Improved left atrial appendage closure procedural efficiency using radiofrequency transseptal wire system.

OBJECTIVE: The radiofrequency (RF) needle has been shown to improve transseptal puncture efficiency and safety compared to mechanical needles. This study aimed to investigate the use of VersaCross RF transseptal wire system (Baylis Medical) to improve procedural efficiency of left atrial appendage closure (LAAC) compared to the standard RF needle-based workflow. METHODS: Eighty-one LAAC procedures using WATCHMAN FLX were retrospectively analyzed comparing the standard RF needle-based workflow to a RF wire-based workflow. Study primary endpoint was time to WATCHMAN device release, and secondary endpoints were transseptal puncture time, LAAC success, fluoroscopy use, and procedural complications. RESULTS: Twenty-five cases using standard RF needle-based workflow were compared to 56 cases using the RF wire-based workflow. Baseline patient characteristics were similar between both groups. LAAC was successful in all patients with no differences in intraprocedural complication rates (p = 0.40). Transseptal puncture time was 1.3 min faster using the RF wire-based workflow compared to the standard RF needle-based workflow (6.5 ± 2.3  vs. 7.8 ± 2.3 min, p = 0.02). Overall, time to final WATCHMAN device release was 4.5 min faster with the RF wire-based workflow compared to the RF needle-based workflow (24.6 ± 5.6 vs. 29.1 ± 9.6 min, p = 0.01). Fluoroscopy time was 21% lower using the RF wire-based workflow (7.6 ± 2.8 vs. 9.6 ± 4.4 min; p = 0.05) and fluoroscopy dose was 67% lower (47.1 ± 35.3 vs. 144.9 ± 156.9 mGy, p = 0.04) and more consistent (F-test, p ˂ 0.0001). CONCLUSIONS: The RF wire-based workflow streamlines LAAC procedures, improving LAAC efficiency and safety by reducing fluoroscopy, device exchanges, and delivery sheath manipulation.

Dearth of electrophysiology fellows: perspectives from cardiology fellows-in-training.

BACKGROUND: Over the last 6 years, there has been a high percentage of unfilled cardiac electrophysiology (EP) training spots each year. The authors aimed to investigate potential explanations for the unfilled positions based on a survey from the current Fellows-In-Training (FITs). METHODS: An attempt was made to reach the current cardiology FITs across all programs of the U.S. via email. An anonymous questionnaire was created consisting of 14 questions. Questions posed were regarding factors affecting each participant's interest in or lack of pursuing an EP fellowship. Descriptive statistics of the responses were performed. RESULTS: A total of 26% (35/134) respondents expressed their interest in applying to an EP fellowship. The most common reasons to apply to EP were: Interest in EP, procedural specialty, and work-life balance. Of the 99 respondents that were not applying to EP, the most common reasons not to apply were: Less interest in EP, two-year training duration, and complexity of the specialty. The top reasons for the fellows to believe there is a dearth of EP FITs were: two-year training duration, lack of interest in EP, and the complexity of the specialty. The changes that would encourage EP fellowship interest were: More exposure to EP training during general cardiology fellowship, shortening the EP training duration, and having more information available regarding employment opportunities. CONCLUSION: The study was able to identify factors responsible for vacancies in EP fellowship positions from the view of current cardiology FITs. Stakeholders at the national level involved in framing policies related to fellowship education would be able to utilize this information to address the shortage of EP FITs and increase recruitment to EP fellowships.

Radiographic changes in ribs following clipping of patent ductus arteriosus in preterm infants.

Objectives: There are no published reports on the rib abnormalities on the plain chest radiograph in preterm infants following surgical clipping of isolated patent ductus arteriosus. The purpose of this study was to describe changes in the ribs on the plain chest radiograph following surgical clipping of patent ductus arteriosus (surgery groups) in preterm infants compared to non-surgical closure of patent ductus arteriosus (control group). Methods: Data from preterm infants with patent ductus arteriosus clipping (surgery) via a left postero-lateral thoracotomy were compared with infants in whom the patent ductus arteriosus closed: spontaneously, with medications or use of an occlusive device (controls). Serial pre- and post-closure plain chest radiographs were randomly reviewed by a reader blinded to the route of closure and up to 1 year following the patent ductus arteriosus closure. Results: Of the total of 196 cases included in the study: 45 of the patent ductus arteriosus closed following treatment with medications, 8 cases closed with an occlusion device, 38 were closed surgically, and in 105 cases, the patent ductus arteriosus closed spontaneously. Compared to the pre-operative period, 36/38 (95%) infants in the surgery group had one or more of the following rib abnormalities: ipsilateral fourth and fifth rib fusion, narrowing of the ipsilateral fifth intercostal space, thinning of the ipsilateral fourth or fifth rib, or a combination of the above on the chest radiograph compared to 0% in the control group (p < 0.001). Conclusion: Radiographic rib abnormalities are common and appear in infancy following surgical clipping of patent ductus arteriosus in preterm infants. Further studies are needed to clarify the natural history of these abnormalities on thoracic cage and cardiopulmonary functions.

Heparin-Induced Pituitary Apoplexy Presenting as Isolated Unilateral Oculomotor Nerve Palsy: A Case Report and Literature Review.

INTRODUCTION: Pituitary apoplexy (PA) is a rare and potentially life-threatening clinical syndrome resulting from pituitary gland hemorrhage and/or infarction. Anticoagulation is a risk factor for triggering PA. Isolated oculomotor nerve palsy is an atypical presentation of PA. CASE PRESENTATION: A 65-year-old African American female with no past medical history of pituitary disease presented to the emergency department (ED) with nonspecific abdominal pain that was thought to be secondary to fecal stasis and subsequently improved with laxatives. She also reported atypical chest pain that was concerning for unstable angina. She was started on aspirin, clopidogrel, and intravenous (IV) heparin. Later, coronary catheterization showed no significant coronary artery disease (CAD). Twelve hours after the procedure, the patient developed acute complete left oculomotor nerve palsy with a severe headache. Magnetic resonance imaging (MRI) of the head showed a large pituitary mass. Pituitary apoplexy was suspected and the patient eventually underwent a successful trans-sphenoidal pituitary resection. DISCUSSION: We report a case of PA manifesting as isolated left oculomotor nerve palsy without visual field defects in the setting of using dual antiplatelet therapy (DAPT) and IV heparin for acute coronary syndrome. To the best of our knowledge, this unique combination has not been previously reported.