Risk of ventricular arrhythmias following implantable cardioverter-defibrillator generator change in patients with recovered ejection fraction: Implications for shared decision-making.

INTRODUCTION: Guidelines indicate primary-prevention implantable cardioverter-defibrillators (ICDs) for most patients with left ventricular ejection fraction (LVEF) ≤ 35%. Some patients' LVEFs improve during the life of their first ICD. In patients with recovered LVEF who never received appropriate ICD therapy, the utility of generator replacement upon battery depletion remains unclear. Here, we evaluate ICD therapy based on LVEF at the time of generator change, to educate shared decision-making regarding whether to replace the depleted ICD. METHODS: We followed patients with a primary-prevention ICD who underwent generator change. Patients who received appropriate ICD therapy for ventricular tachycardia or ventricular fibrillation (VT/VF) before generator change were excluded. The primary endpoint was appropriate ICD therapy, adjusted for the competing risk of death. RESULTS: Among 951 generator changes, 423 met inclusion criteria. During 3.4 ± 2.2 years follow-up, 78 (18%) received appropriate therapy for VT/VF. Compared to patients with recovered LVEF > 35% (n = 161 [38%]), those with LVEF ≤ 35% (n = 262 [62%]) were more likely to require ICD therapy (p = .002; Fine-Gray adjusted 5-year event rates: 12.7% vs. 25.0%). Receiver operating characteristic analysis revealed the optimal LVEF cutoff for VT/VF prediction to be 45%, the use of which further improved risk stratification (p < .001), with Fine-Gray adjusted 5-year rates 6.2% versus 25.1%. CONCLUSION: Following ICD generator change, patients with primary-prevention ICDs and recovered LVEF have significantly lower risk of subsequent ventricular arrhythmias compared to those with persistent LVEF depression. Risk stratification at LVEF 45% offers significant additional negative predictive value over a 35% cutoff, without a significant loss in sensitivity. These data may be useful during shared decision-making at the time of ICD generator battery depletion.

Single incision technique for implantation of subcutaneous implantable cardioverter defibrillators.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) have gained increasing popularity because of certain advantages over transvenous ICDs. However, while conventional ICDs require a single surgical incision to implant, S-ICDS need two or three incisions, making them less appealing. OBJECTIVE: This study sought out to investigate the feasibility of using a single-incision technique to implant S-ICDs. METHODS: Patients qualifying for S-ICDs were considered for a single incision. A single incision is performed by making a left inframammary incision and then the subcutaneous tissue is dissected medially toward the lower sternum. Two sutures are placed in the fascia in the xiphoid area to anchor the lead and a tunneling tool is used to dissect the tissue to place the lead parallel to the sternum. Then subcutaneous tissues are dissected down the lateral chest wall over the muscle fascia to create the pulse generator pocket in the vicinity of the fifth and sixth intercostal spaces and near the mid-axillary line. RESULTS: Eleven patients (six males and five females) successfully underwent S-ICD implantation with a single incision without acute complications (64% for primary prevention). The mean age is 47.4 ± 15.8 years. There were no lead dislodgements, inappropriate shocks, or any other issues during a median follow-up of 10 months (interquartile range 5-17). One patient had a successful appropriate shock for ventricular fibrillation about one year after device implant. CONCLUSIONS: A single incision for subcutaneous ICDs is feasible and safe in our early experience.

Use of High-Frequency Percussive Ventilation to Expand Organ Donor Pool.

A 34-year-old woman was brought in to the emergency department after a motor vehicle accident. She had signs of traumatic head injury with Glasgow Coma Scale score of 3, and her neurological examination was consistent with brain death. She was persistently hypoxic on conventional mechanical ventilation and high-frequency percussive ventilation was initiated. The patient's oxygenation improved and was sustained long enough to provide time for organ procurement. This is the first case portraying high-frequency percussive ventilation as a bridge for donors failing on conventional mechanical ventilation.

The role of atrial fibrillation catheter ablation in patients with heart failure.

Atrial Fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF) frequently coexist, resulting in significant morbidity and mortality. Therapeutic options for patients with AF and HFrEF are limited due to few antiarrhythmic drug (AAD) choices and historically equivocal effects of procedural interventions on mortality. However, recent randomized trials examining catheter ablation (CA) in AF patients with HFrEF have shown a beneficial effect on arrhythmic burden and HF symptoms, as well as an improvement in mortality. This review focuses on the role of CA for AF patients with HFrEF.

Epidemiology, evaluation, and management of conduction disturbances after transcatheter aortic valve replacement.

Aortic stenosis is the most common valvulopathy requiring replacement by means of the surgical or transcatheter approach. Transcatheter aortic valve replacement (TAVR) has quickly become a viable and often preferred treatment strategy compared to surgical aortic valve replacement. However, transcatheter heart valve system deployment not infrequently injures the specialized electrical system of the heart, leading to new conduction disorders including high-grade atrioventricular block and complete heart block (CHB) necessitating permanent pacemaker implantation (PPI), which may lead to deleterious effects on cardiac function and patient outcomes. Additional conduction disturbances (e.g., new-onset persistent left bundle branch block, PR/QRS prolongation, and transient CHB) currently lack clearly defined management algorithms leading to variable strategies among institutions. This article outlines the current understanding of the pathophysiology, patient and procedural risk factors, means for further risk stratification and monitoring of patients without a clear indication for PPI, our institutional approach, and future directions in the management and evaluation of post-TAVR conduction disturbances.

Analyses of electronic health records utilization in a large community hospital.

INTRODUCTION: The Electronic Health Record (EHR) has become an integral component of healthcare delivery. Survey based studies have estimated that physicians spend 4-6 hours of their workday devoted to EHR. Our study was designed to use computer software to objectively obtain time spent on EHR. METHODS: We recorded EHR time for 248 physiciansover 2 time intervals. EHR active use was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. We recorded total time and % of work hours spent on EHR, and differences in those based on seniority. Physicians reported duty hours using a standardized toolkit. RESULTS: Physicians spent 3.8 (±2) hours on EHR daily, which accounted for 37% (±17%), 41% (±14%), and 45% (±12%) of their day for all clinicians, residents, and interns, respectively. With the progression of training, there was a reduction in EHR time (all p values <0.01). During the first academic quarter, clinicians spent 38% (± 8%) of time on chart review, 17% (± 7%) on orders, 28% (±11%) on documentation (i.e. writing notes) and 17% (±7%) on other activities (i.e. physician hand-off and medication reconciliation). This pattern remained unchanged during the fourth quarter. CONCLUSIONS: Physicians spend close to 40% of their work day on EHR, with interns spending the most time. There is a significant reduction in time spent on EHR with training and greater experience, although the overall amount of time spent on EHR remained high.