Randomized trial of conventional versus radiofrequency needle transseptal puncture for cryoballoon ablation: the CRYO-LATS trial.

BACKGROUND: Transseptal puncture to achieve left atrial access is necessary for many cardiac procedures, including atrial fibrillation ablation. More recently, there has been an increasing need for left atrial access using large caliber sheaths, which increases risk of perforation associated with the initial advancement into the left atrium. We compared the effectiveness of a radiofrequency needle-based transseptal system versus conventional needle for transseptal access. METHODS: This prospective controlled trial randomized 161 patients with symptomatic paroxysmal atrial fibrillation undergoing cryoballoon pulmonary vein isolation to transseptal access with a commercially available transseptal system (radiofrequency needle plus stiff pigtail wire; RF + Pigtail group) versus conventional transseptal access (standard group). The primary outcome was time required for left atrial access. Secondary outcomes included failure of the assigned transseptal system, radiation exposure, and complications. RESULTS: The median transseptal puncture time was significantly shorter using the radiofrequency needle plus stiff pigtail wire transseptal system compared with conventional transseptal (840 ± 323 vs. 956 ± 407 s, P = 0.0489). Compared to conventional transseptal puncture, fewer transseptal attempts were required (1.0 ± 0.5 RF applications vs. 1.3 ± 0.8 mechanical punctures, P = 0.0123) and the fluoroscopy time was significantly shorter (72.0 [IQR 48.0, 129.0] vs. 93.0 [IQR 60.0, 171.0] s, P = 0.0490) with the radiofrequency needle plus stiff pigtail wire transseptal system. Failure to achieve transseptal LA access with the assigned system was rarely observed (1.3% vs. 5.7%, P = 0.2192). There were no procedural complications observed with either system. CONCLUSIONS: The use of a radiofrequency needle plus stiff pigtail wire resulted in shorter time to left atrial access and reduced fluoroscopy time compared to left atrial access using conventional transseptal equipment. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT03199703.

"Retained wire femoral lead removal and fibroplasty" for obtaining venous access in patients with refractory venous obstruction.

BACKGROUND: Patients with wire and catheter refractory venous occlusion are traditionally referred for pectoral transvenous lead extraction (TLE) to obtain venous access. TLE causes 1-2 mm circumferential mechanical or laser destruction of tissue surrounding the lead(s). This not only exposes the patient to the risk of major complications but also can damage nontargeted leads. We present a series of patients where retained wire femoral lead removal and fibroplasty was used to obtain venous access in patients with refractory obstruction. METHODS: Between 2008 and 2021, we identified 17 patients where retained wire lead removal followed by fibroplasty was used to retain venous access. Demographic and procedural data were obtained by retrospective review of patient charts. RESULTS: We were able to successfully obtain venous access in all 17 patients in whom this technique was attempted. In two patients the target lead was less than or equal to 1 year old. In the remaining 15 patients, the average dwell time of the target lead(s) was 6 years. There were no procedure-related complications, and no changes in the parameters of other leads were noted. CONCLUSION: Retained wire femoral lead removal and fibroplasty is safe and highly efficacious at obtaining venous access in patients with refractory venous occlusion. If the target lead(s) is less than or equal to 1 year old, this technique can help obtain venous access at the time of the initial surgery, hence avoiding the need for TLE. Furthermore, in patients referred for TLE to obtain venous access, this technique by avoiding the use of TLE tools spares the patient of the associated risks.

Differences in Healthcare Use Between Patients With Persistent and Paroxysmal Atrial Fibrillation Undergoing Catheter-Based Atrial Fibrillation Ablation: A Population-Based Cohort Study From Ontario, Canada.

Background Patients with persistent atrial fibrillation (AF) undergoing catheter-based AF ablation have lower success rates than those with paroxysmal AF. We compared healthcare use and clinical outcomes between patients according to their AF subtypes. Methods and Results Consecutive patients undergoing AF ablation were prospectively identified from a population-based registry in Ontario, Canada. Via linkage with administrative databases, we performed a retrospective analysis comparing the following outcomes between patients with persistent and paroxysmal AF: healthcare use (defined as AF-related hospitalizations/emergency room visits), periprocedural complications, and mortality. Multivariable Poisson modeling was performed to compare the rates of AF-related and all-cause hospitalizations/emergency room visits in the year before versus after ablation. Between April 2012 and March 2016, there were 3768 consecutive patients who underwent first-time AF ablation, of whom 1040 (27.6%) had persistent AF. The mean follow-up was 1329 days. Patients with persistent AF had higher risk of AF-related hospitalization/emergency room visits (hazard ratio [HR], 1.21; 95% CI, 1.09-1.34), mortality (HR, 1.74; 95% CI, 1.15-2.63), and periprocedural complications (odds ratio, 1.36; 95% CI, 1.02-1.75) than those with paroxysmal AF. In the overall cohort, there was a 48% reduction in the rate of AF-related hospitalization/emergency room visits in the year after versus before ablation (rate ratio [RR], 0.52; 95% CI, 0.48-0.56). This reduction was observed for patients with paroxysmal (RR, 0.45; 95% CI, 0.41-0.50) and persistent (RR, 0.74; 95% CI, 0.63-0.87) AF. Conclusions Although patients with persistent AF had higher risk of adverse outcomes than those with paroxysmal AF, ablation was associated with a favorable reduction in downstream AF-related healthcare use, irrespective of AF type.

Electrophysiology Study and Catheter Ablation With Superior Vena Cava Stump.

We report the complete absence of a superior vena cava in a patient without prior history of cardiac surgery or device implantation. This is a very rare congenital cardiac abnormality, which if unrecognized, may lead to complications in patients undergoing electrophysiological studies.