Value of ultrasound for access guidance and detection of subclinical vascular complications in the setting of atrial fibrillation cryoballoon ablation.

AIMS: Vascular complications are the most common complications of atrial fibrillation (AF) ablation. Cryoballoon (CB) ablation for AF needs the insertion of a large 15 Fr sheath in the femoral vein. Our aim was to investigate the impact of vascular ultrasound (US) in guiding access and evaluating post-procedural subclinical complications in a large, multi-centre patient cohort that underwent CB ablation. METHODS AND RESULTS: A total cohort of 1435 consecutive patients were subdivided in 870 US -/-, 265 US -/+, and 300 US +/+ patients depending on US performance for: venipuncture guidance/post-procedural evaluation. Major clinical complications (requiring intervention and/or prolonged stay) were assessed. Irrespective of the clinical status, major US events were systematically determined in the subgroups with US evaluation 1 day post-procedure, if evidence of inadvertent artery puncture/cannulation (communication between artery and collection or artery-vein, regardless of the thrombosis state). Major clinical events were encountered in 1.7% (15/870), 1.1% (3/265), and 0% of patients in US -/-, US -/+, and US +/+ group, respectively (P = 0.02 between US -/- and US +/+ group). In the US -/- group, 5/10 (50%) of pseudo-aneurysms were diagnosed during readmission after a mean of 24 ± 11 days post-procedure. No delayed presentation was seen in the US -/+ group. Major US events during the US protocol post-procedure were seen in 3.8% (10/265) vs. 0.3% (1/300) of patients in US -/+ vs. US +/+ group, respectively, P = 0.004. CONCLUSION: US-guided venipuncture was associated with a near-to-zero risk of vascular complications in our patients undergoing CB ablation.

Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation.

BACKGROUND: In the setting of second-generation cryoballoon (CB2) ablation, left atrial (LA) access is generally achieved using a standard sheath (SS) that is exchanged for the 15Fr cryoballoon delivery sheath (CBS) and dilator over a long wire (CBS over-the-wire technique, CBS-W). Our objective was to evaluate the direct use of the CBS to gain LA access, by advancing the latter over the trans-septal needle (CBS over-the-needle technique, CBS-N), under transesophageal echocardiographic (TEE) guidance. METHODS: Consecutive patients who underwent CB2 ablation with the CBS-N technique were evaluated for feasibility of gaining LA access using TEE guidance and fluoroscopy views. Complications related to the LA access were compared with a matched CBS-W control group. Subanalysis (30 CBS-W vs 30 CBS-N patients) evaluated time-to-LA of the CBS: time from superior vena cava (with SS vs CBS) to LA insertion of the CBS, after exchange or directly, respectively. RESULTS: LA access could be achieved in all 505 patients of the CBS-N group, without technique modification or additional equipment. Challenging interatrial septa were noted in 13% of these patients: previous atrial septal defect repair (1%), hypermobile (10%), aneurysmal (1%), and abnormally thickened/fibrotic (1%). Incidence of complications was similar to the CBS-W group. Subanalysis showed a shorter time-to-LA in the CBS-N versus CBS-W group, 72 ± 46 seconds versus 293 ± 180 seconds, P < .001. CONCLUSIONS: Our study showed that the CBS-N technique is feasible and safe under echocardiographic guidance. Without sheath exchange, it simplifies the CB2 procedure, is less costly, time sparing, and might reduce the risk of air embolism.

Impact of cryoballoon-guided pulmonary vein isolation on non-invasive autonomic tests in patients with paroxysmal atrial fibrillation.

BACKGROUND: Pulmonary vein isolation (PVI) modulates the intrinsic cardiac autonomic nervous system (ANS). We evaluated the impact of PVI on 5 non-invasive autonomic tests. METHODS: Thirty patients (76% male, mean age 60.37 ±â€¯9.02 years) with paroxysmal atrial fibrillation (AF) underwent cryoballoon-guided PVI. Five autonomic tests were performed 24hrs before and after PVI (N = 30) and repeated after 6months (N = 22). Parasympathetic function was measured by heart rate (HR) variability during deep breathing (E/I ratio, I-E difference), Valsalva maneuver (Valsalva-ratio) and head-up tilt test (30/15 ratio). Sympathetic function was measured by systolic BP response to sustained handgrip and 10' tilting and by diastolic BP response to cold water. RESULTS: 24hrs after PVI, baseline HR increased from 57.93 ±â€¯9.06 bpm to 71.10 ±â€¯12.75 bpm (p < 0.001). At 6 months, baseline HR was lower than immediately post-PVI (62.59 ±â€¯7.89 vs 71.36 ±â€¯13.58 bpm, p = 0.032) but still higher in comparison to pre-PVI (62.59 ±â€¯7.89 vs 57.09 ±â€¯8.80 bpm, p < 0.001). No differences were seen in baseline BP and parasympathetic tests acutely and at 6months. Besides an acute lowering in systolic BP increase during handgrip test, all sympathetic tests remained unchanged. CONCLUSIONS: An acute HR increase attenuated at 6months and an acute lowered systolic BP response to sustained handgrip were the only changes after cryoballoon-guided PVI. Non-invasive autonomic tests seem therefore not appropriate to evaluate the autonomic modulatory effect of PVI, either due to a too limited sensitivity or a too localized effect of PVI to influence test results.

Complications of pulmonary vein isolation in atrial fibrillation: predictors and comparison between four different ablation techniques: Results from the MIddelheim PVI-registry.

Aims: To define predictors of complications of pulmonary vein isolation (PVI) and compare safety between different ablation techniques. Methods and results: One thousand patients with atrial fibrillation (AF) (age 60 ± 10, 72% males, CHA2DS2-VASc score 1 ± 1) underwent PVI using various techniques: conventional PVI (CPVI) using mapping with irrigated point-per-point RF ablation (n = 576), multi-electrode RF ablation with the pulmonary vein ablation catheter (PVAC) (n = 272) or high density mesh ablator (HDMA) (n = 59) and cryoballoon (CB) ablation (n = 93). A complication was defined as any procedure-related adverse event resulting in permanent injury or death, requiring intervention or treatment, or prolonging/requiring hospitalization for >48 h. A total of 105 (10.5%) complications occurred in 101 (10.1%) patients. No periprocedural death occurred. Most frequent complications were vascular complications (4%) and pericarditis (3.1%). Seven patients experienced permanent deficit due to PV stenosis (n = 3, 1 CPVI, 2 PVAC) (n = 3) and phrenic nerve palsy (PNP) (n = 4, 3 CPVI, 1 PVAC). Independent predictors of complications were female sex [odds ratio (OR) = 1.73; 95% confidence interval (CI) 1.08-2.79; P = 0.023], CHA2DS2-VASc score (OR = 1.24; 95% CI 1.01-1.52; P = 0.039), and ablation technique (P = 0.006) in multivariable-adjusted analysis. Among the different techniques, CB (P = 0.047) and PVAC ablation (P = 0.003) had lowest overall complication rates. Complication profile (type/severity) differed between techniques (association between CB and PNP, CPVI and pericardial injury, PVAC and transient ischaemic attack/PV stenosis). Conclusion: Overall complication rate of PVI with various techniques is 10.5%. Permanent deficit occurred only after PVAC and CPVI in 0.7% of patients. Female sex and a higher CHA2DS2-VASc score increase, while PVAC and CB-PVI decrease, overall risk. Differences in overall safety and individual complication profile make selection of the ablation technique in relation to clinical risk profile possible.

Efficacy and safety of the second-generation cryoballoon ablation for the treatment of persistent atrial fibrillation in elderly patients.

BACKGROUND: It is expected that ablation procedures will be increasingly offered to a more aged population affected with persistent AF (persAF); however, the clinical outcomes of ablation in this specific population are not well described. We aimed to analyze the efficacy and safety of CB-A in this group of patients compared with a younger cohort. METHODS AND RESULTS: Eighty-three patients with (persAF) aged ≥75 years (group 1; mean age 78.2 ± 3.1 years) and 166 patients also affected with persAF aged <75 years (group 2; mean age 64.3 ± 6.6 years) were included in the study. The primary outcome was freedom from recurrent sustained (>30 seconds) atrial arrhythmias without anti-arrhythmic medication after a blanking period of 3 months. At 2 years, clinical success was achieved in 108 out of 249 patients (43.4%). Median follow-up was 24 months (IQR: 18.4-25.5 months). Older patients suffered from more recurrences than those in the younger cohort ((53/83 patients, 63.9% vs 88/166 patients, 53.0%; P = .03). Thirty (12.0%) patients suffered a complication, but the incidence of complications was not different between both groups. The most frequent complication was transient phrenic nerve injury. CONCLUSIONS: The global 2 years efficacy of CB-A PVI in persAF is 43.4%. A lower success rate is achieved in the older patients (36.1%) compared to the younger age group (47.0%). However, the complication rate was not different between age groups.

Progressive Thinning of the Basal Interventricular Septum by Giant Cell Myocarditis.

We describe a patient with ventricular tachycardia and complete atrioventricular block. Remarkable thinning of the basal interventricular septum preceded left ventricular dysfunction. Endomyocardial biopsy demonstrated giant cell myocarditis. The patient received combined immunosuppressive therapy and a cardioverter-defibrillator. Eligibility screening for heart transplantation was initiated. (Level of Difficulty: Advanced.).

Prediction of prolonged length of stay in the intensive care unit after cardiac surgery: the need for a multi-institutional risk scoring system.

BACKGROUND AND AIM OF THE STUDY: Predictive models for the length of stay (LOS) in the intensive care unit (ICU) following cardiac surgery have been developed in the last decade. These risk models use different endpoint and risk factor definitions. This review discusses the need for a uniform multi-institutional risk scoring system for a prolonged ICU LOS. METHODS: The MEDLINE database was searched for studies assessing the prognostic value of clinical variables predicting ICU LOS. Information on study design, patient population, extended ICU LOS definition, and predictors was retrieved. RESULTS: There is no consensus on the definition of a prolonged ICU LOS. This is mainly because some studies take the continuous variables of "days in the intensive care unit" and try to make it dichotomous when actually the LOS should be analyzed as a "continuous variable." We also report a cardiac surgeon-related component. The most important risk factors were: increased age, no elective surgery, type of cardiac surgery, low left ventricular ejection fraction, recent myocardial infarction, history of pulmonary disease, history of renal disease, and reoperation/reexploration. CONCLUSIONS: There is a need for the development of a multi-institutional risk scoring system for prolonged ICU LOS following cardiac surgery. This predictive model could aid in quality assessment, practice improvement, patient counseling, and decision making. In order to develop this risk model, uniformed and standardized definitions are needed.

Predictors of long-term outcome in patients undergoing a first repeat ablation consisting solely of re-isolation of reconnected pulmonary veins.

AIMS: To define predictors of long-term outcome of a first repeat ablation solely consisting of re-isolation of reconnected pulmonary veins (PVs). METHODS: Three hundred seven patients (age 59 ± 9%, 77% males, non-paroxysmal AF 43%) with recurrent AF after first PVI were studied. Re-isolation of reconnected PVs was guided by a circular mapping catheter and 3D mapping system using RF ablations. A PV was defined as "triggering" in case of spontaneous ectopy or AF paroxysms originating from the PV. RESULTS: After a mean follow-up of 5.05 ± 2.21 years, 194 (63.2%) patients (73.0% in PAF vs 50.4% in non-PAF, log Rank <0.001) were free from AF. A "triggering" PV was present in 48 (15.6%) during the first PVI and in 52 (16.9%) at repeat. Independent predictors of recurrence were a non-PAF type (HR: 1.814, 95%CI: 1.090 - 3.018, p=0.022) and early recurrence (≤ 3 months) after first PVI (HR: 1.632, 95%CI: 1.091 - 2.443, p=0.017) while a "triggering" PV at first or repeat was a predictor of good outcome (HR: 0.574; 95%CI: 0.344 - 0.959; p=0.034) in the multivariable analysis. CONCLUSIONS: A repeat ablation solely consisting of re-isolation of reconnected PVs results in a high degree of long-term AF freedom, especially in PAF and in case of a PV trigger at index or repeat. Patients with non-PAF or experiencing early AF recurrence after first PVI are less responsive.

Atrial fibrillation ablation with the second generation cryoballoon: Multicenter propensity score matched comparison between freezing strategies.

BACKGROUND: Second generation cryoballoon (CB-A) ablation is highly effective in achieving pulmonary vein (PV) isolation and freedom from atrial fibrillation (AF). However, the ideal freezing strategy is still under debate. Our objective was to investigate the efficacy and outcome between different freezing strategies used with the CB-A in a multicenter, matched population. METHODS: From a total cohort of 1018 patients having undergone CB-A ablation for drug-refractory AF, 673 patients with follow-up ≥6months were included and stratified according to the applied freezing strategy: bonus freeze (BF) versus single freeze (SF). Final population of 256 BF patients was compared with 256 propensity-score matched SF patients. RESULTS: BF strategy consisted of 3 different protocols: 3cycles of 180s; 2cycles of 240s; and cycles of 240s followed by 180s in 99/256 (39%); 42/256 (16%); and 115/256 (45%) patients, respectively. SF approach included cycles of 240s in 23/256 (9%), and 180s in 233/256 (91%) patients. Electrical isolation could be achieved in all PVs by both protocols, with shorter procedure and fluoroscopy times in the SF group (mean 106 vs 65min, and 18 vs 14min, respectively, P<0.001). Phrenic nerve palsy persisted after discharge in a total of 11 patients (2.1%): 4 (1.6%) in the BF group vs 7 (2.7%) in the SF group, P=0.5. AF-free survival was similar between the 2 groups during follow-up (mean 18±10months) (log rank, P=0.6). CONCLUSIONS: CB-A ablation showed equal efficacy and outcome between SF and BF strategy.

Preoperative prediction of intensive care unit stay following cardiac surgery.

OBJECTIVE: Following cardiac surgery, a great variety in intensive care unit (ICU) stay is observed, making it often difficult to adequately predict ICU stay preoperatively. Therefore, a study was conducted to investigate, which preoperative variables are independent risk factors for a prolonged ICU stay and whether a patient's risk of experiencing an extended ICU stay can be estimated from these predictors. METHODS: The records of 1566 consecutive adult patients who underwent cardiac surgery at our institution were analysed retrospectively over a 2-year period. Procedures included in the analyses were coronary artery bypass grafting, valve replacement or repair, ascending and aortic arch surgery, ventricular rupture and aneurysm repair, septal myectomy and cardiac tumour surgery. For this patient group, ICU stay was registered and 57 preoperative variables were collected for analysis. Descriptives and log-rank tests were calculated and Kaplan-Meier curves drawn for all variables. Significant predictors in the univariate analyses were included in a Cox proportional hazards model. The definitive model was validated on an independent sample of 395 consecutive adult patients who underwent cardiac surgery at our institution over an additional 6-month period. In this patient group, the accuracy and discriminative abilities of the model were evaluated. RESULTS: Twelve independent preoperative predictors of prolonged ICU stay were identified: age at surgery>75 years, female gender, dyspnoea status>New York Heart Association class II (NYHA II), unstable symptoms, impaired kidney function (estimated glomerular filtration rate (eGFR)<60 ml min(-1)), extracardiac arterial disease, presence of arrhythmias, mitral insufficiency>colour flow mapping (CFM) grade II, inotropic support, intra-aortic balloon pumping (IABP), non-elective procedures and aortic surgery. The individual effect of every predictor on ICU stay was quantified and inserted into a mathematical algorithm (called the Morbidity Defining Cardiosurgical (MDC) index), making it possible to calculate a patient's risk of having an extended ICU stay. The model showed very good calibration and very good to excellent discriminative ability in predicting ICU stay >2, >5 and >7 days (C-statistic of 0.78; 0.82 and 0.85, respectively). CONCLUSIONS: Twelve independent preoperative risk factors for a prolonged ICU stay following cardiac surgery were identified and constructed into a proportional hazards model. Using this risk model, one can predict whether a patient will have a prolonged ICU stay or not.

Is EuroSCORE useful in the prediction of extended intensive care unit stay after cardiac surgery?

OBJECTIVE: Risk stratification allows preoperative assessment of cardiac surgical risk faced by individual patients and permits retrospective analysis of postoperative complications in the intensive care unit (ICU). The aim of this single-center study was to investigate the prediction of extended ICU stay after cardiac surgery using both the additive and logistic model of the European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHODS: A retrospective observational study was conducted. We collected clinical data of 1562 consecutive patients undergoing cardiac surgery over a 2-year period at the Antwerp University Hospital, Belgium. EuroSCORE values of all patients were obtained. The outcome measure was the duration of ICU stay in days. The predictive performance of EuroSCORE was analyzed by the discriminatory power of a receiver operating characteristic (ROC) curve. Each EuroSCORE value was used as a theoretical cut-off point to predict duration of ICU stay. Three subsequent ICU stays were defined as prolonged: more than 2, 5 and 7 days. ROC curves were constructed for both the additive and logistic model. RESULTS: Patients had a median ICU stay of 2 days and a mean ICU stay of 5.5 days. Median additive EuroSCORE was 5 (range, 0-22) and logistic EuroSCORE was 3.94% (range, 0.00-87.00). In the additive EuroSCORE model, a predictive value of 0.76 for an ICU stay of >7 days, 0.72 for >5 days and 0.67 for >2 days was found. The logistic EuroSCORE model yielded an area under the ROC curve of 0.77, 0.75 and 0.68 for each ICU length of stay, respectively. CONCLUSIONS: In our patient database, prolonged length of stay in the ICU correlated positively with EuroSCORE. The logistic model was more discriminatory than the additive in tracing extended ICU stay. The overall predictive performance of EuroSCORE is acceptable and most likely based on the presence of variables that are risk factors for both mortality and extended ICU stay. Hence, EuroSCORE is a useful predicting tool and provides both surgeons and intensivists with a good estimate of patient risk in terms of ICU stay.

Intrapulmonary glomus tumor in a young woman.

A 21-year-old female patient presented with pneumonia and on chest roentgenogram a solitary pulmonary nodule was incidentally found. After an observation period she underwent left upper lobectomy because of documented tumor growth. Pathology showed an intrapulmonary glomus tumor of the proper type, which is a very rare occurrence. Literature review revealed only 11 published cases of this subtype. Radiological investigation is helpful for localization and characterization of the tumor. However, pathological examination is required for definitive diagnosis. Complete surgical excision is the treatment of choice. Although uncommon, glomus and carcinoid tumors should be considered in the differential diagnosis of solitary pulmonary nodules in young patients.