Sensor-Based Measurement Method to Support the Assessment of Robot-Assisted Radiofrequency Ablation.

Digital surgery technologies, such as interventional robotics and sensor systems, not only improve patient care but also aid in the development and optimization of traditional invasive treatments and methods. Atrial Fibrillation (AF) is the most common cardiac arrhythmia with critical clinical relevance today. Delayed intervention can lead to heart failure, stroke, or sudden cardiac death. Although many advances have been made in the field of radiofrequency (RF) catheter ablation (CA), it can be further developed by incorporating sensor technology to improve its efficacy and safety. Automation can be utilized to shorten the duration of RF ablation, provided that the interactions between the tissue and the RF tools are well understood and adequately modeled. Further research is needed to develop the optimal catheter design. This paper describes the systematic methodology developed to support robot-assisted RF CA characterization measurements. The article describes the custom instruments developed for the experiments, particularly the contact force limiter, the measurement procedure, and the evaluation of the results, as enablers for new results. The aim was to establish an objective, repeatable, robust measurement method and adjacent procedure.

Long-Term Efficacy and Safety of Left Atrial Appendage Closure Procedures.

The aim of the present single-center, nonrandomized, retrospective study was to assess the safety and long-term efficacy of percutaneous left atrial appendage closure (LAAC) procedures and to compare the different LAAC devices and therapeutic regimes in this respect.Medical data of 136 patients (pts) (mean age, 72.5 ± 7.6 years; score for atrial fibrillation stroke risk estimation [CHA2DS2-VASc], 4.6 ± 1.6; and score for estimation of major bleeding risk for patients on anticoagulant therapy [HAS-BLED], 2.6 ± 0.9) who underwent percutaneous LAAC procedures in Gottsegen National Cardiovascular Center from January 2010 to January 2020 were analyzed.The rates of outpatient cardiac mortality, ischemic brain event, and major bleeding were 3.8, 1, and 1.9/100 pt years, respectively. The rate of successful device deployment was 96.4%. There was one case of procedural mortality (0.7%), one case of device dislocation (0.7%), one case of ischemic stroke (0.7%), and one case of myocardial infarction (0.7%). Two cases of pericardial tamponades (1.5%) and four cases of major femoral complications (3%) occurred. Although the implantation success of different occluder types was similar, significant differences were found concerning procedural characteristics. Patients on single antiplatelet therapy (SAPT) in the first 3 months after the LAAC procedure did not suffer from stroke or embolic events.The present study confirmed the safety and effectivity of percutaneous LAAC. Robust relative stroke risk reduction and less pronounced but significant bleeding risk reduction were observed. Device implantation success was high. The perioperative complication rate was relatively low. The results of long-term observations regarding ischemic events confirmed the safety of using a simplified antithrombotic regime after LAAC in pts with high bleeding risk.

Evaluation of Isolation Area, Myocardial Injury and Left Atrial Function Following High-Power Short-Duration Radiofrequency or Second-Generation Cryoballoon Ablation for Atrial Fibrillation.

This randomized study aims to compare the left atrial (LA) lesion size, function, and tissue damage following pulmonary vein isolation (PVI) by high-power short-duration (HPSD) radiofrequency (RF) and second-generation cryoballoon (CB2) ablation. We enrolled 40 patients with paroxysmal atrial fibrillation who underwent PVI by HPSD RF (n = 21) or CB2 (n = 19). Every patient underwent LA CT angiography and transthoracic echocardiography (TTE) to assess the LA anatomy and function. Biomarker levels (hs-cTnT, hs-CRP, LDH) were compared pre- and post-procedurally. Pre- and post-ablation high-density mapping (HDM) was performed. The isolation area was defined under 0.2 mV bipolar voltage (low voltage area, LVA). We calculated the post-PVI LVA/LA surface ratio using LA CT-HDM merge images. At 3-month follow-up, TTE was performed to assess the changes in LA function. Post-ablation hs-cTnT level was significantly higher in the RF group (RF: 1249 ± 469 ng/L, CB2: 995 ± 280 ng/L, p = 0.024). Post-PVI hs-CRP (RF: 9.53 ± 10.30 mg/L, CB2: 12.36 ± 5.76 mg/L, p = 0.034) and LDH levels (RF: 349.9 ± 65.6 U/L, CB2: 451.6 ± 91.3 U/L, p < 0.001) were significantly higher following CB2 ablation. Post-PVI LVA/LA surface ratios were 8.37 ± 6.42% in the RF group and 13.58 ± 8.92% in the CB2 group (p = 0.022). LA function did not change significantly after the PVI procedure. Our data indicate that second-generation cryoballoon ablation produces a significantly larger LA lesion size compared to "point-by-point" HPSD radiofrequency. Both techniques preserve LA function. The myocardial component of tissue loss appears to be higher using HPSD radiofrequency ablation, with less collateral damage.

Functional electrographic flow patterns in patients with persistent atrial fibrillation predict outcome of catheter ablation.

AIMS: Electrographic flow (EGF) mapping is a method to detect action potential sources within the atria. In a double-blinded retrospective study we evaluated whether sources detected by EGF are related to procedural outcome. METHODS: EGF maps were retrospectively generated using the Ablamap® software from unipolar data recorded with a 64-pole basket catheter from patients who previously underwent focal impulse and rotor modulation-guided ablation. We analyzed patient outcomes based on source activity (SAC) and variability. Freedom from atrial fibrillation (AF) was defined as no recurrence of AF, atypical flutter or atrial tachycardia at the follow-up visits. RESULTS: EGF maps were from 123 atria in 64 patients with persistent or long-standing persistent AF. Procedural outcome correlation with SAC peaked at >26%. S-type EGF signature (source-dependent AF) is characterized by stable sources with SAC > 26% and C-type (source-independent AF) is characterized by sources with SAC ≤ 26%. Cases with AF recurrence at 3-, 6-, or 12-month follow-up showed a median final SAC 34%; while AF-free patients had sources with significantly lower median final SAC 21% (p = .0006). Patients with final SAC and Variability above both thresholds had 94% recurrence, while recurrence was only 36% for patients with leading source SAC and variability below threshold (p = .0001). S-type EGF signature post-ablation was associated with an AF recurrence rate 88.5% versus 38.1% with C-type EGF signature. CONCLUSIONS: EGF mapping enables the visualization of active AF sources. Sources with SAC > 26% appear relevant and their presence post-ablation correlates with high rates of AF recurrence.

Extensive scar modification for the treatment of intra-atrial re-entrant tachycardia in patients after congenital heart surgery.

BACKGROUND: Catheter ablation is an important therapeutic option for atrial tachycardias in patients with CHD. As a result of extensive scarring and surgical repair, multiple intra-atrial re-entrant tachycardia circuits develop and serve as a substrate for arrhythmias. The best ablation approach for patients with multiple intra-atrial re-entrant tachycardias has not been investigated. Here, we compared substrate-based ablation using extensive scar modification to conventional ablation. METHODS: The present study included patients with surgically corrected CHD that underwent intra-atrial re-entrant tachycardia ablation. Extensive scar modification was defined as substrate ablation based on a dense voltage map, aimed to eliminate all potentials in the scar region. The control group had activation mapping-based ablation. A clinical composite endpoint was assessed. Points were given for type, number, and treatment of intra-atrial re-entrant tachycardia recurrence. RESULTS: In 40 patients, 63 (extensive scar modification 13) procedures were performed. Acute procedural success was achieved in 78%. Procedural duration was similar in both groups. Forty-nine percent had a recurrence within 1 year. During a 5-year follow-up (2.5-7.5 years), 46% required repeat catheter ablation. Compared to baseline, clinical composite endpoint significantly decreased by 46% after 12 months (p = 0.001). Acute procedural success, procedural parameters, recurrence and repeat ablation were similar between extensive scar modification and activation mapping-based ablation. CONCLUSION: Catheter ablation using extensive scar modification for intra-atrial re-entrant tachycardias occurring after surgically corrected CHD illustrated similar short- and long-term outcomes and procedural efficiency compared to catheter ablation using activation mapping-based ablation. The choice of ablation approach for multiple intra-atrial re-entrant tachycardia should remain at the discretion of the operator.

The Role of Atrial Fibrosis Detected by Delayed - Enhancement MRI in Atrial Fibrillation Ablation.

INTRODUCTION: Atrial Fibrillation (AF) is associated with remodeling of the atrial tissue, which leads to fibrosis that can contribute to the initiation and maintenance of AF. Delayed- Enhanced Cardiac Magnetic Resonance (DE-CMR) imaging for atrial wall fibrosis detection was used in several studies to guide AF ablation. The aim of present study was to systematically review the literature on the role of atrial fibrosis detected by DE-CMR imaging on AF ablation outcome. METHODS: Eight bibliographic electronic databases were searched to identify all published relevant studies until 21st of March, 2016. Search of the scientific literature was performed for studies describing DE-CMR imaging on atrial fibrosis in AF patients underwent Pulmonary Vein Isolation (PVI). RESULTS: Of the 763 citations reviewed for eligibility, 5 articles (enrolling a total of 1040 patients) were included into the final analysis. The overall recurrence of AF ranged from 24.4 - 40.9% with median follow-up of 324 to 540 days after PVI. With less than 5-10% fibrosis in the atrial wall there was a maximum of 10% recurrence of AF after ablation. With more than 35% fibrosis in the atrial wall there was 86% recurrence of AF after ablation. CONCLUSION: Our analysis suggests that more extensive left atrial wall fibrosis prior ablation predicts the higher arrhythmia recurrence rate after PVI. The DE-CMR imaging modality seems to be a useful method for identifying the ideal candidate for catheter ablation. Our findings encourage wider usage of DE-CMR in distinct AF patients in a pre-ablation setting.

Introducing a novel catheter-tissue contact feedback feature in robotic navigated catheter ablation: Utility, feasibility, and safety.

BACKGROUND: The quality of catheter-tissue contact is one of the most important determinants of catheter ablation (CA) success. The absence of catheter-tissue contact feedback has been regarded a major limitation of remote magnetic navigation (RMN)-guided CA. The e-Contact module (ECM) is a novel feature designed for RMN that measures the quality of catheter-tissue contact. OBJECTIVE: The purpose of this study was to describe the first clinical experience with this feature and to test its effect on procedural parameters and interference with other ablation equipment during CA procedures as well as its safety. METHODS: This was a prospective, single-center, 2-phase study investigating ECM use during complex RMN procedures in 30 patients. Impact of ECM on procedural parameters was evaluated in the feasibility phase (FP), and its interference with other equipment was tested in the interference phase (IP) using pacing maneuvers at 3 randomly selected right atrial sites. Intracardiac electrograms were evaluated for disturbances by 2 independent electrophysiologists. RESULTS: For FP, mean procedural time was 162 ± 66 minutes, fluoroscopy time 21 ± 9 minutes, and ablation time 34 ± 21 minutes. For IP, no significant differences in pacing capture or thresholds were found (ECM- vs ECM+: site 1: 2.05 vs 2.21 mA; P = .320; site 2: 2.15 vs 2.12 mA; P = .873; site 3: 2.51 vs 2.50 mA; P = .976). Electrogram disturbances did not significantly differ between ECM- and ECM+. No adverse events were reported. CONCLUSION: The ECM is a novel catheter-tissue contact technology designed for RMN-guided CA. Our study suggests that this feature is feasible and does not interfere with other electrophysiology equipment while maintaining an excellent safety profile.

High Cerebrovascular Thromboembolic Event Rate Long after Unsuccessful Catheter Ablation for Atrial Fibrillation.

BACKGROUND: Although catheter ablation (CA) is an accepted therapeutic option for atrial fibrillation (AF), data is lacking concerning the long-term thromboembolic event (TE) and mortality rate of patients after unsuccessful CA for AF. OBJECTIVE: The aim of the current study was to detect the long-term TE and mortality rate of patients with successful CA (group A) of AF and compared those with unsuccessful ablation (group B). METHODS: Following a 4-years of follow-up (FU) 330 patients were included into the groupA, and 105 patients into the group B. Primary outcome was defined as all stroke/TIA occurrence. Secondary outcome was considered as all-cause mortality and stroke - and TIA only occurrence. RESULTS: Seventeen patients developed a stroke/TIA during a median of 5.8 [5.1-7.3] years of FU. In the group A 8 (2.4%) patients developed a stroke/TIA during a FU of 2037 person-years (incidence rate 3.92 per 1000 person-years), compared to 9 patients in the group B during a FU of 726 person-years (incidence rate 12.4 per 1000 person-years). The crude HR for primary outcome was 2.84 (95% CI 1.078-7.48) in the group B compared with the group A. Cumulative TIA-alone incidence (3.97, CI 1.10-14.34, p=0.035) and the annualized TIA-alone incidence rate was significantly higher in the group B. (p=0.029). Neither the mortality rate nor the incidence rate of stroke-alone differed significantly among the groups. CONCLUSIONS: The risk of all stroke/TIA and TIA-alone is higher among patients after unsuccessful CA of AF compared to those after successful ablation.

The Stratified Population Screening of Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multisystemic vascular disease with a wordwide prevalence of 1:5000-1:10000. We introduce our algorithm for the stratified population screening of HHT. Probands are selected from the consecutive hospital database review for HHT (I7800) and recurrent epistaxis (R0400) and the review of patient records referred by family practicioners. A proportion of probands might be de novo diagnosed with HHT in the 10-year study period. The checkup of probands consists of physical examination, arteriovenous malformation exploration and and genetic testing (ACVRL1 and ENG sequence analysis). The family screening of HHT consists of physical examination and screening for the family-specific mutation of each at-risk individual, and furthermore, arteriovenous malformation exploration in individuals with suspected/definite HHT and/or carrying the mutation. Twenty-five definite HHT patients were explored: 7 of them by the I7800 review, 1 by the R0400 review, 3 were de novo diagnosed, and the remaining 14 were explored by the systematic family screening. Considering the 20 patients alive at the end of the study period and the unavailable 5 potential HHT patients and 12 at-risk family members, the HHT prevalence is estimated to be 1:6090-1:11267 in our study area, implying our algorithm's effectivity in the stratified population screening of HHT.

Prospective evaluation of iatrogenic atrial septal defect after cryoballoon or radiofrequency catheter ablation of atrial fibrillation-"EVITA" study.

PURPOSE: Iatrogenic atrial septal defect (IASD) after catheter ablation (CA) for atrial fibrillation (AF) due to transseptal puncture (TSP) can occur. The aim of this prospective study was to describe the incidence of IASD and to detect any cerebrovascular accident (CVA) after radiofrequency (RF) and cryoballoon (CB) CA. METHODS: Between July 2014 and September 2016, 94 patients (pts) (RF; 48, CB; 46, 30 (31.9%) women, mean age = 60 ± 9.7 years) with paroxysmal AF were enrolled who underwent CA procedure for the first time. During RF ablation a single (n = 30, 62.5%) or double (n = 18, 37.5%) TSP was performed. Transoesophageal echocardiography before the procedure and at the 3-month and 12-month follow-up (FU) was accomplished. During the FU period, we evaluated the occurrence of any postprocedural CVA. RESULTS: At the 3-month FU, IASD was detected in 17/94 (18.1%) pts; in 9/48 (18.8%) pts in the RF while in 8/46 (17.4%) pts in the CB group (p = 0.866), all of them with left-to-right shunt. In the RF group, 6/30 (20%) pts with a single TSP while 3/18 (16.7%) pts in the double TSP group had IASD (p = 0.780). 14/17 (82.4%) IASDs showed high spontaneous closure rate at the 12-month FU. None of the pts died or suffered from CVA. CONCLUSION: Persistent IASD can occur rather frequently following AF CA. No significant difference was observed between the RF and CB techniques concerning the presence of IASD at 3-month. IASDs showed a high spontaneous closure rate. No cerebral thromboembolic event was observed in the 12-month FU period.

Left-sided phrenic nerve injury during redo pulmonary vein isolation long after a previous contralateral self-limiting phrenic nerve palsy.

We present a unique case of a left-sided phrenic nerve injury (PNI) long after a previous contralateral PNI following pulmonary vein isolation (PVI) procedures. Firstly, right-sided PNI after cryoballoon ablation, and secondly a left-sided PNI was observed following a redo PVI extended with box-lesion and left atrial appendage isolation (LAAI).

Robotic navigation shows superior improvement in efficiency for atrial fibrillation ablation.

BACKGROUND: Because of the expanding atrial fibrillation (AF) burden, AF catheter ablation (CA) techniques have to become more efficient. Efficient AF CA procedures are characterized by successful pulmonary vein isolation (PVI) within reasonable procedure time. Currently there are many PVI techniques available and all show substantial improvements over time. However, the magnitude of improvement in procedural efficiency has not yet been compared between different techniques. The aim of this study was to compare efficiency improvement between manually (MAN) guided, cryoballoon (CB) and remote magnetic navigation (RMN) guided PVI. METHODS: A total of 221 patients were included in this retrospective study. Procedural parameters of 115 patients treated with first-generation PVI techniques (MAN-1, CB-1, RMN-1) performed in 2010, were compared to 106 patients who were treated with the latest, second generation techniques (MAN-2, CB-2, RMN-2). Efficiency was characterized by the following parameters: total ablation time, total procedure time, first pass isolation (FPI) (i.e. successful isolation after the first pulmonary vein (PV) encirclement) and touch-up rates. RESULTS: Every technique showed significant improvement of procedure times from the first to the second generation (P<0.001). In-between second generation techniques, the procedure times were comparable. The greatest magnitude of procedure time improvement was observed within the RMN groups (∆-180min), which was significantly greater compared to CB (∆-48 min, P<0.001) and MAN (∆-98min, P=0.011) groups. The highest FPI rates were observed in RMN-2 (78% and 74%; left and right PVs respectively), which was significantly higher compared to other techniques (MAN-2: 24% and 24%; CB-2: 50% and 48%; P<0.001). CONCLUSIONS: The highest magnitude of efficiency improvement was detected in RMN guided PVI.

[Genetic diagnostics of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)]. / A herediter haemorrhagiás teleangiectasia (Osler­Weber­Rendu-kór) genetikai diagnosztikája.

Introduction: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant multisystemic vascular disease with a worldwide prevalence of 1 : 5000 - 1 : 10 000. Diagnosis is based on clinical Curacao criteria. Approximately 85% of HHT cases have heterozygous family-specific mutations in the ENG or ACVRL1 genes. Aim: We investigated 23 Hungarian HHT families, established the genetic diagnosis, executed family-screening and confirmed founder effects. Method: Probands were identified by the stratified population screening of the primary attendance area of our institution and from individuals contacting our study group voluntarily. Diagnosis is based on the otorhinolaryngological physical examination completed with characteristic telangiectasis sites, a visceral arteriovenous malformation screening and the sequence analysis of ENG and ACVRL1 genes. The family screening consists of physical examination and genetic screening for the family-specific mutation, followed by the arteriovenous malformation screening in patients with definite/suspected HHT and/or in individuals with the mutation. Results: Sixty-three individuals with family-specific mutations were identified in 22 families, 48 of them with definite and 12 with suspected HHT. Seven ENG and ACVRL1 mutations were detected, respectively; most of these are pathogenic. Three founder mutations were observed. One proband with definite HHT had wild-type alleles in all tested HHT-specific loci. Conclusions: The significance of genetic testing is confirming or excluding HHT in young asymptomatic individuals in families with pathogenic mutations. As ENG and ACVRL1 mutations result in overlapping fenotypes, the genetic testing lacks any prognostic value. The identification of founder effects might simplify the genetic diagnosis of new HHT patients from a given region. Orv Hetil. 2019; 160(18): 710-719.

Comparison of long-term outcome between patients aged < 65 years vs. ≥ 65 years after atrial fibrillation ablation.

BACKGROUND: Atrial fibrillation (AF) is the most frequent arrhythmia, and its prevalence is increasing with aging. We aimed to compare the long-term outcome data of patients < 65 years vs. ≥ 65 years who underwent catheter ablation (CA) for drug-refractory AF. METHODS: Consecutive patients with primary pulmonary vein isolation performed between March 2001 and December 2011, and those who completed a five-year of follow-up were divided into two groups: patients aged < 65 years into group 1, and patients aged ≥ 65 into group 2. Long-term outcome data concerning mortality, thromboembolic events (TE) and success rates were compared between these groups. RESULTS: A total number of 390 patients were included, group 1 contained 310 patients, and 80 patients in group 2. In group 2, patients had more often impaired renal function (P < 0.001) and thyroid disease (P = 0.047). A total of fifteen patients died during the 6.63 ± 2.1 years of follow-up, with a significantly higher incidence in the older group (8/80 vs. 7/310 patients, P = 0.004). The majority of fatal outcome was due to cancerous diseases in both groups. No difference was observed concerning the long-term TE rate (12/310 vs. 4/80 patients, P = 0.75). Rhythm control failed in 25.9% of the patients, with no difference between the groups: 26.4% in group 1 vs. 23.7% in group 2 (P = 0.67). CONCLUSIONS: Despite growing prevalence of AF in aging population, the elderly patients are underrepresented in CA procedures. Similar clinical success and TE complication rate are observed between the age-groups. Our data suggest more liberal criteria might be applied while selecting patients for AF ablation.

Type and rate of atrial fibrillation termination due to rotational activity ablation combined with pulmonary vein isolation.

BACKGROUND: There remains controversy about the optimal ablation technique and termination rate of atrial fibrillation (AF) during catheter ablation in patients with persistent AF. The aim of this study was to determine the rate and timing of AF termination during combined pulmonary vein isolation (PVI) and focal impulse and rotor modulation (FIRM)-guided ablation of rotational activity (RoAc). METHODS: This single-center, prospective cohort study enrolled 38 consecutive patients (63% male, mean age 63 ± 11 years) with persistent AF (mean left atrial size: 46 ± 7 mm), who underwent FIRM mapping and ablation of the identified RoAcs followed by PVI. We systematically evaluated the incidence and timing of AF termination during AF ablation. RESULTS: "Late-onset termination" of AF could be observed in 12 (32%) patients after ablation of the identified RoAcs. In a further 10 (26%) patients, "abrupt" AF termination during PVI was achieved. In total, the combined technique of conventional PVI and RoAc ablation resulted in AF termination rate of 58%. ECV was performed in 16 "nonterminating" patients. At 1-year follow-up, 76.1% (16 of 21) of patients remained free from AF/AT, 4 of 10 patients (25%) within the "abruptly" terminated group, 7 of 12 (58.3%) patients among the "late-terminated" group, and 5 of 16 (31, 25%) patients in the "nonterminating" group. CONCLUSION: Large area RoAc ablation combined with PVI results in a moderate termination rate of persistent AF with two distinctive timing patterns. More studies are needed to determine the clinical significance of type of AF termination and long-term success rate of RoAc ablation in patients with persistent AF.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement our technique should offer easier access and better results than other currently available implantation methods.

The Short and Long-Term Efficacy of Pulmonary Vein Isolation as a Sole Treatment Strategy for Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Pulmonary vein isolation (PVI) is an accepted treatment strategy for catheter ablation (CA) of paroxysmal atrial fibrillation (PAF). In this study, we aimed to assess the short, mid- and long-term outcome of PVI as a sole treatment strategy for PAF. METHODS: Six bibliographic electronic databases were searched to identify all published relevant studies until December 14, 2015. Search of the scientific literature was performed for studies describing outcomes with mean follow-up > 24 months after PAF ablation. Only articles with 1, 3 or 5-year follow up were included, from the same group of investigators. RESULTS: Of the 2398 references reviewed for eligibility, 13 articles (enrolling a total of 1774 patients) were included in the final analysis. Pooled analysis showed that the 12- and 62 -month success rate of a single CA procedure was 78% (95% CI 0.76% to 0.855) and 59% (95% CI 0.56% to 0.64%), respectively. The results did not differ by type of CA performed. Major complications mentioned in the enrolled studies were cerebrovascular event, pericardial tamponade and PV stenosis. CONCLUSION: There is a progressive and significant decline in freedom from AF between 1, 3 and 5- year after successful PVI in patients with PAF. Our analysis suggests that a high short-time success rate after PVI does not necessarily result in high chronic success rate.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods.

Long-term cerebral thromboembolic complications of transapical endocardial resynchronization therapy.

PURPOSE: Cardiac resynchronization therapy (CRT) is an established therapeutic option in selected heart failure patients (pts). However, the transvenous left ventricular (LV) lead implantation remains ineffectual in a considerable number of pts. Transapical LV (TALV) lead implantation is an alternative minimally invasive, surgical, endocardial implantation technique. The aim of the present prospective study is to determine the long-term outcome, including the cerebral thromboembolic complications, of pts who underwent TALV lead placement. METHODS: Twenty-six CRT candidates (19 men (78 %); mean age 61 ± 10 years) with a previously failed transvenous approach underwent TALV lead placement as a last resort therapy. The following data was collected: mortality rate, reoperation rate, and cerebrovascular event rate. Patients underwent a cerebral CT scan to determine any possible cerebrovascular event related to the presence of the TALV lead. RESULTS: Eleven out of 26 (47 %) patients survived after a median follow-up of 40 ± 24.5 months. Major acute ischemic stroke occurred in two cases, while in one case transient ischemic stroke was observed. Cerebral CT scan examination performed in asymptomatic patients revealed chronic ischemic lesions with minimal extension in two patients. Reoperation occurred in one case due to TALV lead fracture. CONCLUSIONS: This is the first study reporting the long-term outcome, mortality, and thromboembolic event rate exclusively after TALV lead implantation. Patients who underwent TALV lead implantation have a comparable long-term mortality rate to conventional CRT, although a major ischemic cerebrovascular event after TALV lead implantation is worrisome and has an impact on the outcome.

Disappearance of Idiopathic Outflow Tract Premature Ventricular Contractions After Catheter Ablation of Overt Accessory Pathways.

BACKGROUND: Multiple mechanisms have been proposed for idiopathic premature ventricular contractions (PVCs) originating from the outflow tracts (OTs). Recent observations such as the coexistence of these arrhythmias with atrioventricular nodal reentrant tachycardias and the association between discrete prepotentials and successful ablation sites of ventricular arrhythmias (VAs) from the OTs suggest a common link. OBJECTIVE: In this case series we draw attention to a unique association between accessory pathways (APs) and idiopathic PVCs from the OTs, disappearing after AP ablation. METHODS: We identified 6 cases in collaboration with several international electrophysiology centers, which presented with pre-excitation in association with OT, and in 1 case inflow tract (IT), PVCs on 12-lead surface ECG. RESULTS: Six cases displayed pre-excitation and PVCs, in 5 cases originating from the right ventricular outflow tract (RVOT) and in 1 case from the right ventricular inflow tract (RVIT). In all patients, PVCs were monomorphic and had fixed coupling intervals, in 3 cases presenting in bigeminy. Catheter ablation of the AP led to the simultaneous disappearance of PVCs in 5 of 6 cases. The sites of ablation were remote from the OTs in all these cases. In most cases, the occurrence of OT PVCs was closely associated with the presence of pre-excitation. CONCLUSION: The coexistence of pre-excitation and PVCs from the OTs and the fact that in 5 of 6 cases PVCs disappeared after AP ablation suggests a common mechanism for arrhythmia genesis.