Endomyocardial biopsy at the time of ablation or device implantation.

PURPOSE: Cardiomyopathies frequently lead to conduction system disease and/or arrhythmias necessitating device therapy, catheter ablation, or both. Endomyocardial biopsy (EMB) is avoided with recent right ventricle (RV) lead implants and optimal timing is uncertain. We determined outcomes of EMB at the time of ablation or device implantation procedures. METHODS: We retrospectively analyzed patients undergoing EMB during their electrophysiological procedure between January 2014 and July 2016. EMB was obtained using cephalic/subclavian access prior to device implants or femoral venous/arterial access after ablation procedures. Sites of electrogram (EGM) abnormality and/or scar on imaging were targeted when possible. RESULTS: Twenty-five patients (23 male, 59.7 ± 15.1 years) were included. Sixteen had reduced ejection fraction. EMB was performed during device implants in 9, during ablation in 13, and during combined procedures in 3 patients. RV and left ventricle (LV) EMB were obtained in 19 and 6 patients, respectively. 3.9 ± 1.8 samples/patient (median 4) were obtained. EMB yielded a diagnosis in 7 (28%, all RV) patients (4 cardiac implantable electronic device implantation, 2 ablation, and 1 both): cardiac amyloid in 4, lymphocytic myocarditis in 2, and cardiac sarcoid in 1. All 7 patients had imaging or voltage abnormalities in the chamber biopsied. Abnormal but non-diagnostic findings, most commonly fibrotic change, were found in 14 patients. At mean follow-up of 1.1 ± 0.9 years, 5 other patients received a clinical diagnosis (3 cardiac sarcoid, 1 arrhythmogenic cardiomyopathy, and 1 Brugada syndrome/arrhythmogenic cardiomyopathy overlap syndrome). Two patients developed minor device pocket hematomas and one developed pericardial effusion (underwent concomitant epicardial mapping and ablation for VT). CONCLUSIONS: RV or LV EMB can be performed safely during EP procedures and can assist with diagnosis, influencing management. EGM-guided EMB in patients presenting with scar-related VT was low yield for specific pathologies.

Mortality and Cerebrovascular Events After Heart Rhythm Disorder Management Procedures.

BACKGROUND: Recognition of rates and causes of hard, patient-centered outcomes of death and cerebrovascular events (CVEs) after heart rhythm disorder management (HRDM) procedures is an essential step for the development of quality improvement programs in electrophysiology laboratories. Our primary aim was to assess and characterize death and CVEs (stroke or transient ischemic attack) after HRDM procedures over a 17-year period. METHODS: We performed a retrospective cohort study of all patients undergoing HRDM procedures between January 2000 and November 2016 at the Mayo Clinic. Patients from all 3 tertiary academic centers (Rochester, Phoenix, and Jacksonville) were included in the study. All in-hospital deaths and CVEs after HRDM procedures were identified and were further characterized as directly or indirectly related to the HRDM procedure. Subgroup analysis of death and CVE rates was performed for ablation, device implantation, electrophysiology study, lead extraction, and defibrillation threshold testing procedures. RESULTS: A total of 48 913 patients (age, 65.7±6.6 years; 64% male) who underwent a total of 62 065 HRDM procedures were included in the study. The overall mortality and CVE rates in the cohort were 0.36% (95% confidence interval [CI], 0.31-0.42) and 0.12% (95% CI, 0.09-0.16), respectively. Patients undergoing lead extraction had the highest overall mortality rate at 1.9% (95% CI, 1.34-2.61) and CVE rate at 0.62% (95% CI, 0.32-1.07). Among patients undergoing HRDM procedures, 48% of deaths directly related to the HDRM procedure were among patients undergoing device implantation procedures. Overall, cardiac tamponade was the most frequent direct cause of death (40%), and infection was the most common indirect cause of death (29%). The overall 30-day mortality rate was 0.76%, with the highest being in lead extraction procedures (3.08%), followed by device implantation procedures (0.94%). CONCLUSIONS: Half of the deaths directly related to an HRDM procedure were among the patients undergoing device implantation procedures, with cardiac tamponade being the most common cause of death. This highlights the importance of the development of protocols for the quick identification and management of cardiac tamponade even in procedures typically believed to be lower risk such as device implantation.

Blood Pressure Responses to Endovascular Stimulation: A Potential Therapy for Autonomic Disorders With Vasodilatation.

BACKGROUND: We have previously shown that sympathetic ganglia stimulation via the renal vein rapidly increases blood pressure. This study further investigated the optimal target sites and effective energy levels for stimulation of the renal vasculatures and nearby sympathetic ganglia for rapid increase in blood pressure. METHODS: The pre-study protocol for endovascular stimulations included 2 minutes of stimulation (1-150 V and 10 pulses per second) and at least 2 minutes of rest during poststimulation. If blood pressure and/or heart rate were changed during the stimulation, time to return to baseline was allowed prior to the next stimulation. RESULTS: In 11 acute canine studies, we performed 85 renal artery, 30 renal vein, and 8 hepatic vasculature stimulations. The mean arterial pressure (MAP) rapidly increased during stimulation of renal artery (95 ± 18 mmHg vs. 103 ± 15 mmHg; P < 0.0001), renal vein (90 ± 16 mmHg vs. 102 ± 20 mmHg; P = 0.001), and hepatic vasculatures (74 ± 8 mmHg vs. 82 ± 11 mmHg; P = 0.04). Predictors of a significant increase in MAP were energy >10 V focused on the left renal artery, bilateral renal arteries, and bilateral renal veins (especially the mid segment). Overall, heart rate was unchanged, but muscle fasciculation was observed in 22.0% with an output >10 V (range 15-150 V). Analysis after excluding the stimulations that resulted in fasciculation yielded similar results to the main findings. CONCLUSIONS: Stimulation of intra-abdominal vasculatures promptly increased the MAP and thus may be a potential treatment option for hypotension in autonomic disorders. Predictors of optimal stimulation include energy delivery and the site of stimulation (for the renal vasculatures), which informs the design of subsequent research.

Pericardial effusion following drain removal after percutaneous epicardial access for an electrophysiology procedure.

OBJECTIVES: To determine the frequency and predictors of pericardial effusion following epicardial sheath removal. BACKGROUND: Pericardial effusion can occur following cardiac surgical or interventional procedures including percutaneous epicardial access (EpiAcc), which is increasingly used as part of electrophysiology ablation procedures. METHODS: A retrospective analysis of the Mayo Clinic comprehensive electronic medical record was performed from all patients who underwent planned EpiAcc as part of an electrophysiology ablation procedure between January 1, 2004 and June 30, 2013. RESULTS: Of 144 patients (mean age 51.3 ± 15.5 years, 68% male) who underwent planned EpiAcc as part of an electrophysiology ablation (95.8% pericardial access success rate), seven (4.9%) developed a postoperative pericardial effusion requiring repeat EpiAcc. Inferior access was utilized in 74 (51.4%) patients. Patients with pericardial effusion tended to be younger (41.1 years vs 51.8 years, P = 0.08) and were more likely to have undergone inferior approach access (85.7% vs 49.6%, P = 0.06) than those who did not develop postoperative pericardial effusion. Seventy-one percent of patients with postoperative pericardial effusion versus 32.1% of patients without postoperative pericardial effusion had a preprocedure ejection fraction ≥55% (P = 0.03). There were no procedural-related deaths, and no difference in mortality between groups. CONCLUSIONS: Postoperative pericardial effusion requiring repeat access/drainage was relatively infrequent, occurring in 4.9% of patients shortly after epicardial procedures. While the majority occur early and therefore require close observation, some patients may present in a delayed manner.

Refractory inappropriate sinus tachycardia successfully treated with radiofrequency ablation at the arcuate ridge.

Supraventricular tachycardias similar to sinus rhythm are difficult to evaluate and treat with catheter ablation. In addition to inappropriate sinus tachycardia (IST), curative ablation of atrial tachycardia arising from the crista terminalis is well described. We report the case of a 48-year-old woman with multiple failed ablation attempts for IST successfully ablated on the arcuate ridge. Ultrasound and fluoroscopy-guided mapping and ablation of this specific endocavitary anatomic site may be helpful in certain patients with the diagnosis of IST.