Iatrogenic Left Ventricle Outflow Tract Ventricular Tachycardia Following Transcatheter Aortic Valve Replacement: A Case Series.

Focal left ventricular outflow tract ventricular tachycardia (LVOT-VT) is rarely reported following transcatheter aortic valve replacement (TAVR). Similarly, unexplained sudden cardiac death after TAVR also is rarely described and may be attributed to VT. We present two cases of patients who underwent TAVR and later presented with VT of suggested LVOT origin. Both patients were treated with amiodarone for suppression of VT.

Fear of Recurrence of Atrial Fibrillation: Translating a Cancer Fear Model to the Atrial Fibrillation Patient Experience.

Background: Atrial fibrillation occurs when rapid and disorganized electrical signals cause the atria in the heart to beat irregularly and is associated with an increased risk for stroke. Despite medical advancements, first and second line atrial fibrillation treatments exhibit significant recurrence rates. Because of this, atrial fibrillation patients often experience disease-specific fears that are not routinely assessed and targeted in clinical management. Fear of recurrence models in cancer research and other cardiac-specific fears have paved the way for a patient-centric approach to disease intervention. Purpose: Clinical assessment focused solely on the taxonomy of anxiety disorders may miss key components unique to the atrial fibrillation patient experience. An anxiety disorder diagnosis in the presence of an arrhythmia could be misleading and ultimately fail to address patient needs. Modeled from the cancer literature, providers may benefit from a broader disease specific conceptualization for AF patients that differs from a general DSM-5 diagnosis. Aims: The objectives of this paper are: (1) to review the medical aspects of atrial fibrillation, (2) to examine the comparability of fear of recurrence concept from cancer literature to the atrial fibrillation patient, and (3) to suggest considerations of these novel concepts in patient care. Future Directions: Increased understanding of fear of recurrence among atrial fibrillation patients aims to define and assess fear of recurrence components, determine treatment targets, and ultimately improve patient outcomes.

Managing atrial fibrillation: The intersection of cardiology, health psychology, and the patient experience.

Atrial fibrillation (AF) is the most common cardiac dysrhythmia and is an accelerating public health challenge. Challenges related to detection, management, and prevention of disability and dysfunction secondary to AF are increasingly apparent. The subspecialty of cardiology, cardiac electrophysiology, is primarily tasked with the treatment of AF. Patients with AF are often ambushed by the condition with approximately 28% to 38% of patients experiencing significant anxiety or depressive symptoms. Behavioral risk reduction can be targeted by achieving and maintaining a healthy BMI, abstaining from smoking, avoiding alcohol consumption, and sustaining regular physical activity. AF patients are also tasked with considering possible treatment options, adhering to medication regiments & lifestyle changes, utilizing wearable technologies, and managing emotional distress, to minimize health risks and optimize quality of life. Major medical organizations have called for integrated, multidisciplinary management as the treatment of choice for AF patients. Health psychologists bring valuable expertise but are not uniformly involved in the care of AF patients. The purposes of this article are to (a) review the existing research on the medical, psychological, and behavioral aspects of contemporary management of AF, (b) highlight the intersections between cardiac electrophysiology and clinical health psychology in managing AF, and (c) call for more health psychologists in this specialized area of cardiac electrophysiology. This opportunity for health psychologists may challenge the profession to further specialize as "cardiac psychologists" and mirror our medical colleagues. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

High-power short-duration ablation of atrial fibrillation: A contemporary review.

Catheter ablation using radiofrequency (RF) energy has been widely used to treat patients with atrial fibrillation (AF). The optimal levels of power and duration to increase the success rate while minimizing complications have not been fully established. Different centers continue to use various power protocols for catheter ablation of AF. Herein, we present a comprehensive review of the impact of power output on efficacy and safety of RF ablation for AF. High-power short-duration (HPSD) ablation can be performed safely with similar procedural efficacy as low-power long-duration ablation strategy. HPSD ablation has the potential to shorten procedural and RF times and create more durable and localized lesions.

Mobile-ECG screening in rural pharmacies: rates of atrial fibrillation and associated risk factors.

INTRODUCTION: Atrial fibrillation (AFib) is a growing health concern, affecting more than 40 million patients worldwide and increasing stroke risk by five times. Community screening initiatives in rural healthcare establishments are becoming more feasible with the development of innovative, mobile-ECG (mECG) technology. The purpose of this research was to characterize increased rates of stroke risk factors and to determine AFib incidence in rural, pharmacy settings. METHODS: The researchers examined the prevalence of risk factors associated with AFib and calculated CHA2DS2-VASc stroke risk scores in a previously undiagnosed AFib community sample of 250 participants. Eligible participants at two rural pharmacies were administered a 1-lead mECG reading. Participants were then asked to complete questionnaires on demographic and medical history information. All participants were given educational materials on AFib and medical referrals when indicated. RESULTS: Prevalence rates of six, known independent stroke risk factors (CHA2DS2-VASc scores: (2.68 ± 1.35)) were significantly higher in the study sample than reported national US averages. Screening via mECG indicated preliminary AFib rates of approximately 4%; however, upon independent adjudication of the readings from three electrophysiologists AFib prevalence ranged between 1% and 8%. DISCUSSION: Collectively, an alarming rate of untreated stroke risk in a rural pharmacy sample was identified by the researchers utilizing mECG technology. These results suggest potential value to the use of mECG technology to screen for AFib in at-risk communities.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients.

OBJECTIVE: Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database. METHODS: We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization. RESULTS: There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA. CONCLUSION: Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

The impact of mechanical oesophageal deviation on posterior wall pulmonary vein reconnection.

AIMS: During atrial fibrillation ablation, oesophageal heating typically prompts reduction or termination of radiofrequency energy delivery. We previously demonstrated oesophageal temperature rises are associated with posterior left atrial pulmonary vein reconnection (PVR) during redo procedures. In this study, we assessed whether mechanical oesophageal deviation (MED) during an index procedure minimizes posterior wall PVRs during redo procedures. METHODS AND RESULTS: Patients in whom we performed a first-ever procedure followed by a clinically driven redo procedure were divided based on both the use of MED for oesophageal protection and the ablation catheter employed (force or non-force sensing) in the first procedure. The PVR sites were compared between MED using a force-sensing catheter (MEDForce), or no MED with a non-force (ControlNoForce) or force (ControlForce) sensing catheter. Despite similar clinical characteristics, the MEDForce redo procedure rate (9.2%, 26/282 patients) was significantly less than the ControlNoForce (17.2%, 126/734 patients; P = 0.002) and ControlForce (17.5%, 20/114 patients; P = 0.024) groups. During the redo procedure, the posterior PVR rate with MEDForce (2%, 1/50 PV pairs) was significantly less than with either ControlNoForce (17.7%, 44/249 PV pairs; P = 0.004) or ControlForce (22.5%, 9/40 PV pairs; P = 0.003), or aggregate Controls (18.3%, 53/289 PV pairs; P = 0.006). However, the anterior PVR rate with MEDForce (8%, 4/50 PV pairs) was not significantly different than Controls (aggregate Controls-3.5%, 10/289 PV pairs, P = 0.136; ControlNoForce-2.4%, 6/249 PV pairs, P = 0.067; ControlForce-10%, 4/40 PV pairs, P = 1.0). CONCLUSION: Oesophageal deviation improves the durability of the posterior wall ablation lesion set during AF ablation.

Variable Presentations and Ablation Sites for Manifest Nodoventricular/Nodofascicular Fibers.

BACKGROUND: Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS: Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS: NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS: Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.

Impact of Technique and Technology on Mitral Isthmus Ablation.

PURPOSE OF REVIEW: Mitral isthmus ablation is an established strategy in the treatment of peri-mitral atrial flutter and as an adjunct to pulmonary vein isolation. The objective of this review is to summarize the techniques and specific strategies that allow for increased success and durability of mitral isthmus ablation. RECENT FINDINGS: Achieving bidirectional block across the mitral isthmus remains a challenge due to the increased thickness in this region, convective cooling as a result of coronary sinus blood flow, and the occurrence of epicardial connections. Several strategies to achieve durable mitral isthmus block, such as coronary sinus ablation, coronary sinus balloon occlusion, ethanol ablation via the vein of Marshall, and using alternate mitral lines in select cases, are described in detail in this review.

Infusion Needle Radiofrequency Ablation for Treatment of Refractory Ventricular Arrhythmias.

BACKGROUND: Catheter ablation is effective for eliminating most drug-refractory ventricular arrhythmias (VA). However, a major reason for procedural failure is arrhythmia originating deep within the myocardium where it is inaccessible to conventional endocardial or epicardial approaches. Affected patients have limited therapeutic options. OBJECTIVES: The objective of this study was to assess the safety and outcome of a novel radiofrequency ablation catheter that used an extendable/retractable 27-g needle capable of targeting deep arrhythmia (intramural) substrate. METHODS: Patients who failed at least one prior catheter ablation procedure for sustained ventricular tachycardia (VT) or nonsustained VA with associated left ventricular dysfunction were enrolled at 3 centers. The target was sustained monomorphic VT in 26 patients, including 8 with recent VT storm or VT requiring intravenous medication, and 5 with incessant VA associated with ventricular dysfunction. RESULTS: Needle ablation was performed in 31 patients (median of 2 failed prior ablation procedures; 71% nonischemic heart disease). After a median of 15 needle lesions/patient, ablation abolished at least 1 inducible VT in 19 of 26 VT patients (73%), and suppressed ambient arrhythmia in 4 of 5 nonsustained arrhythmia patients. At the 6-month follow-up, 48% of patients were free of recurrent arrhythmia and another 19% were improved. Procedure-related complications included a single pericardial effusion treated with percutaneous drainage and a left ventricular pacing lead dislodgement with no deaths. CONCLUSIONS: In patients with recurrent ventricular arrhythmias refractory to medications and conventional catheter ablation, intramural needle radiofrequency ablation offers significant arrhythmia control with an acceptable procedural risk.

Esophageal Deviation During Atrial Fibrillation Ablation: Clinical Experience With a Dedicated Esophageal Balloon Retractor.

OBJECTIVES: The goal of this study was to determine the safety and feasibility of a novel esophageal balloon retractor (DV8) for MED during PVI. BACKGROUND: The authors previously showed that mechanical esophageal deviation (MED) is feasible using an off-the-shelf metal stylet to allow uninterrupted ablation along the posterior left atrium during pulmonary vein isolation (PVI). Although it is an attractive strategy to avoid esophageal thermal injury, this technique was hampered by both the propensity for oropharyngeal trauma from the stiff stylet and the limited lateral esophageal displacement. METHODS: In 200 consecutive patients undergoing atrial fibrillation ablation, the DV8 balloon retractor was used for MED; contrast was instilled into the esophagus to accurately delineate the trailing esophageal edge. Deviation was performed to maximize the distance from the trailing esophageal edge to the closest point of the ablation line (MEDEffective) and correlated to occurrences of luminal esophageal temperature elevation. RESULTS: In patients undergoing MED during a first-ever PVI of 304 vein pairs, the MEDEffective during right and left PVI were 21.2 ± 8.7 mm and 15.5 ± 6.8 mm, respectively. Deviation of at least 5 mm of MEDEffective was achievable in 97.7%. Luminal esophageal temperature increases universally occurred (100%) at MEDEffective <5 mm, less often (28%) at MEDEffective 5 to 20 mm, and rarely (1.9%) at MEDEffective >20 mm. There were no esophageal complications, but 2 patients experienced oropharyngeal bleeding due to trauma related to device placement. CONCLUSIONS: MED with the balloon retractor safely moved the esophagus away from the site of energy delivery during atrial fibrillation ablation.

Real world utilization and impact of the wearable cardioverter-defibrillator in a community setting.

INTRODUCTION: The wearable cardioverter-defibrillator (WCD) is used in patients at risk for sudden cardiac death (SCD) but not immediate candidates for intracardiac defibrillator (ICD) implantation. METHODS: We performed a single center retrospective study of patients prescribed WCD upon hospital discharge from January 2002 to October 2015. Clinical characteristics were obtained from the hospital electronic database and device data from Zoll LifeVest database. RESULTS: Of 140 patients, 62% were men, 85.9% were African-American and mean age was 58.2 ± 15.5 years. Ischemic cardiomyopathy was present in 45 (32%) and non-ischemic cardiomyopathy in 64 patients (46%). Mean left ventricular ejection fraction (EF) was 0.28 ± 0.4. WCD was worn for 7657 patient-days (21 patient-years), with each patient using WCD for median of 43 days (IQR: 7-83 days), and daily mean use 17.3 ± 7.5 h. There were a total of 6 (4.2%) WCD shocks of which 2 (1.4%) were appropriate (one for VT, one for VF) and 4 (2.8%) were inappropriate (2 had supraventricular tachycardia, 2 had artifact). Two patients who received appropriate shocks were African-American with non-ischemic cardiomyopathy (EF<20%), non-sustained VT and wide QRS duration. Upon termination of WCD use, 45 (32%) received ICD while EF improved in 34 patients (32%). CONCLUSIONS: In a predominantly minority, community setting, WCD compliance is high and use is effective in aborting SCD. However, inappropriate shocks do occur. A significant proportion of patients did not ultimately require ICD implantation suggesting this may be a cost-effective strategy in patients at risk of SCD.

Use of the new contact force sensing ablation catheter dramatically reduces fluoroscopy time during atrial fibrillation ablation procedures.

OBJECTIVES: To study the impact of contact force (CF) sensing on fluoroscopy, procedure, left atrial (LA) and ablation times and number of ablations during atrial fibrillation (AF) ablation. BACKGROUND: Catheter ablation is an effective treatment for symptomatic AF. Recently a new ablation catheter providing real-time CF has been approved for use. METHODS: A nested case-control study was performed comparing radiofrequency ablation of AF using the irrigated CF-sensing ThermoCool SmartTouch catheter versus open-irrigated ThermoCool SF catheter (Biosense Webster, Inc., Diamond Bar, California). Demographic and procedure data were obtained and student t-test was used to compare data between groups. RESULTS: Thirty consecutive adult patients were included with 15 patients in each group. Mean fluoroscopy time was significantly lower in CF group (19.4 ± 8 vs 40.7 ± 8 min, p < 0.0001). LA time was significantly lower in CF group (151.7 ± 44 vs 185.7 ± 35 min, p = 0.01). There were no significant differences in procedure time between CF and SF groups (204 ± 37 vs 207 ± 36 min) and ablation time (121 ± 32 vs 122 ± 37 min). When patients who only underwent pulmonary vein isolation (PVI) were compared, fluoroscopy time was significantly lower in CF group (18 ± 9 vs 37.8 ± 5 min, p < 0.0001) as was LA time (141.4 ± 39 vs 171.8 ± 30 min, p = 0.04). Fluoroscopy time was also significantly lower in CF subgroup with additional ablation (20.9 ± 7 vs 44.9 ± 10 min, p < 0.001). CONCLUSION: Use of CF-sensing catheter significantly reduced fluoroscopy and LA times during AF ablation with similar acute efficacy.