Outcomes of combined left bundle branch area pacing with atrioventricular nodal ablation in patients with atrial fibrillation and pulmonary disease.

INTRODUCTION: Concomitant left bundle branch area pacing (LBBAP) with atrioventricular (AV) nodal ablation is emerging as a viable management option in atrial fibrillation refractory to medical management. Its viability in patients with pulmonary disease and atrial fibrillation is unknown. METHODS AND RESULTS: This is a retrospective, observational cohort study in consecutive patients who underwent concomitant LBBAP with AV nodal ablation with advanced pulmonary disease at the Cleveland Clinic Fairview Hospital between January 2019 and January 2023. Patient characteristics, comorbidities, and medication use were extracted via chart review. Rates of hospitalizations, medication use, and structural disease seen on echocardiography were compared before and after the procedure. There were 27 patients with group 3 pulmonary hypertension who underwent the procedure. In the 24 months preprocedure, there were 114 admissions for heart failure or atrial fibrillation compared to 9 admissions postprocedure (p < .001). Mean follow up was 17.3 ± 12.1 months. There were no significant complications or lead dislodgements. Echocardiographic characteristics were similar prior to and after pacemaker implantation. Use of medications for rate and rhythm control was common preprocedure, and was reduced dramatically postprocedure. CONCLUSION: This small, retrospective cohort study suggests concomitant LBBAP with AV nodal ablation may be safe and efficacious for management of atrial fibrillation in patients with advanced pulmonary disease.

Same-day discharge after atrial fibrillation ablation.

Background: Atrial fibrillation (AF) catheter ablation has become an increasingly effective and safe strategy for the management of AF. With increased safety of catheter ablation, same-day discharge (SDD) is a potential way to minimize health care resource utilization and improve patient experience. Objective: To evaluate the safety and patient satisfaction of SDD after contemporary AF ablation. Methods: Consecutive patient undergoing AF ablation at our institution between 1/2020 and 10/2021 were enrolled in registry for clinical, quality, procedural and outcomes data. Patients were considered for SDD per physician discretion and patients' preference based upon clinical evaluation. Adjudicated ninety-day major complications, thirty-day adverse events, and thirty-day re-admissions were collected in a prospective registry for all patients. Results: A total of 2142 consecutive patients underwent elective AF ablation during the study period. After excluding cases with missing data, 1830 patients were included in the analysis. Of those, 350 (19 %) patients were discharged the same day (SDD group) and 1480 (81 %) stayed overnight. Patients in the SDD group compared to overnight stay group were younger, more likely to be male, White patients, lower CHA2DS2-VASc score and to be on lower rates of warfarin as an anticoagulation strategy. After propensity score matching, SDD was associated with lower rate of major complications and higher patient satisfaction. The majority of life-treating complications occurred interprocedurally or within 6 h of procedure termination. Conclusion: The present study demonstrated that SDD after contemporary AF ablation is feasible, safe and associated with higher patient satisfaction using a proposed SDD pathway and criteria.

Catheter ablation of atrial fibrillation in elderly and very elderly patients: safety, outcomes, and quality of life.

BACKGROUND: Atrial fibrillation (AF) risk increases with age. We aim to assess the efficacy and safety of catheter ablation in the older population. METHODS: All patients undergoing AF ablation (2013-2021) at our institution were enrolled in a prospectively maintained registry. The primary endpoint was AF recurrence. Patients were divided into 3 groups: non-elderly (< 65 years), elderly (65-75 years), and very elderly (> 75 years). Patient surveys at baseline and during follow-up were used to calculate quality of life (QoL) metrics: the AF severity score as well as the AF burden. RESULTS: A total of 7020 patients were included (42% non-elderly, 42% elderly, and 16% very elderly). Periprocedural major complications were low (< 1.5%) and similar in all groups besides pericardial effusion which was more frequent with older age and similar between the elderly and very elderly. At 3 years, AF recurrence for persistent AF (PersAF) was highest in the very elderly group (48%), followed by the elderly group (42%), and was the lowest in the non-elderly group (36%). In paroxysmal AF (PAF), there was no difference in AF recurrence between the elderly and non-elderly, while the very elderly remained associated with a significantly increased risk. Multivariable Cox analysis confirmed these findings (PersAF; elderly: HR = 1.23, P = 0.003; very elderly: HR = 1.44, P < 0.001) (PAF; elderly: HR = 1.04, P = 0.62; very elderly: HR = 1.30, P = 0.01). Catheter ablation resulted in a significant improvement in quality of life, irrespective of age group. CONCLUSION: Catheter ablation in elderly and very elderly patients is safe, efficacious, and associated with QoL benefits. Overall, major complications were minimal and did not differ significantly between age groups, with the exception of pericardial effusions which were higher in the elderly and very elderly compared to non-elderly adults. Very elderly patients had a higher rate of AF recurrence when compared with elderly or non-elderly patients. Nevertheless, ablation resulted in a remarkable improvement in QoL and a reduction of AF burden and AF symptoms with a similar magnitude, irrespective of age.

Atrial Fibrillation Ablation in Young Adults: Measuring Quality of Life Using Patient-Reported Outcomes Over 5 Years.

BACKGROUND: Ablation is used for both rhythm control and improved quality of life (QoL) in atrial fibrillation (AF). It has been suggested that young adults may experience high recurrence rates after ablation and data remain lacking regarding QoL benefits. We aimed to investigate AF ablation outcomes and QoL benefits in young adults undergoing AF ablation using a large prospectively maintained registry and automated patient-reported outcomes (PRO). METHODS: All patients undergoing AF ablation (2013-2016) at our center were prospectively enrolled. Patients aged 50 years or younger were included. For PROs, QoL measures and symptoms were assessed at baseline, 3 months after ablation, and every 6 months thereafter. The AF severity score served as the main assessment of QoL. RESULTS: A total of 241 young adults (age, 16-50 years) were included (17% female, 40.3% persistent AF). In all, 77.2% of patients remained arrhythmia-free during the first year of follow-up (80% in nonstructural AF and 66% in structural AF). Using PROs, 90% of patients reported improvement in QoL throughout all survey time points up to 5 years postablation (P<0.0001). The baseline median AF severity score was 14 and improved to between 2 and 4 on all follow-up after ablation (P<0.0001). Patients also reported fewer and shorter AF episodes, fewer emergency room visits secondary to AF, and fewer hospitalizations (P<0.0001). CONCLUSIONS: Ablation remains an effective rhythm-control strategy in young adults with AF. Young adults also experience significant improvement in QoL with reduction of the frequency and duration of AF episodes and AF-related healthcare utilization.

Impact of redo ablation for atrial fibrillation on patient-reported outcomes and quality of life.

INTRODUCTION: Catheter ablation for atrial fibrillation (AF) is frequently used for the purpose of rhythm control and improved quality of life (QoL). Although success rates are high, a significant proportion of patients require redo ablation. Data are scarce on patient-centered outcomes and QoL in patients undergoing redo AF ablation. We aimed to assess QoL and clinical outcomes using a large prospectively maintained patient-reported outcomes (PRO) registry. METHODS: All patients undergoing redo AF ablation (2013-2016) at our center were enrolled in a prospective registry for outcomes and assessed for QoL using automated PRO surveys (baseline, 3 and 6 months after ablation, every 6 months thereafter). Data were collected over 3 years of follow-up. The atrial fibrillation symptom severity scale (AFSSS) was used as the main measure for QoL. Additional variables included patient-reported improvement, AF burden, and AF-related healthcare utilization including emergency room (ER) visits and hospitalizations. RESULTS: A total of 848 patients were included (28% females, mean age 63.8, 51% persistent AF). By automated PRO, significant improvement in QoL was noted (baseline median AFSSS of 12 [5-18] and ranged between 2 and 4 on subsequent assessments; p < .0001), with ≥70%of patients reported remarkable improvement in their AF-related symptoms. The proportion of patients in AF at the time of baseline survey was 36%, and this decreased to <8% across all time points during follow-up (p < .0001). AF burden was significantly reduced (including frequency and duration of episodes; p < .0001), with an associated decrease in healthcare utilization after 6 months from the time of ablation (including ER visits and hospitalizations; p < .0001). The proportion of patients on anticoagulants or antiarrhythmics decreased on follow-up across all time points (p < .0001 for all variables). CONCLUSION: Most patients derive significant QoL benefit from redo AF ablation; with reduction of both AF burden and healthcare utilization.

Multimodality imaging evaluation of incidentally discovered intracardiac mass.

Incidentally discovered intracardiac masses often represent diagnostic dilemmas. No guideline-directed algorithm exists for evaluation and management in these cases. Understanding the utility and limitations of different imaging modalities expedites evaluation of differential diagnoses and management, particularly when there are discordant imaging findings. This case further demonstrates that benign cardiac tumors may grow rapidly, and that new and rapid emergence of an intracardiac mass does not necessarily correlate with a diagnosis of thrombus or malignancy. It also highlights the importance of a broad differential diagnosis and a systematic management approach in patients with intracardiac masses.

Super and Nonresponders to Catheter Ablation for Atrial Fibrillation: A Quality-of-Life Assessment Using Patient Reported Outcomes.

[Figure: see text].

The utility of a novel mapping algorithm utilizing vectors and global pattern of propagation for scar-related atrial tachycardias.

BACKGROUND: Activation maps of scar-related atrial tachycardias (AT) can be challenging to interpret due to difficulty in inaccurate annotation of electrograms, and an arbitrarily predefined mapping window. A novel mapping software integrating vector data and applying an algorithmic solution taking into consideration global activation pattern has been recently described (Coherent™, Biosense Webster "Investigational"). OBJECTIVE: We aimed to assess the investigational algorithm to determine the mechanism of AT compared with the standard algorithm. METHODS: This study included patients who underwent ablation of scar-related AT using the Carto 3 and the standard activation algorithm. The mapping data were analyzed retrospectively using the investigational algorithm, and the mechanisms were evaluated by two independent electrophysiologists. RESULTS: A total of 77 scar-related AT activation maps were analyzed (89.6% left atrium, median tachycardia cycle length of 273 ms). Of those, 67 cases with a confirmed mechanism of arrhythmia were used to compare the activation software. The actual mechanism of the arrhythmia was more likely to be identified with the investigational algorithm (67.2% vs. 44.8%, p = .009). In five patients with dual-loop circuits, 3/5 (60%) were correctly identified by the investigational algorithm compared to 0/5 (0%) with the standard software. The reduced atrial voltage was prone to lead to less capable identification of mechanism (p for trend: .05). The investigational algorithm showed higher inter-reviewer agreement (Cohen's kappa .62 vs. .47). CONCLUSIONS: In patients with scar-related ATs, activation mapping algorithms integrating vector data and "best-fit" propagation solution may help in identifying the mechanism and the successful site of termination.

Atrial fibrillation future clinic. Novel platform to integrate smart device electrocardiogram into clinical practice.

Background: Direct-to-consumer devices allow patients to record electrocardiograms (ECG) and detect atrial fibrillation (AF). Clinical adoption of these devices has been limited owing to the lack of efficient workflow. Objective: To assess a new care model for following patients after AF ablation that uses a smartphone ECG coupled with a novel cloud-based platform. Methods: This was a pilot study to describe AF detection, healthcare utilization, use of additional ECGs and cardiac monitors, and changes in anxiety after AF ablation. Patients presenting 3-4 months after early successful AF ablation were randomized into a control group with standard clinical follow-up or a self-monitoring group using smartphone ECG (Kardia Mobile, KM) coupled with a cloud-based platform (KardiaPro, KP) that alerted the physician when AF was detected and followed for 6 months. Results: A total of 100 patients were randomized: 51 to the KM/KP group and 48 to the control group (1 withdrew). AF was detected in 18 patients (18.2%), 11 (21.6%) in the KM/KP group and 7 (14.6%) in the control group (P = .42). AF detection occurred at a median of 68 and 91 days in the KM/KP and control groups, respectively (P = .93). These differences were not statistically significant. Healthcare utilization and changes in anxiety were similar between the groups. More patients required additional ECGs or cardiac monitors in the control group (27.1%) compared to the KM/KP group (5.9%) (P = .004). Conclusions: Smartphone ECG with a cloud-based platform can be incorporated into the care of post-AF ablation patients without increasing anxiety and with less need for additional traditional monitors.

Atrial Fibrillation in Transthyretin Cardiac Amyloidosis: Predictors, Prevalence, and Efficacy of Rhythm Control Strategies.

OBJECTIVES: This study sought to determine the incidence and prevalence of atrial fibrillation (AF) in transthyretin cardiac amyloidosis (ATTR-CA); to study the factors associated with the development of AF in this population; to study the prognostic implications of AF and maintenance of normal sinus rhythm (NSR) in patients with ATTR-CA; and to determine the impact of ATTR-CA stage on AF prevalence, outcomes, and efficacy of rhythm control strategies. BACKGROUND: AF is common in patients with ATTR-CA. The aim of this study was to determine the predictors, prevalence, and outcomes of AF in patients with ATTR-CA in addition to the efficacy of rhythm control strategies. METHODS: This was a retrospective cohort study of 382 patients with ATTR-CA diagnosed at our institution between January 2004 and January 2018. Means testing, and univariable and multivariable models were used. RESULTS: AF occurred in 265 (69%) patients. Factors associated with the development of AF included older age, advanced ATTR-CA stage, and higher left atrial volume index. Antiarrhythmic therapy (AAT) was used in 35% of patients with AF; cardioversion was performed in 45%, and 5% underwent AF ablation. Rhythm control strategies were substantially more effective when performed earlier in the disease course. During a mean follow-up of 35 months, no difference in mortality between patients with AF and those without AF was observed (65% vs. 49%; p = 0.76). On Cox proportional hazards analyses, maintenance of normal sinus rhythm and tafamidis use were associated with improved survival, whereas advanced ATTR-CA stage and higher New York Heart Association functional class were associated with increased mortality. CONCLUSIONS: With advancing ATTR-CA stage, AF became more prevalent, occurring in 69% of our entire study cohort. Rhythm control strategies including AAT, direct-current cardioversion, and AF ablation were substantially more effective when performed earlier during the disease course.

Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants.

BACKGROUND: Many centers continue to routinely perform transesophageal echocardiograms before atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOACs). One study suggested that the procedures could be done without transesophageal echocardiogram but used intracardiac echocardiography imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage in DOAC compliant patients. METHODS: All patients undergoing AF ablation at the Cleveland Clinic (2011-2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter on DOAC were included. Periprocedural thromboembolic complications were assessed. RESULTS: A total of 900 patients were included. Their median CHA2DS2-VASc score was 2 (interquartile range 1-3). All were on DOACs (333 rivaroxaban, 285 dabigatran, 281 apixaban, and 1 edoxaban). Thromboembolic complications occurred in 4 patients (0.3%): 2 ischemic strokes, 1 transient ischemic attack without residual deficit, and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%): 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries. CONCLUSIONS: In DOAC compliant patients who present for ablation in AF/atrial flutter, the procedures could be performed without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage; with low risk of complications.

Clinical Outcomes and Characteristics With Dofetilide in Atrial Fibrillation Patients Considered for Implantable Cardioverter-Defibrillator.

BACKGROUND: Dofetilide is one of the only anti-arrhythmic agents approved for atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF). However, postapproval data and safety outcomes are limited. In this study, we assessed the incidence and predictors of LVEF improvement, safety, and outcomes in patients with AF with LVEF ≤35% without prior implantable cardioverter defibrillator, cardiac resynchronization therapy, or AF ablation. METHODS: An analysis of 168 consecutive patients from 2007 to 2016 was performed. Incidences of adverse events, drug continuation, implantable cardioverter defibrillator and cardiac resynchronization therapy implantation, LVEF improvement (>35%) and recovery (≥50%), AF recurrence, and AF ablation were determined. Multivariable regression analysis to identify predictors of LVEF improvement/recovery was performed. RESULTS: The mean age was 64±12 years. Dofetilide was discontinued before hospital discharge in 46 (27%) because of QT prolongation (14%), torsades de pointe or polymorphic ventricular tachycardia/fibrillation (6% [sustained 3%, nonsustained 3%]), ineffectiveness (5%), or other causes (3%). At 1 year, 43% remained on dofetilide. Freedom from AF was 42% at 1 year, and 40% underwent future AF ablation. LVEF recovered (≥50%) in 45% and improved to >35% in 73%. Predictors of LVEF improvement included presence of AF during echocardiogram (odds ratio, 4.22 [95% CI, 1.71-10.4], P=0.002), coronary artery disease (odds ratio, 0.35 [95% CI, 0.16-0.79], P=0.01), left atrial diameter (odds ratio, 0.52 per 1 cm increase [95% CI, 0.30-0.90], P=0.01), and LVEF (odds ratio, per 1% increase, 1.09 [95% CI, 1.02-1.16], P=0.006). The C statistic was 0.78. CONCLUSIONS: In patients with LVEF ≤35%, who are potential implantable cardioverter defibrillator candidates, treated with dofetilide as an initial anti-arrhythmic strategy for AF, drug discontinuation rates were high, and many underwent future AF ablation. However, most patients had improvement in LVEF, obviating the need for primary prevention implantable cardioverter defibrillator.

Transvenous lead extraction in patients with prior extraction procedures: Procedural profiles and outcomes.

BACKGROUND: Subclinical venous injuries are common during transvenous lead extraction (TLE), but their implications for future TLE are unclear. Little is known about whether a prior TLE adds risk or complexity to subsequent extraction procedures. OBJECTIVE: The purpose of this study was to assess procedural profiles and outcomes of TLE based on whether patients had prior extraction procedures. METHODS: All 3258 consecutive patients undergoing TLE at the Cleveland Clinic (1996-2012) were included. Procedural profiles and outcomes were determined. RESULTS: Of 3258 TLEs, 198 had prior TLE. Median number of leads in place was 2 in both groups, but patients with prior TLE were more likely to have defibrillator leads (47% vs 41%; P = .08) and more likely to be pacemaker-dependent (32% vs 25%; P = .02). The age of oldest lead (median 2134 vs 1902 days; P = .4) and combined age of leads (median 2948 vs 2676 days; P = .6) were comparable. Procedures were longer in those with prior TLE (166 ± 79 minutes vs 149 ± 74 minutes; P = .004) with comparable fluoroscopy times (median 13 vs 11 minutes; P = .07), and successful extraction was more likely to require specialized tools (88% vs 81%; P = .006) with higher likelihood of rescue femoral workstation (12% vs 4%; P <.0001). Clinical success rates were comparable in those with prior TLE (99.5% vs 98.9%; P = .8) with similar major (3.0% vs 1.9%; P = .3) and minor (3.0% vs 3.7%; P = .8) complication rates. CONCLUSION: Extraction procedures were more challenging in patients with prior TLE compared to those without prior TLE but with excellent success and low complication rates.

Use of virtual visits for the care of the arrhythmia patient.

BACKGROUND: Virtual visits (VVs) are a modality for delivering health care services remotely through videoconferencing tools. Data about patient and physician experience in using VVs are limited. OBJECTIVE: The purpose of this study was to assess patient and physician experience with the use of VVs in cardiac electrophysiology. METHODS: We performed a prospective survey of cardiac electrophysiology patients and physicians who participated in an outpatient VV from December 2018 to July 2019. RESULTS: One-hundred consecutive VVs were included. Sixty-four patients elected to complete a survey. Patients rated their experience as either excellent/very good in scheduling a VV (87%), seeing their physician of choice (100%), transmitting arrhythmia data (88%), rating their physician's ability to communicate (98%), asking all questions (98%), rating the level of care received (98%), paying for the cost of a VV (67%), and rating their overall level of satisfaction (98%). Thirty-eight of 64 patients (59.4%) preferred a VV for their next visit, 12 of 64 (18.8%) preferred an in-office visit, 13 of 64 (20.3%) responded that their decision for a virtual or office visit depended on indication, and 1 of 64 (1.6%) had no preference. A total of 14 cardiac electrophysiologists participated in 100 VVs. Nine visits were not included due to technical difficulty. Physician responses to survey questions were rated as excellent/very good in the ability to communicate (92%), accessing monitoring data (95%), and overall level of satisfaction (98%). CONCLUSION: In our small study population, most patients and physicians prefer VVs. Convenience, cost, and reason for follow-up were important determinants that affected both patient and physician preference.

Catheter Ablation in Patients With Cardiogenic Shock and Refractory Ventricular Tachycardia.

BACKGROUND: There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support. METHODS: Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010-2017). RESULTS: All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction-induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia. CONCLUSIONS: Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.

Cardiac venous injuries: Procedural profiles and outcomes during left ventricular lead placement for cardiac resynchronization therapy.

BACKGROUND: Injury to the cardiac venous structures can complicate left ventricular lead placement for cardiac resynchronization therapy (CRT). Little is known about the outcomes of coronary sinus (CS) dissection with or without perforation. OBJECTIVE: The purpose of this study was to determine the outcomes in patients who had a CS injury during CRT implantation. METHODS: All patients undergoing procedures for CRT implantation at the Cleveland Clinic (2001-2018) were enrolled in a prospectively maintained registry for procedural profiles and complications. All patients with cardiac venous injuries during the procedures were included. RESULTS: CS injury occurred in 35 of 5011 patients (0.7%; 6 perforations (17.1%), 29 dissections without perforation (82.9%)). In patients with dissection in the absence of perforation, attempts at CS lead placement after dissection were successful in 21 of 29 patients (72.4%). In those with perforation (n=6, 17.1%), CS lead placement was successful in one of them (16.7%). Cardiac tamponade occurred in 2 patients (5.7%), and the procedure was aborted in both of them. Overall, CS lead placement failed in 13 patients (37%) but 9 (25.7%) underwent subsequent CRT with CS lead placement (n=6, 17.1%; median 58 days later) or epicardial leads (n=3, 8.6%). Three of the remaining 4 patients (8.6%) refused to undergo further procedures, and the fourth (2.9%) died of a complicated course. CONCLUSION: CS injury is not common during CRT implantation procedures and did not preclude successful lead placement in 23 of 35 patients (65.7%) during the index procedure and 6 of 6 (100%) during the subsequent attempted procedures. A low rate of mortality was observed in such patients, but CS injury was associated with increased morbidity.

Should fast pathway ablation be reconsidered in typical atrioventricular nodal re-entrant tachycardia?

INTRODUCTION: Atrioventricular nodal re-entry tachycardia (AVNRT) is the most common, regular narrow-complex tachycardia. The established treatment is catheter ablation of the AV nodal slow pathway (SP). However, in a select group of patients with long PR intervals in sinus rhythm, SP ablation can lead to AV block due to the absence of robust anterograde conduction through the fast pathway (FP). This report aims to demonstrate that AV nodal FP ablation is a reasonable approach in patients with AVNRT and poor or absent anterograde FP conduction. METHODS AND RESULTS: Standard electrophysiology study techniques were used in the electrophysiology laboratory. Catheter ablations were performed using radiofrequency energy. Mapping of intracardiac activation was performed with electroanatomical mapping systems. Outcomes were assessed acutely during the procedure and during routine clinical follow-up. Six patients with first-degree AV block and recurrent AVNRT who underwent ablation of their tachycardia at our institution are presented. One patient underwent ablation of AV nodal SP resulting in high-degree AV block necessitating pacemaker implantation. The remaining five patients underwent ablation of the AV nodal FP guided by electroanatomical mapping of the earliest atrial activation in tachycardia. These five had successful treatment of the tachycardia with preservation of anterograde AV nodal conduction. Mapping and ablation approach to eliminate retrograde FP conduction are described. CONCLUSION: In select patients with AVNRT and poor anterograde FP conduction, retrograde FP ablation is reasonable and is less likely to result in AV block and pacemaker dependency.

Transvenous Lead Extraction in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy.

OBJECTIVES: This study aimed to evaluate the effectiveness and safety of transvenous lead extraction (TLE) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). BACKGROUND: ARVC is an increasingly diagnosed cardiomyopathy that often requires device implantation to prevent sudden death. Little is known about TLE in this setting, which has potential challenges and risks, primarily due to right ventricular (RV) wall thinning and fragility. METHODS: All consecutive patients with ARVC who underwent TLE at our institution between 1996 and 2016 were included. When extraction tools were used, sheaths were advanced to the RV with countertraction at the lead tip. Success and complications were defined in concordance with Heart Rhythm Society guidelines. RESULTS: Twenty-two TLE procedures in patients with ARVC involved extraction of 27 leads (22 defibrillators and 5 pacemakers). TLEs were performed due to evidence of lead malfunction (n = 17; 77%) or device infection (n = 5; 23%). Twenty-four leads (89%) were RV, and 3 leads (11%) were right atrial. The median age of the oldest extracted lead was 1,691 days (interquartile range [IQR]: 1,168 to 2,726 days). Specialized extraction tools were required in 20 procedures (91%). None required the use of a snare or a femoral workstation. The median procedural and fluoroscopic times were 152 min (IQR: 129 to 185 min) and 11 min (IQR: 6 to 18 min), respectively. Complete procedural success with removal of all leads was achieved in all cases. There were no major complications. CONCLUSIONS: In a high-volume center, TLE in patients with ARVC was associated with a high success rate and a low rate of complications when guideline-established techniques and tools were used.

Life-Threatening Complications of Atrial Fibrillation Ablation: 16-Year Experience in a Large Prospective Tertiary Care Cohort.

OBJECTIVES: This study sought to assess the incidence and outcomes of life-threatening complications from atrial fibrillation ablations in a high volume center. BACKGROUND: With increasing rates of atrial fibrillation ablation procedures, an increase in life-threatening procedure-related complications has been reported despite improvements in technology and ablation strategies. METHODS: Between 2000 and 2015, 10,378 patients underwent atrial fibrillation ablation at our institution and were enrolled in a prospectively maintained data registry. We identified all patients who had life-threatening cardiac, neurological, respiratory, or vascular complications to the ablation resulting in death or requiring emergent intervention. RESULTS: Major life-threatening complications occurred in 100 patients (0.9%). The most common was pericardial effusion requiring pericardiocentesis (0.5%), with 7 (0.07%) requiring emergent surgical repair for cardiac perforation. Stroke occurred in 27 patients (0.3%) with a vast majority having an ischemic stroke (93%) followed by hemorrhagic (3.5%) and ischemic stroke with hemorrhagic conversion (3.5%). The yearly incidence of stroke decreased from an average of 1.1% per year in the first tertile (2000 to 2004) to 0.2% per year in the last 2 tertiles (2005 to 2015). Permanent neurological deficits occurred in 23 patients. Vascular complications causing hemorrhagic shock occurred in 7 patients (0.06%), 5 of whom required urgent surgical intervention. Acute coronary syndrome requiring urgent percutaneous coronary revascularization occurred in 2 patients whereas 1 developed a right coronary artery air embolus. No procedural death or atrio-esophageal fistulae occurred. CONCLUSIONS: In a large quaternary care center, the incidence of life-threatening complications is low. Experienced operators, high volume, continuous quality improvement initiatives, and efficient back-up support have allowed exemplary safety profiles and 0 procedure-related deaths over 16 years.

New Model of Automated Patient-Reported Outcomes Applied in Atrial Fibrillation.

Background The value of patient-reported outcomes (PRO) is increasingly recognized in patient-centered care. Longitudinal data collection may be challenging and cost prohibitive. Automation of PRO collection may complement routine clinical follow-up, especially for procedures aiming to improve quality of life, such as atrial fibrillation (AF) ablation. Methods We aimed to develop a fully automated platform to collect PRO and evaluate its first clinical application in a prospective cohort of AF ablation. The duration of follow-up and data availability were assessed with automated PRO and routine follow-up versus routine follow-up alone (primary outcome). Quality of life and healthcare utilization (secondary outcomes) by PRO were assessed. Results Between 2013 and 2016, 2175 patients were eligible to receive 10 903 PRO assessment invitations, and the automated platform sent all invitations as programmed. More follow-up assessments were obtained with automated PRO and routine follow-up compared with routine follow-up alone (12 859 versus 10 248; P<0.0001) which allowed longer duration of follow-up (378 versus 217 days, 74% increase; P<0.0001). By automated PRO, a large number of disease-specific variables were collected and showed improvement in quality of life (baseline median AF symptom severity score AFSSS of 12 [6-18] and ranged between 2 and 3 on subsequent assessments; P<0.0001). This improvement was also true for each of the AFSSS individual components ( P<0.0001). In PRO, there was a significant reduction in AF burden (such as frequency and duration of episodes; P<0.0001) and associated healthcare utilization (including emergency visits and hospitalizations; P<0.0001) after the ablation procedures. Conclusions A fully automated system for PRO collection enhanced clinical follow-up and allowed collection of disease-specific data when applied in a prospective cohort of AF ablation.