Esophageal luminal temperature monitoring using a multi-sensor probe lowers the risk of esophageal injury in cryo and radiofrequency catheter ablation for atrial fibrillation.

BACKGROUND: Esophageal luminal temperature monitoring is a commonly used strategy to reduce esophageal thermal injury in catheter ablation for atrial fibrillation (AFib). OBJECTIVES: We sought to compare the incidence of endoscopically detected esophageal lesions (EDEL) between two commonly used esophageal luminal temperature probes. METHODS: Consecutive patients undergoing ablation with esophageal luminal temperature monitoring and upper endoscopy within 24 h after ablation were included. RESULTS: Four hundred forty-five patients (64 ± 10 years, 44% female) were included. Esophageal temperature monitoring was done with a single-sensor probe in 213 (48%) and multi-sensor probe in 232 (52%). Cryoballoon (CB) ablation was performed in 118 (27%) and radiofrequency (RF) ablation in 327 (73%) of patients. EDEL was present in 94 (22.9%) of which 85 were mild, 8 were moderate, and 1 was severe, and none progressed to atrial-esophageal fistula. The use of the multi-sensor probe during CB ablation was associated with a reduction in EDEL compared to single sensor (6.8% vs 24.3%; P = 0.016). Similarly, in the RF ablation group, EDEL was present in 19.5% of the multi-sensor group vs 32.8% in the single-sensor group (P = 0.001). Logistic regression showed that multi-sensor probe use was associated with reduction in EDEL with an odds ratio of 0.23 in CB ablation (P = 0.024) and 0.44 for RF ablation (P = 0.001). CONCLUSIONS: Esophageal luminal temperature monitoring during AFib ablation using a multi-sensor probe was associated with a significant reduction in EDEL compared to a single-sensor probe.

Cryoballoon temperature parameters during cryoballoon ablation predict pulmonary vein reconnection and atrial fibrillation recurrence.

BACKGROUND: Cryoballoon ablation (CBA) is an established approach for rhythm management of atrial fibrillation (AF). We sought to assess balloon temperature (BT) parameters as predictors of pulmonary vein (PV) reconnection within the index procedure and AF recurrence following CBA. METHODS: BT was monitored in 119 AF patients undergoing CBA. PVs were assessed for reconnection during the procedure and patients were followed for arrhythmia recurrence. RESULTS: PV reconnection was identified in 39 (8.3%) of 471 PVs. BT was significantly colder in the absence of PV reconnection (30 s: - 33.5 °C [- 36; - 30] vs - 29.5 °C [- 35; - 25.5], p = 0.001; 60 s: - 41 °C [- 44; - 37] vs - 36.5 °C [- 42; - 33.5], p < 0.001; nadir: - 47 °C [- 52; - 43] vs - 41.5 °C [- 47; - 38], p < 0.001). PV reconnection was associated with significantly longer time to reach - 15 °C and - 40 °C (14.5 s [11.5-18.5] vs 12 s [10-15.5], p = 0.023; and 75 s [40-95.5] vs 46 s [37-66.75], p = 0.005) and shorter rewarming time (5.75 s [4.75-8.5] vs 7 s [6-9], p = 0.012). ROC analysis of these procedural parameters had an AUC = 0.71 in predicting PV reconnection. AF recurrence occurred in 51 (42.8%) patients. Kaplan-Meier analysis showed better arrhythmia-free survival for patients in whom BT decreased below - 40 °C in all PVs and patients who had no early PV reconnections, compared to patients in whom BT below - 40 °C was not achieved in at least one PV (log rank = 6.3, p = 0.012) and patients who had PV reconnections (log rank = 4.1, p = 0.043). CONCLUSIONS: Slower BT decline, warmer BT nadir, and faster rewarming time predict early PV reconnection. Absence of early PV reconnections and BT dropping below - 40 °C in all PVs during CBA are associated with lower rates of AF recurrence.

Predictors of high-degree atrioventricular block in patients with new-onset left bundle branch block following transcatheter aortic valve replacement.

BACKGROUND: The development of new left bundle branch block (LBBB) is frequently seen post TAVR and is a known risk factor for progression to high degree AV block. The timing and likelihood of progression into complete heart block is variable and can develop after hospital discharge. We sought to determine predictors for the development of high degree AV block in patients who developed LBBB following TAVR. METHODS: All patients between 2014 and 2019 underwent electrophysiology study after developing LBBB post TAVR. Data on these patients including baseline characteristics, echo parameters, EKG variables, HV interval, and the need for subsequent pacemaker implantation were extracted. A prolonged HV interval was defined as ≥ 65 ms. Clinically significant conduction abnormality was defined as development of high-degree AV block or clinically significant complete heart block. RESULTS: Thirty-four patients were included in our study of which 10 (29.4%) developed clinically significant heart block, while 24 (70.6%) did not. The mean HV interval for patients with clinically significant heart block was 70.1 ms vs 57.8 ms for those who did not (p = 0.022). Pre-existing first-degree heart block prior to TAVR (p = 0.026), history of AFib (p = 0.05) in addition to STS score (p = 0.037) were predictors of development of high-degree AV block in our patient population. CONCLUSIONS: In patients who develop LBBB following TAVR, HV interval, pre-existing first-degree heart block, and STS score predict progression to high-degree AV block. Performance of a routine electrophysiology study should be considered for high-risk patients who develop LBBB following TAVR.

Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America.

BACKGROUND: Despite the increase in the number of female physicians across most specialties within cardiology, <10% of clinical cardiac electrophysiology (EP) fellows are women. OBJECTIVES: This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender. METHODS: The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties. RESULTS: A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P < 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001). CONCLUSIONS: Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field.

Absence of left bundle branch block and blood urea nitrogen predict improvement in left ventricular ejection fraction in patients with cardiomyopathy and wearable cardioverter defibrillators.

OBJECTIVE: To identify predictors of left ventricular ejection fraction (LVEF) improvement in patients with newly detected cardiomyopathy using wearable cardioverter defibrillators (WCDs). BACKGROUND: WCDs are useful in preventing sudden cardiac death in patients with reduced LVEF <35% while awaiting implantable cardioverter defibrillator (ICD) placement. In many patients, LVEF improves and an ICD is not indicated. METHODS: Patients who received WCDs from November 2013 to November 2015 were identified and followed over a period of 2 years. Clinical variables were examined. The primary outcome was improvement in LVEF ≥35%. Predictors of outcome were determined using a multivariate logistic regression model. RESULTS: A total of 179 patients were followed. Median age was 65 (interquartile range [IQR]: 56, 73) years, 69.3% were men. Median baseline LVEF was 20% (IQR: 15, 30). LVEF improved ≥35% in 47.5% patients, with patients being younger (62 vs 68.5 years, P = .006), having lower blood urea nitrogen (BUN) (19 vs 24 mg/dL, P = .002), fewer left bundle branch block (LBBB 9.5% vs 25.8%, P = .004), shorter QRS duration (98 vs 112 ms, P < .001), and higher use of angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) (92.9% vs 74.4%, P = .001) compared to those without LVEF improvement. Absence of LBBB (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.11-0.70), lower BUN (OR 0.13, 95% CI 0.02-0.76), and ACEI/ARB use (OR 3.53, 95% CI 1.28-9.69) were identified as independent predictors. Ventricular tachycardia/ventricular fibrillation was observed in three patients, all of whom received successful WCD shocks. CONCLUSION: Absence of LBBB, lower BUN, and ACEI/ARB use predicts LVEF improvement. WCDs help treat arrhythmic events.