured 1 h prior to PVI to establish a baseline reference. RESULTS: Sixty patients were studied, with 81.7% males and a mean age of 54.6 +/- 9.9 years. No patient had underlying structural heart disease. The baseline troponin T level was normal (<0.01 microg/L) in all 30 patients. Post-procedure troponin T levels were elevated in all 60 patients compared with baseline (P < 0.05), with a mean level of 0.85 microg/L and a range of 0.26-1.57 microg/L after an average RF ablation time of 56 +/- 15 min. All levels were above the reference range for diagnosis of acute myocardial infarction (>0.15 microg/L). Troponin T level was not related to the number of RF lesions, RF time, procedure time, or associated external cardioversion. CONCLUSIONS: Troponin T elevations occurred in all patients undergoing PVI, to levels at least 20 times the normal concentration, into the range for diagnosis of acute myocardial infarction. Therefore, troponin T would not be specific for ischaemia in the setting of chest pain post-catheter ablation for AF.

Ablation of atrial fibrillation after the retirement age: considerations on safety and outcome.

BACKGROUND: Although the incidence of atrial fibrillation (AF) progressively increases with age, the vast majority of AF ablation is done in middle-aged patients. We evaluated the feasibility and safety of catheter ablation in patients older than 65 years of age with paroxysmal and persistent AF. METHODS: Out of a total of 230 consecutive AF ablation procedures, 45 patients were older than 65 years of age and underwent 53 procedures. The ablation strategy consisted of wide-area circumferential lines around both ipsilateral pulmonary veins using a three-dimensional mapping system. RESULTS: The mean age was 69 ± 3.5 years (35 males). The mean duration for AF was 8.7 ± 6.5 years. Thirty-nine had paroxysmal and six persistent AF despite use of 1.38 ± 0.77 antiarrhythmic drugs. All patients had a structurally normal heart. Eleven had systemic hypertension. Mean procedure time was 187 ± 33 min. Acute procedural success rate with abolition of all pulmonary vein potentials was achieved in all patients. Pericardial tamponade requiring percutaneous drainage occurred in one (1.9%) patient. There were no cardioembolic events. Among the 43 patients whose clinical outcome was assessed at 6 months, 34 (79%) had a significant reduction (>90%) of the total symptomatic AF burden, compared to pre-ablation, with a complete lack of symptomatic AF in 32 (74%) patients. The success rate was higher for patients with paroxysmal versus persistent AF (81 vs. 67%). Six patients (11%) underwent repeat procedures. CONCLUSIONS: Catheter ablation is a safe and effective treatment for patients over the age of 65 years with symptomatic, drug-refractory AF. Therefore, patients should not be excluded from undergoing AF catheter ablation on the basis of age alone.