Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation.

BACKGROUND: Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott, Chicago, IL, USA) and Watchman device (Boston Scientific, Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device. OBJECTIVE: The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices. METHODS: Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death). RESULTS: The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods. CONCLUSION: There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.

Low voltage area guided substrate modification in nonparoxysmal atrial fibrillation: A systematic review and meta-analysis.

BACKGROUND: Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in nonparoxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results. METHODS: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with nonparoxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time. RESULTS: A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group (risk ratio [RR] 0.63 (27% vs. 36%),95% confidence interval [CI] 0.48-0.62, p < .001]. Also, redo ablation was significantly lower in LVA ablation group (RR 0.52[18% vs. 26.7%], 95% CI 0.38-0.69, p < .00133). No difference was found in the overall adverse event (RR 0.7 [4.3% vs. 5.4%], 95% CI 0.36-1.35, p = .29). CONCLUSION: LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events.

Establishing Safe Working Parameters for Radiofrequency Ablation In Vitro Using Acoustic Sensing, Probability Mapping, and Catheter Contact Angle.

Surgical quality and safety in radiofrequency catheter ablation (RFA) are critical in arrhythmia procedures. Steam pops, in particular, are potentially catastrophic events that must be avoided; otherwise, they may cause significant damage to the myocardium. This study aimed to evaluate the effect of applied RFA inclination angle and tissue contact parameters on the ablated volume and "steam pop" formation. An ex vivo model consisting of a viable ovine myocardium, an ablation catheter, and a circulating warmed 0.9% NaCl saline solution was used. RFA was conducted while controlling for contact force, electrical power, ablation time, flow rate, irrigation, and catheter tip angle. Irrigation was delivered to the catheter tip manually when indicated. Acoustic transducers were included in the setup to detect preliminary acoustic signals. A total dataset of 567 measurements was taken. Benign precursory signals (hissing and lower-intensity "pops") were detected by acoustic sensors preceding the occurrence of "steam pops." Furthermore, a Pearson coefficient of r = 0.809 with P < .01 was shown to exist between the acoustic intensity of a "steam pop" and the ablated lesion volume. RFA powers of 25 and 30 W with a duration of 20 s induced more "steam pops" than ablation powers of ≤20 W with a duration of ≥30 s. There was also an increased probability of "steam pop" formation with the use of a non-irrigated catheter tip, as compared to an irrigated catheter tip. A more acute catheter angle increased the lesion size at powers of 20 and 25 W (r = -0.568 and r = -0.653, both P < .05, respectively). There is a potential benefit of using acoustic sensing as a warning before the occurrence of "steam pops." Varying power, duration, and catheter tip angle will generate different ablation sizes and need to be tailored to individual needs and procedures.

QTc interval on 24-hour holter monitor: To trust or not to trust?

INTRODUCTION: QT interval represents the ventricular depolarization and repolarization. Its accurate measurement is critical since prolonged QT can lead to sudden cardiac death. QT is affected by heart rate and is corrected to QTc via several formulae. QTc is commonly calculated on the ECG and not the 24-h Holter. METHODS: 100 patients presenting to our institution were evaluated by an ECG followed by a 24-h Holter. QTc measurement on both platforms using Bazett and Fridericia formulae was recorded and compared. RESULTS: Mean age was 14.09 years, with the majority being males. Mean heart rate was 125.87. In the ECG, the mean QTc interval via the Bazett formula was 0.40 s compared with 0.38 s using the Fridericia formula. The mean corrected QT via the Bazett formula was 0.45, 0.39, and 0.42 s for the shortest RR, the longest RR, and the average RR, respectively. In contrast to the Fridericia formula, the corrected QT interval was 0.40, 0.39, and 0.40 s for the shortest RR, the longest RR, and the average RR, respectively. Using the Bazett formula, the highest specificity was reached during the longest RR interval (92.2%), while the highest sensitivity was recorded during the shortest RR interval (40%). As for the Fridericiaformula, sensitivity always reached 0%, while the highest specificity was reached during the average RR interval. CONCLUSION: QTc measured during Holter ECG reached a high specificity regardless of RR interval using the Fridericia and during the longest and the average RR interval for the Bazett formula. The consistently low sensitivity reveals that Holter ECG should not be used to rule out prolonged QT.

Advances in telemedicine for the management of the elderly cardiac patient.

Telemedicine is the use of information and communication technology to deliver healthcare at a distance. It has been resorted to during the COVID-19 pandemic to lessen the need for in-person patient care decreasing the risk of transmission, and it can be of benefit afterward in the management of cardiac disease. The elderly population has unique challenges concerning the use of telehealth technologies. We thus review the advances in telemedicine technologies in treating elderly cardiac patients including in our discussion only studies with a mean age of participants above 60. Remote monitoring of blood pressure, weight, and symptoms, along with home ECG recording has been found to be superior to usual in-clinic follow up. Combining remote monitoring with video conferencing with physicians, patient education websites, and applications is also of benefit. Remote monitoring of Implantable Cardioverter Defibrillators (ICD) and Cardiac Resynchronization Therapy Defibrillators (CRT-D) is also beneficial but can be at the cost of an increase in both appropriate and inappropriate interventions. Implantable sensing devices compatible with remote monitoring have been developed and have been shown to improve care and cost-effectiveness. New smartphone software can detect arrhythmias using home ECG recordings and can detect atrial fibrillation using smartphone cameras. Remote monitoring of implanted pacemakers has shown non-inferiority to in clinic follow up. On the other hand, small-scale questionnaire-based studies demonstrated the willingness of the elderly cardiac patients to use such technologies, and their satisfaction with their use and ease of use. Large-scale studies should further investigate useability in samples more representative of the general elderly population with more diverse socioeconomic and educational backgrounds. Accordingly, it seems that studying integrating multiple technologies into telehealth programs is of great value. Further efforts should also be put in validating the technologies for specific diseases along with the legal and reimbursement aspects of the use of telehealth.

Ivabradine: A Potential Therapeutic for Children With Refractory SVT.

Background: In April 2015, ivabradine was approved by the Food and Drug Administration for the treatment of patients with coronary artery disease and heart failure (HF). The use of this medication has been linked with improved clinical outcomes and reduced rates of hospitalization in patients with symptomatic HF and a baseline heart rate of 70 bpm and above. Nonetheless, little is known about the use of ivabradine in pediatric patients with supraventricular tachycardia (SVT). This use is not well-studied and is only endorsed by a few case reports and case series. Aim: This study discusses the off-label utilization of ivabradine in pediatric patients with SVT, and highlights its efficacy in treating treatment-resistant (refractory) SVT. Methods: We conducted a retrospective single-center observational study involving pediatric patients with SVT treated at our center between January 2016 and October 2020. We identified the total number of patients with SVT, and the number of patients with refractory SVT treated with Ivabradine. Similarly, we performed a thorough review of the databases of PubMed, Medline and Google Scholar to compare the clinical course of our patients to those described in the literature. Results: Between January 2016 and October 2020, 79 pediatric patients with SVT were seen and treated at our center. A treatment-resistant SVT was noted only in three patients (4%). Ivabradine was used in these patients as a single or combined therapy. The rest (96%) were successfully treated with conventional anti-arrhythmics such as ß-blockers, flecainide, and other approved medications. In the ivabradine group, successful reversal to sinus rhythm was achieved in two of the three patients (66%), one patient was treated with a combination therapy of amiodarone and ivabradine, and the other patient was treated only with ivabradine. Conclusion: Overall, promissory results are associated with the use of ivabradine in pediatric patients with refractory SVT. Ivabradine appears to be a safe and well-tolerated medication that can induce adequate suppression of SVT, complete reversal to sinus rhythm, and effective enhancement of left ventricular function.

Safety of mapping in the sinus of valsalva region under intracardiac echocardiography guidance without angiography.

BACKGROUND: Radiofrequency ablation at the region of the sinus of Valsalva carries a risk to the ostia of the coronary arteries. Coronary angiography is usually utilized to document a safe distance for mapping and ablation. OBJECTIVE: To show that catheter ablation in the aortic root could be guided by phased-array intra cardiac echocardiography (ICE) and electro anatomic mapping without the need for coronary angiography. METHODS: We reviewed all patients referred to our lab that underwent mapping and/or ablation in the sinus of Valsalva region. Procedures were carried out by operators that are skilled in the use of ICE. The need for angiography was documented, also the rate of success along with the immediate and 30-day complications rate. RESULTS: Seventy patients (average age 48.7 ± 13.8 years; 64.3% males) were referred for ablation of ventricular and atrial arrhythmias. PVC constituted 95.7% of the cases. All patients underwent mapping and/or ablation at the sinus of Valsalva region without the need for coronary angiography to visualize the coronary ostia. Acute and effective ablation was achieved in 57 out of 70 (81.4%) patients partially effective ablation was achieved in 10 (14.3%) patients, and failure to ablate in the remaining 3 patients (4.3%). There was no occurrence of any adverse events, neither immediately or at day 30 after the procedure. CONCLUSION: In the hands of experienced operators, mapping and radiofrequency ablation in the sinus of Valsalva can be safely and reliably performed using intracardiac echocardiography alone without the need for supplementary catheter coronary angiography.

Genomic and Proteomic Study of the Inflammatory Pathway in Patients With Atrial Fibrillation and Cardiometabolic Syndrome.

Atrial fibrillation (AF) and cardiometabolic syndrome (CMS) have been linked to inflammation and fibrosis. However, it is still unknown which inflammatory cytokines contribute to the pathogenesis of AF. Furthermore, cardiometabolic syndrome (CMS) risk factors such as obesity, hypertension, insulin resistance/glucose intolerance are also associated with inflammation and increased level of cytokines and adipokines. We hypothesized that the inflammatory immune response is exacerbated in patients with both AF and CMS compared to either AF or CMS alone. We investigated inflammatory cytokines and fibrotic markers as well as cytokine genetic profiles in patients with lone AF and CMS. CMS, lone AF patients, patients with both lone AF and CMS, and control patients were recruited. Genetic polymorphisms in inflammatory and fibrotic markers were assessed. Serum levels of connective tissue growth factor (CTGF) were tested along with other inflammatory markers including platelet-to-lymphocyte ratio (PLR), monocyte-to-HDL ratio (MHR) in three groups of AF+CMS, AF, and CMS patients. There was a trend in the CTGF levels for statistical significance between the AF and AF+CMS group (P = 0.084). Genotyping showed high percentages of patients in all groups with high secretor genotypes of Interleukin-6 (IL-6) (P = 0.037). Genotyping of IFN-γ and IL-10 at high level showed an increase in expression in the AF + CMS group compared to AF and CMS alone suggesting an imbalance between the inflammatory and anti-inflammatory cytokines which is exacerbated by AF. Serum cytokine inflammatory cytokine levels showed that IL-4, IL-5, IL-10, IL-17F, and IL-22 were significant between the AF, AF+CMS, and CMS patients. Combination of both CMS and AF may be associated with a higher degree of inflammation than what is seen in either CMS or AF alone. Thus, the identification of a biomarker capable of identifying metabolic syndrome associated with disease will help in identification of a therapeutic target in treating this devastating disease.

Fast pathway ablation in a patient with PR prolongation.

The classical form of typical atrioventricular node reentrant tachycardia (AVNRT) is a "slow-fast" pathways tachycardia, and the usual therapy is an ablation of the slow pathway since it carries a low risk of atrioventricular (AV) block. In patients with long PR interval and/or living on the anterograde slow pathway, an alternative technique is required. We report a case of a 42-year-old lady with idiopathic restrictive cardiomyopathy, persistent atrial fibrillation status post pulmonary vein isolation, and premature ventricular complex ablation with a systolic dysfunction, who presented with incessant slow narrow complex tachycardia of 110 bpm that appeared to be an AVNRT. Her baseline EKG revealed a first-degree AV block with a PR of 320 ms. EP study showed no evidence of anterograde fast pathway conduction. Given this fact, the decision was to attempt an ablation of the retrograde fast pathway. The fast pathway was mapped during tachycardia to its usual location into the anteroseptal region, then radiofrequency ablation in this location terminated tachycardia. After ablation, she continued to have her usual anterograde conduction through slow pathway and the tachycardia became uninducible. In special populations with prolonged PR interval or poor anterograde fast pathway conduction, fast pathway ablation is the required ablation for typical AVNRT.

Erosion of Cardiovascular Implantable Device: Conservative Therapy or Extraction?

The standard of care for device infection is normally a complete removal of the implantable system, including lead extraction in local or systemic infection cases. Despite the importance of lead extraction techniques, these techniques are complex and have some major risks. Success rates were high, but they are less favorable in patients with several comorbidities. An 80-year-old male presented for device erosion. The patient is known to have several cardiac comorbidities: a transcatheter aortic valve replacement (TAVR), mitral clips for severe aortic stenosis, mitral regurgitation, dual-chamber implantable cardioverter defibrillators (ICD) for secondary prevention. Several weeks ago, he noted tenderness and redness at the site of his device pocket, and his physician, after checking his wound, suggested a possible skin irritation with no systemic infection and started antibiotics treatment. Two weeks later, he noted thinning of the skin around the device with a hematoma and ecchymosis, and slight skin erosion. Strategies for assessment of the wound and pocket cleaning were taken. The strategy was to remove the left-sided device and keep the leads since the patient lately has no elevated inflammatory labs, negative cultures, no fever, nor signs of vegetation on transesophageal echocardiography (TEE) and refused any additional examination as positron emission tomography (PET) scan, and reimplant a new system on the contralateral side. The procedure was divided into two sequences: extracting the device and after one-week implantation of a right-sided new system. In this case, chronic antibiotics were discussable to decrease the recurrence rate, but they did increase the severity of the patient's thrombocytopenia. Despite extraction being the gold standard of treatment in most cases of devices with local and systemic infection, there are some frail patients with several comorbidities where extraction is unbearable due to its major risks and complex procedure. In these specific cases with local infection and device erosion with no signs of any systemic infection, conservative therapy could be a viable option.

Cardiac implantable electronic device infections: Observational data from a tertiary care center in Lebanon.

With increasing rates of device implantation, there is an increased recognition of device infection. We conducted a retrospective observational study in a tertiary care center in Lebanon, with data collected from medical records of patients presenting with cardiac implantable electronic device (CIED) infection from 2000 to 2017 with the purpose of identifying etiologies, risk factors and other parameters, and comparing them to available data from the rest of the world. We identified a total of 22 CIED infections. The most common microbial etiologies, including involvement in polymicrobial infection, were coagulase-negative staphylococci (45.5%) and Staphylococcus aureus (22.7%). Rare cases of Brucella melitensis, Sphingomonas paucimobilis, and Kytococcus schroeteri device infection were seen. Heart failure was seen in 77.3% of patients, hypertension in 68.2%, and chronic kidney disease in 50%. Skin changes were the most common presenting symptoms (86.4%). Antibiotics were given to all patients and all had their devices removed, with 36.4% undergoing new device implantation. This is the first study of CIED infections in Lebanon and the Middle East. Local epidemiology and occupational exposure must be considered while contemplating the microbial etiology of infection. Close monitoring after device implantation is important in preventing device infection that carries high risk of morbidity and mortality.

Non-familial cardiomyopathies in Lebanon: exome sequencing results for five idiopathic cases.

BACKGROUND: Cardiomyopathies affect more than 0.5% of the general population. They are associated with high risk of sudden cardiac death, which can result from either heart failure or electrical abnormalities. Although different mechanisms underlie the various types of cardiomyopathies, a principal pathology is common to all and is usually at the level of the cardiac muscle. With a relatively high incidence rate in most countries, and a subsequent major health burden on both the families and governments, cardiomyopathies are gaining more attention by researchers and pharmaceutical companies as well as health government bodies. In Lebanon, there is no official data about the spectrum of the diseases in terms of their respective prevalence, clinical, or genetic profiles. METHODS: We used exome sequencing to unravel the genetic basis of idiopathic cases of cardiomyopathies in Lebanon, a relatively small country with high rates of consanguineous marriages. RESULTS: Five cases were diagnosed with different forms of cardiomyopathies, and exome sequencing revealed the presence of already documented or novel mutations in known genes in three cases: LMNA for an Emery Dreifuss Muscular Dystrophy case, PKP2 for an arrhythmogenic right ventricle dysplasia case, and MYPN for a dilated cardiomyopathy case. Interestingly two brothers with hypertrophic cardiomyopathy have a novel missense variation in NPR1, the gene encoding the natriuretic peptides receptor type I, not reported previously to be causing cardiomyopathies. CONCLUSION: Our results unravel novel mutations in known genes implicated in cardiomyopathies in Lebanon. Changes in clinical management however, require genetic profiling of a larger cohort of patients.

Out-of-hospital cardiopulmonary resuscitation: a position statement of the Lebanese Society of Cardiology and the Lebanese Society of Emergency Medicine.

Out of hospital cardiac arrest (OHCA) is a leading cause of death worldwide. Early cardiopulmonary resuscitation (CPR) and early defibrillation are key to improving outcomes of patients with OHCA including return of spontaneous circulation (ROSC) and survival to hospital discharge with good neurologic outcomes. Lebanon like other developing countries, suffers from absence of organized prehospital cardiac arrest care bundle and from absence of a legal framework for community involvement in cardiac arrest care. Scientific societies, involved non-governmental organizations (NGOs) and local governmental stakeholders organized a national meeting to launch a strategy aiming at improving OHCA outcomes in Lebanon. This article represents a position statement of the Lebanese Society of Cardiology and the Lebanese Society of Emergency Medicine summarizing the strategy to improve out-of-hospital CPR. Participating stakeholders developed and submitted a law proposal of a "Good Samaritan Law" to the Lebanese parliament. Several of activities were also launched aiming at establishing public access defibrillation programs and at training bystanders in different areas in Lebanon to perform bystander CPR and use automated external defibrillators (AEDs). Additional recommendations were proposed to local emergency medical system (EMS) agencies to improve prehospital care and introduce medical direction to prehospital activities.

Incessant Long R-P Tachycardia.

A 13-year-old boy had a positive P wave in V1 with a negative P wave in lead I, aVL, and aVR, as well as a positive P wave in the inferior leads, which correlated with a left atrial appendage (LAA) atrial tachycardia (AT) focus. P-wave morphologies can provide clues regarding an AT's origin, and this P-wave negative in lead I favored LAA AT. Careful mapping along the atria and coronary sinus to determine the earliest site of activation for the surface P wave is a reliable method for precisely localizing the AT origin as a target for catheter ablation.

A Confused Pacemaker.

The electrocardiogram (ECG) raises the question of inappropriate device behavior and the possibility of ventricular lead oversensing causing failure of ventricular pacing. Careful analysis of the ECG proved that the mode of pacing was set to managed ventricular pacing (MVP) mode. The MVP mode should not be used in the setting of a complete atrioventricular conduction block.

Anatomic distribution of culprit lesions in patients with non-ST-segment elevation myocardial infarction and normal ECG.

BACKGROUND: In patients presenting with non-ST-elevation myocardial infarction (NSTEMI), left anterior descending (LAD) coronary artery and three-vessel disease are the most commonly encountered culprit lesions in the presence of ST depression, while one third of patients with left circumflex (LCX) artery related infarction have normal ECG. We sought to determine the predictors of presence of culprit lesion in NSTEMI patients based on ECG, echocardiographic, and clinical characteristics. METHODS: Patients admitted to the coronary care unit with the diagnosis of NSTEMI between June 2012 and December 2013 were retrospectively identified. Admission ECG was interpreted by an electrophysiologist that was blinded to the result of the coronary angiogram. Patients were dichotomized into either normal or abnormal ECG group. The primary endpoint was presence of culprit lesion. Secondary endpoints included length of stay, re-hospitalization within 60 days, and in-hospital mortality. RESULTS: A total of 118 patients that were identified; 47 with normal and 71 with abnormal ECG. At least one culprit lesion was identified in 101 patients (86%), and significantly more among those with abnormal ECG (91.5% vs. 76.6%, P=0.041).The LAD was the most frequently detected culprit lesion in both groups. There was a higher incidence of two and three-vessel disease in the abnormal ECG group (P=0.041).On the other hand, there was a trend of higher LCX involvement (25% vs. 13.8%, P=0.18) and more normal coronary arteries in the normal ECG group (23.4% vs. 8.5%, P=0.041). On multivariate analysis, prior history of coronary artery disease (CAD) [odds ratio (OR) 6.4 (0.8-52)], male gender [OR 5.0 (1.5-17)], and abnormal admission ECG [OR 3.6 (1.12-12)], were independent predictors of a culprit lesion. There was no difference in secondary endpoints between those with normal and abnormal ECG. CONCLUSIONS: Among patients presenting with NSTEMI, prior history of CAD, male gender and abnormal admission ECG were independent predictors of a culprit lesion. An abnormal ECG was significantly associated with two and three-vessel disease, while normal ECG was more associated with LCX involvement or normal angiogram. Admission ECG did not impact secondary outcomes.

Efficacy of ablation at the anteroseptal line for the treatment of perimitral flutter.

BACKGROUND: Left atrial flutter following atrial fibrillation (AF) ablation is increasingly common and difficult to treat. We evaluated the safety and efficacy of ablation of the anteroseptal line connecting the right superior pulmonary vein (RSPV) to the anteroseptal mitral annulus (MA) for the treatment of perimitral flutter (PMF). METHODS: We systematically studied patients who were previously treated with AF ablation and who presented to the electrophysiology laboratory with atrial tachyarrhythmias between January 2000 and July 2010. The diagnosis of PMF was confirmed by activation mapping and/or entrainment. After re-isolation of any recovered pulmonary vein, a linear radiofrequency (RF) ablation was performed on the line that connected the RSPV to the anteroseptal MA. In this analysis, we included only patients who were treated with an anteroseptal line for their PMF. RESULTS: Ablation was performed at the anteroseptal line in 27 PMF patients (63±13 years; 9 women) who had undergone prior ablation for paroxysmal (n=3) or persistent (n=24) AF, using electroanatomic activation mapping (70% CARTO, 30% NavX). The anteroseptal ablation line was effective in 22/27 (81.5%) patients in the acute-care setting. Termination of AF to sinus rhythm occurred in 15/22 (68.2%) patients, and 7/22 (31.8%) patients׳ AF converted to another right or left atrial flutter. At the 6-month follow-up, 20% of patients demonstrated recurrent left atrial tachyarrhythmia. Only one patient required repeat ablation, and the remaining patients׳ condition was controlled with antiarrhythmic medications. No major procedural complications or heart block occurred. CONCLUSION: Ablation at the left atrial anteroseptal line is safe and efficacious for the treatment of PMF. Unlike ablation at the traditional mitral isthmus line, ablation at the left atrial anteroseptal line does not require ablation in the coronary sinus.

CARDIAC DEFIBRILLATOR IMPLANTATION via PERSISTENT LEFT SUPERIOR VENA CAVA.

Persistent left superior vena cava (PLSVC) is an uncommon anomaly. We describe a case of a left-sided implantation of an implantable cardioverter defibrillator (ICD) through a PLSVC, assessing the technical approach to such a procedure, along with a review of the clinical implications that might ensue. Learning objectives: LSVC is a rare anatomical venous variation. Knowledge of its presence and clinical implications will render a lead implantation safer and will limit complications that might ensue.