Telehealth Follow-up Using a Real-Time Electrocardiogram Device Improves Electrocardiogram Monitoring Duration and Patient Satisfaction After Catheter Ablation.

Background: There is a strong demand for remote monitoring systems to gather health data. This study investigated the safety, usefulness, and patient satisfaction in outpatient care using telehealth with real-time electrocardiogram (ECG) monitoring after catheter ablation. Methods and Results: In all, 38 patients who underwent catheter ablation were followed up using telehealth. At the 3- and 6-month follow-up, a self-fitted Duranta ECG monitoring device was sent to the patient's home before the online consultation. Patients attached the devices themselves, and the doctors viewed the patients by video chat and performed real-time ECG monitoring. The frequency of hospital visits and the ECG monitoring duration were compared with conventional in-person follow-up data (n=102). The completion rate for telehealth follow-up was 32 of 38 patients (84%). The number of hospital visits during the 6 months was significantly lower with telehealth follow-up than with conventional follow-up (median [interquartile range] 1 [1-1] vs. 5 [3-5]; P<0.0001). However, the ECG monitoring duration was approximately 4-fold longer for the telehealth follow-up (median [interquartile range] 89 [64-117] vs. 24 [0.1-24] h; P<0.0001). No major adverse events were observed during the telehealth follow-up. Patient surveys showed high satisfaction with telehealth follow-up due to reduced hospital visits. Conclusions: A combination of telehealth follow-up with real-time ECG monitoring increased the ECG monitoring duration and patient satisfaction without any adverse events.

Open-chest epicardial ablation of ventricular tachycardia during a left ventricular assist device implantation: a case report.

Background: Ventricular arrhythmias (VAs) are common after a left ventricular assist device (LVAD) implantation. Further, the majority of post-LVAD ventricular tachycardias (VTs) are secondary to a preexisting cardiomyopathy substrate. Intraoperative ablation of patients with recurrent preoperative VTs may reduce post-LVAD VTs. Case summary: A 59-year-old female with advanced heart failure due to non-ischaemic cardiomyopathy (LV ejection fraction = 24%) and recurrent VTs was referred for an LVAD implantation as a bridge to a heart transplant (INTERMACS Profile-5A). The previous endocardial ablation failed due to an epicardial arrhythmogenic substrate. Therefore, open-chest epicardial mapping during the LVAD implantation was indicated and three target areas of the arrhythmogenic substrate were found, which were ablated by radiofrequency applications. To minimize the cardiopulmonary bypass time, cardiopulmonary bypass was initiated after ablation, and then, an LVAD was implanted. An additional 68 min was required for mapping and ablation. All procedures were performed without any complications, and the post-operative course was uneventful. Thereafter, no VT episodes were observed without any anti-arrhythmic drugs during a 15-month follow-up with LVAD support. Discussion: Intraoperative epicardial mapping and ablation during an LVAD implantation can play an important role in the management of LVAD recipients with recurrent VAs.

The relationship between the incision line and position of the latissimus dorsi muscle for subcutaneous implantable cardioverter-defibrillator intermuscular implantations.

INTRODUCTION: Intermuscular implantations of subcutaneous implantable cardioverter-defibrillators (S-ICD) have been recommended, but the position of the anterior border of the latissimus dorsi muscle (LDM) has not previously been evaluated in establishing an incision line to facilitate the intermuscular approach. The objective of this study is to evalua the position and trend of the anterior border of the LDM in patients who are candidates for implantable cardioverter-defibrillators. METHODS: The distance from the back to the anterior border of the LDM (A) and the anterior-posterior width of the chest wall (B) were measured on computed tomography retrospectively, and the ratio (=A/B) was used as the position of the anterior border of the LDM. In addition, the variability and factors affecting the values were evaluated. RESULTS: An analysis was performed on 78 patients, and the position of the anterior border of the LDM (=A/B) exhibited a normal distribution, with a mean value of 0.53 ± 0.062 (0.41-0.69). The position of the anterior border of the LDM tended to be more anterior in younger, taller, male, primary prevention, nonheart failure, low brain natriuretic peptide level, and nondiabetic patients. CONCLUSION: The position of the anterior border of the LDM varied from case to case with variable results. Conventional incisions on the midaxillary line may be inappropriate for intermuscular implantations, and the position of the anterior border of the LDM should be evaluated in each individual case to establish the incision line.

Variations in the bifurcation of deep femoral artery important for electrophysiologist.

Knowing the vascular anatomy of the common femoral artery bifurcation and ultrasound-guided puncture, including doppler, is helpful in recognizing anatomic variations and avoiding complications.

Predictors of recurrence in patients without non-inducibility of ventricular tachycardia at the end of ablation.

Background: Ventricular tachycardia (VT) non-inducibility at the end of ablation is associated with a less likely VT recurrence. However, it is not clear whether we should use VT non-inducibility as a routine end point of VT ablation. The aim of this study was to evaluate VT recurrence in patients in whom VT non-inducibility was not achieved at the end of the radiofrequency (RF) ablation and the factors attributing to the VT recurrence. Methods: We analyzed that 62 patients in whom VT non-inducibility was not achieved at the end of the RF ablation were studied. Results: Over 2 years, 22 (35%) of the cases had VT recurrences. A multivariate analysis showed that an LVEF ≥35% (HR: 0.19; 95% CI: 0.06-0.49; p < .01) and elimination of the clinical VT as an acute ablation efficacy (HR: 0.23; 95% CI: 0.04-0.81; p = .02) were independent predictors of fewer VT recurrences. RF ablation was associated with a 91.1% reduction in VT episodes. Conclusion: Even if VT non-inducibility was not achieved, patients with an LVEF ≥35% or in whom the clinical VT could be eliminated might be prevented from having VT recurrences. The validity of the VT non-inducibility of any VT should be evaluated considering each patient's background and the results of the procedure.

Revisiting the Anatomy of the Left Ventricular Summit.

The left ventricular summit corresponds to the epicardial side of the basal superior free wall, extending from the base of the left coronary aortic sinus. The summit composes the floor of the compartment surrounded by the aortic root, infundibulum, pulmonary root, and left atrial appendage. The compartment is filled with thick adipose tissue, carrying the coronary vessels. Thus, the treatment of ventricular tachycardia originating from the summit is challenging, and three-dimensional understanding of this complicated region is fundamental. We revisit the clinical anatomy of the left ventricular summit with original images from the Wallace A. McAlpine collection.

The impact of the procedural parameters on the lesion characteristics associated with AF recurrence: Late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) analysis.

BACKGROUND: Lesion gaps assessed by late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) are associated with the atrial fibrillation (AF) recurrence after pulmonary vein isolation. Animal studies have demonstrated that the catheter-contact force (CF), stability, and orientation are strongly associated with lesion formation. However, the impact of those procedural factors on the lesion characteristics associated with AF recurrence has not been well discussed. METHODS: A total of 30 patients with paroxysmal AF who underwent catheter ablation were retrospectively enrolled. Radiofrequency (RF) applications were performed with 35 W for 30 s in a point-by-point fashion under esophageal temperature monitoring. The inter-lesion distance was 4 mm. The lesions were visualized by LGE-MRI 3 months postprocedure and assessed by the LGE volume (ml), gap number (GN), and average gap length (AGL [mm]). The gaps were defined as nonenhancement sites of >4 mm. The procedural factors including the catheter-CF, stability, and orientation were calculated on the NavX system. RESULTS: Six (20%) of 30 patients had AF recurrences 12 months postablation. A univariate analysis demonstrated that the AGL was associated with AF recurrence (hazard ratio [HR]: 1.20, confidence interval [CI]: 1.03-1.42, p = .02). All AF recurrence were found in patients with an AGL of >7 mm. The catheter-CF and stability were associated with an AGL of >7 mm, but not the orientation (CF-HR: 0.62, CI: 0.39-0.97, p = .038; stability-HR: 0.8, CI: 0.66-0.98, p = .027). CONCLUSIONS: RF ablation with a low CF and poor catheter stability has a potential risk of creating large lesion gaps associated with AF recurrence.

Trans-jugular vein approach for ablation of ventricular premature contractions originating from the tricuspid annulus.

A young-male underwent radiofrequency (RF) ablation of ventricular premature contractions (VPCs) of over 30,000/day and the morphology exhibited left bundle branch block and a superior axis, which indicated the VPCs originated from the inferior portion of the right ventricle (RV). While the PENTARAY catheter was placed under the tricuspid valve (TV), the earliest potential, which preceded the QRS onset by 34 ms, was recorded. Pace mapping there presented a very similar QRS morphology to the target VPC. However, the radiofrequency (RF)-catheter could not be placed under the TV even when a deflectable sheath was used, because the deflectable curve of the RF-catheter was larger than that of the PENTARAY. An over-the-vale RF application was not effective, so the trans-jugular approach with a deflectable sheath was indicated. The tip of the sheath was placed at a higher portion of the RV cavity to maintain an adequate distance for the RF-catheter tip to be deflected and placed under the TV. With this maneuver, the tip of the RF-catheter was successfully placed under the TV, which was confirmed by intracardiac ultrasound. Small atrial potentials and larger ventricular potentials could be recorded from the distal tip of the RF-catheter, which might indicate that the tip was placed at the TV annulus. An RF application at that site permanently abolished the VPC. Placing the tip of the RF-catheter under the TV by the femoral approach is very difficult in some cases. The trans-jugular approach with a deflectable sheath is one option for arrhythmias from the TV.

Ventricular arrhythmia events in heart failure patients with cardiac resynchronization therapy with or without a defibrillator for primary prevention.

Background: It is uncertain whether cardiac resynchronization therapy with a defibrillator (CRT-D) provides better survival benefits than a CRT-pacemaker (CRT-P) in heart failure patients with a reduced ejection fraction (≦35%, HFrEF) treated with contemporary HF therapy. Methods: We retrospectively analyzed the ventricular arrhythmia (VAs; sustained ventricular tachycardia/fibrillation) events in HFrEF patients who underwent CRT without a prior history of VAs or aborted sudden cardiac death before the CRT implantation. Between January/2010 and December/2020, a CRT device was implanted in 79 HFrEF patients (mean age: 69 ± 12 years, male: 57, ischemic cardiomyopathy: 16). CRT-D and CRT-P devices were implanted in 50 and 29 patients, respectively, at each physician's discretion. CRT-Ds were indicated in younger patients than were CRT-Ps (66 ± 12 vs. 73 ± 12 years, p = 0.03), but the gender distribution did not differ (female, 24% [12 of 50] vs. 35% [10 of 29], p = 0.44). The VA events during a median follow-up of 3.5-years (interquartile range [IQR]:1.6-5.5) and their predictors were analyzed. Results: VA events occurred in 9 patients with CRT-Ds (18%) and one with a CRT-P (3%, p = 0.08). The VA event rate was significantly lower in patients without a prior non-sustained ventricular tachycardia (NSVT: ≥3 beats; rate, ≥120 bpm; lasting <30 s, HR 0.05; 95% CI 0.01-0.30; p < 0.01) and females (HR 0.11; 95% CI 0.01-0.93; p = 0.04). Of note, no female patients without a prior history of NSVT experienced VA events. Conclusion: HFrEF CRT candidates without a prior history of NSVT and females may obtain less benefit from a primary preventive defibrillator indication.

Treatment Strategy for Fatal Arrhythmias in Ebstein's Anomaly Combined With Leadless Pacemaker and S-ICD Implantations.

The management of heart rhythm disorders in patients with adult congenital heart disease and limited vascular access is challenging. We present the case of a 38-year-old woman with Ebstein's anomaly who underwent implantation of a combination of a leadless pacemaker and a subcutaneous implantable cardioverter-defibrillator to manage fatal arrhythmias. (Level of Difficulty: Intermediate.).

Case report of a ventricular fibrillation storm with a cardiac conduction disorder and HCN4 variant 18 years after ablation of atrial flutter.

Background: Genetic abnormalities causing various arrhythmias including atrial arrhythmias, specialized cardiac conduction disorders, and malignant ventricular arrhythmias have been reported. However, it is sometimes difficult to diagnose and treat patients with various arrhythmias. Case summary: A 49-year-old woman who underwent ablation of typical atrial flutter (AFL) at 31 years of age visited the emergency room due to a cardiopulmonary arrest. Her 12-lead electrocardiogram during sinus rhythm after resuscitation exhibited first-degree atrioventricular block with right bundle branch block and right axis deviation. No structural heart disease was evident on standard imaging screening. An implantation of a single-chamber implantable cardioverter defibrillator (ICD) was indicated. After the ICD implantation, she then experienced multiple ventricular fibrillation (VF) episodes. Radiofrequency catheter ablation of triggered ventricular premature contractions (VPCs) was performed but failed because the clinical VPCs could not be induced during the session. Although no pathogenic variants associated with Brugada syndrome or long-QT syndrome were found, a rare HCN4 variant, c.1209+2_1209+3insGAGT (rs786205418), was identified in a gene panel analysis. Because high-frequency clinical pacing was effective for suppressing the VF, the single-chamber ICD was upgraded to a dual-chamber ICD. Thereafter, high-rate pacing successfully prevented any further ventricular arrhythmias during the follow up. Discussion: A clinical course with prominent wide QRS complexes and AFL in one's early 30s followed by sudden onset of a VF storm about 20 years later is extremely rare. Her clinical phenotype expression was possibly associated with a rare HCN4 variant; however, further study is needed to confirm whether this variant was pathological or not.

Ability of Left Atrial Distensibility After Radiofrequency Catheter Ablation to Predict Recurrence of Atrial Fibrillation.

This study sought to assess the left atrial (LA) functional recovery after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) and to evaluate the determining factor of procedural success of RFCA, using a novel preload stress echocardiography. A total of 111 patients with AF were prospectively recruited. The echocardiographic parameters were obtained during the leg-positive pressure (LPP) maneuver, both at baseline and midterm after RFCA. As an index of LA distensibility, the LA expansion index was calculated as (LAVmax - LAVmin) × 100 / LAVmin. During a median follow-up period of 14.2 months, AF recurrence was observed in 23 patients (20.7%). In LA functional parameters at baseline, only the Δ LA expansion index was significantly larger in the success group (16 ± 11% vs 4 ± 9%, p <0.05). At midterm follow-up, the Δ LA expansion index significantly increased to 32 ± 19% (p <0.05), together with structural LA reverse remodeling only in the success group. Moreover, the Δ stroke volume index during the LPP stress test significantly increased only in the success group (from 2.3 ± 1.3 ml/m2 to 3.1 ± 4.8 ml/m2, p <0.05). In a multivariate analysis, left ventricular ejection fraction (hazard ratio 0.911, p <0.05) and baseline Δ LA expansion index (hazard ratio 0.827, p <0.001) were independent predictors of AF recurrence. In conclusion, the baseline Δ LA expansion index during LPP stress is a reliable marker for predicting procedural success after RFCA. Moreover, maintenance of sinus rhythm resulted in an improvement of the preload reserve after RFCA.

Sex Differences in the Regional Analysis of Nonpulmonary Vein Foci and Epicardial Adipose Tissue in Patients With Atrial Fibrillation.

BACKGROUND: The mechanism underlying the sex differences in atrial fibrillation (AF) recurrence following pulmonary vein (PV) isolation is not fully understood. We hypothesized that non-PV foci and epicardial adipose tissue (EAT) play a key role.Methods and Results: Data from 304 consecutive patients (75% males) who underwent contrast-enhanced computed tomography and catheter ablation of AF were reviewed. The EAT around the atrium was measured separately in 4 parts of the atrium. All patients underwent high-dose isoproterenol infusions to assess the non-PV foci. Significantly more non-PV foci and less EAT around the atrium were observed in female patients than in male patients. In males, those with non-PV foci on the left atrial (LA) anterior wall had significantly greater EAT for the same lesions than those without non-PV foci. During a median follow-up of 27 months, the predictors of AF recurrence after first catheter ablation were female sex, presence of non-PV foci, LA diameter, and septal EAT index. A sex-specific analysis revealed that LA diameter was a predictor only in males and that the presence of non-PV foci in the septal region was a strong predictor in males (hazard ratio [HR]: 2.24) and females (HR: 3.65). CONCLUSIONS: Sex-specific differences were observed in non-PV foci sites and local EAT and in regard to the predictors of AF recurrence.