Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND: Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES: The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS: Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS: Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS: This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery.

Left Atrial Appendage Occlusion versus Novel Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation-One-Year Survival.

Aim To compare the 1-year survival rate of patients with atrial fibrillation (AF) following left atrial appendage occluder (LAAO) implantation vs. treatment with novel oral anticoagulants (NOACs). METHODS: We have conducted an indirect, retrospective comparison between LAAO and NOAC registries. The LAAO registry is a national prospective cohort of 419 AF patients who underwent percutaneous LAAO between January 2008 and October 2015. The NOACs registry is a multicenter prospective cohort of 3138 AF patients treated with NOACs between November 2015 and August 2018. Baseline patient characteristics were retrospectively collected from coded diagnoses of hospitalization and outpatient clinic notes. Follow-up data was sorted from coded diagnoses and the national civil registry. Subjects were matched according to propensity score. Baseline characteristics were compared using Chi-Square and student's t-test. Survival analysis was performed using Kaplan-Meier survival curves, log-rank test, and multivariable Cox regression, adjusting for possible confounding variables. RESULTS: This study included 114 subjects who underwent LAAO implantation and 342 subjects treated with NOACs. The mean age of participants was 77.9 ± 7.44 and 77.1 ± 11.2 years in the LAAO and NOAC groups, respectively (p = 0.4). The LAAO group had 70 (61%) men compared to 202 (59%) men in the NOAC group (p = 0.74). No significant differences were found in baseline comorbidities, renal function, or CHA2DS2-VASc score. One-year mortality was observed in 5 (4%) patients and 32 (9%) patients of the LAAO and NOAC groups, respectively. After adjusting for confounders, LAAO was significantly associated with a lower risk for 1-year mortality (HR 0.38, 95%CI 0.14-0.99). In patients with impaired renal function, this difference was even more prominent (HR 0.21 for creatinine clearance (CrCl) < 60 mL/min). CONCLUSIONS: In a pooled analysis of two registries, we found a significantly lower risk for 1-year mortality in patients with AF who were implanted with LAAO than those treated with NOACs. This finding was more prominent in patients with impaired renal function. Future prospective direct studies should further investigate the efficacy and adverse effects of both treatment strategies.

Reply to Kataoka, N.; Imamura, T. How to Improve Clinical Outcomes in Patients with Tachycardia-Induced Cardiomyopathy. Comment on "Katz et al. Long-Term Outcomes of Tachycardia-Induced Cardiomyopathy Compared with Idiopathic Dilated Cardiomyopathy. J. Clin. Med. 2023, 12, 1412".

In a letter to the editor titled "How to improve clinical outcomes in patients with tachycardia-induced cardiomyopathy", Dr. Naoya Kataoka and Dr. Teruhiko Imamura [...].

Complicated Pocket Infection in Patients Undergoing Lead Extraction: Characteristics and Outcomes.

Cardiac implantable electronic device (CIED) infection can present with pocket or systemic manifestations, both necessitating complete device removal and pathogen-directed antimicrobial therapy. Here, we aim to characterize those presenting with both pocket and systemic infection. A retrospective analysis of CIED extraction procedures included 300 patients divided into isolated pocket (n = 104, 34.7%), complicated pocket (n = 54, 18%), and systemic infection (n = 142, 47.3%) groups. The systemic and complicated pocket groups frequently presented with leukocytosis and fever > 37.8, as opposed to the isolated pocket group. Staphylococcus aureus was the most common pathogen in the systemic and complicated pocket groups (43.7% and 31.5%, respectively), while Coagulase-negative staphylococci (CONS) predominated (31.7%) in the isolated pocket group (10.6%, p < 0.001). No differences were observed in procedural success or complications rates. Kaplan-Meier survival analysis found that at three years of follow-up, the rate of all-cause mortality was significantly higher among patients with systemic infection compared to both pocket groups (p < 0.001), with the curves diverging at thirty days. In this study, we characterize a new entity of complicated pocket infection. Despite the systemic pattern of infection, their prognosis is similar to isolated pocket infection. We suggest that this special category be presented separately in future publications of CIED infections.

Inducibility of Multiple Ventricular Tachycardia's during a Successful Ablation Procedure Is a Marker of Ventricular Tachycardia Recurrence.

Even after a successful ventricular tachycardia ablation (VTA), some patients have recurrent ventricular tachycardia (VT) during their follow-up. We assessed the long-term predictors of recurrent VT after having a successful VTA. The patients who underwent a successful VTA (defined as the non-inducibility of any VT at the procedure's end) in 2014-2021 at our center in Israel were retrospectively analyzed. A total of 111 successful VTAs were evaluated. Out of them, 31 (27.9%) had a recurrent event of VT after the procedure during a median follow-up time of 264 days. The mean left ventricular ejection fraction (LVEF) was significantly lower among patients with recurrent VT events (28.9 ± 12.67 vs. 23.53 ± 12.224, p = 0.048). A high number of induced VTs (>two) during the procedure was found to be a significant predictor of VT recurrence (24.69% vs. 56.67%, 20 vs. 17, p = 0.002). In a multivariate analysis, a lower LVEF (HR, 0.964; p = 0.037) and a high number of induced VTs (HR, 2.15; p = 0.039) were independent predictors of arrhythmia recurrence. The inducibility of more than two VTs during a VTA procedure remains a predictor of VT recurrence even after a successful VT ablation. This group of patients remains at high risk for VT and should be followed up with and treated more vigorously.

Surgical ablation for atrial fibrillation: impact of Diabetes Mellitus type 2.

BACKGROUND: Diabetes mellitus (DM) type 2 is an independent risk factor for atrial fibrillation (AF). Surgical ablation or "maze procedure" is an option for patients with AF undergoing concomitant or isolated cardiac surgery. The aim of this study was to evaluate the impact of DM type 2 on early and long-term outcomes of patients following surgical AF ablation. METHODS: We performed an observational cohort study in Israel's largest tertiary care center. All data of patients who underwent surgical AF ablation, between 2006 and 2021 were extracted from our departmental database. Patients were divided into Group I (non-diabetic patients) and Group II (DM type 2 patients). We compared the two groups with respect to freedom from recurrent atrial arrhythmia, and mortality rate. RESULTS: The study population included 606 patients. Group I (non-DM patients), consisting of 484 patients, and Group II (DM type 2 patients), comprised 122 patients. Patients with DM were older, had more hypertension and incidence of cerebrovascular accident (CVA)/transient ischemic attack (TIA), higher EuroSCORE (p < .05 for all), and a longer bypass time-130 ± 40 vs. 122 ± 36 min (p = 0.028). The mean follow-up duration was 39.0 ± 22.7 months. Freedom from atrial fibrillation was similar between the non-DM and DM type 2 groups after a 1-year follow-up, 414 (88.2%) vs. 101 (87.1%) (p = 0.511), after a 3-year follow-up, 360 (86.3%) vs. 84 (79.9%) (p = 0.290) and after a 5-year follow-up, 226 (74.1%) vs. 55 (71.5%) (p = 0.622) respectively. Furthermore, 1- and 3-year mortality was similar between non-DM and DM type 2 groups, 2.5% vs. 4.9%, (p = 0.226) and 5.6% vs. 10.5% (p = 0.076) respectively. 5-year mortality was higher in Group II (DM type 2 patients) compared with Group I (non-DM patients), 11.1% vs. 23.4% (p = 0.009). CONCLUSION: Surgical ablation had a high success rate, with freedom from recurrent atrial arrhythmia at 1- 3- and 5- years follow-up in both the DM type 2 and non-DM groups. Furthermore,1- and 3-year mortality after surgical ablation was also similar in both groups. However, 5-year mortality was higher in the DM type 2 group.

Long-Term Outcomes of Tachycardia-Induced Cardiomyopathy Compared with Idiopathic Dilated Cardiomyopathy.

BACKGROUND: data on the natural course and prognosis of tachycardia-induced cardiomyopathy (TICMP) and comparison with idiopathic dilated cardiomyopathies (IDCM) are scarce. OBJECTIVE: To compare the clinical presentation, comorbidities, and long-term outcomes of TICMP patients with IDCM patients. METHODS: a retrospective cohort study of patients hospitalized with new-onset TICMP or IDCM. The primary endpoint was a composite of death, myocardial infarction, thromboembolic events, assist device, heart transplantation, and ventricular tachycardia or fibrillation (VT/VF). The secondary endpoint was recurrent hospitalization due to heart failure (HF) exacerbation. RESULTS: the cohort was comprised of 64 TICMP and 66 IDCM patients. The primary composite endpoint and all-cause mortality were similar between the groups during a median follow-up of ~6 years (36% versus 29%, p = 0.33 and 22% versus 15%, p = 0.15, respectively). Survival analysis showed no significant difference between TICMP and IDCM groups for the composite endpoint (p = 0.75), all-cause mortality (p = 0.65), and hospitalizations due to heart failure exacerbation. Nonetheless, the incidence of recurrent hospitalization was significantly higher in TICMP patients (incidence rate ratio 1.59; p = 0.009). CONCLUSIONS: patients with TICMP have similar long-term outcomes as those with IDCM. However, it portends a higher rate of HF readmissions, mostly due to arrhythmia recurrences.

Electrocardiographic findings in patients with arrhythmogenic cardiomyopathy and right bundle branch block ventricular tachycardia.

AIMS: Little is known about patients with right bundle branch block (RBBB)-ventricular tachycardia (VT) and arrhythmogenic cardiomyopathy (ACM). Our aims were: (i) to describe electrocardiogram (ECG) characteristics of sinus rhythm (SR) and VT; (ii) to correlate SR with RBBB-VT ECGs; and (iii) to compare VT ECGs with electro-anatomic mapping (EAM) data. METHODS AND RESULTS: From the European Survey on ACM, 70 patients with spontaneous RBBB-VT were included. Putative left ventricular (LV) sites of origin (SOOs) were estimated with a VT-axis-derived methodology and confirmed by EAM data when available. Overall, 49 (70%) patients met definite Task Force Criteria. Low QRS voltage predominated in lateral leads (n = 37, 55%), but QRS fragmentation was more frequent in inferior leads (n = 15, 23%). T-wave inversion (TWI) was equally frequent in inferior (n = 28, 42%) and lateral (n = 27, 40%) leads. TWI in inferior leads was associated with reduced LV ejection fraction (LVEF; 46 ± 10 vs. 53 ± 8, P = 0.02). Regarding SOOs, the inferior wall harboured 31 (46%) SOOs, followed by the lateral wall (n = 17, 25%), the anterior wall (n = 15, 22%), and the septum (n = 4, 6%). EAM data were available for 16 patients and showed good concordance with the putative SOOs. In all patients with superior-axis RBBB-VT who underwent endo-epicardial VT activation mapping, VT originated from the LV. CONCLUSIONS: In patients with ACM and RBBB-VT, RBBB-VTs originated mainly from the inferior and lateral LV walls. SR depolarization and repolarization abnormalities were frequent and associated with underlying variants.

Outcome and safety of intraoperative defibrillation testing during device replacement: the Simpler trial.

AIMS: Intraoperative defibrillation testing (DT) during implant or replacement of implantable cardioverter-defibrillators (ICDs) has been a matter of debate for many years. This debate was put to rest by the Simple and Nordic ICD trials, and the practice of testing during new implantations has essentially been almost abandoned. Old registries demonstrated an increased incidence of significant findings in DT during replacements. The aim of the present study was to evaluate frequency of significant findings and safety of DT in subjects undergoing device replacement. METHODS AND RESULTS: A prospective observational multi-centre study included consecutive patients undergoing ICD generator replacement. The primary outcome was a failure to terminate induced ventricular fibrillation (VF) with a single shock 10 J below the maximal capacity of the device. Secondary outcomes included complications of DT. Patients were followed-up at 1- and 6-months post-procedure. A total of 92 patients were eligible, and consented to the study, of which 84 underwent DT during battery replacement. The median age was 68 years and 79.8% were males. Induction of VF was successful in 84 patients as was a successful conversion on the first attempt in all. There were no procedure-related complications. During follow up one patient had two appropriate ICD shock events. In four patients, ICD programming was changed. None suffered inappropriate shock. There was no evidence of lead malfunction. Two deaths occurred, none of which was related to arrhythmia. CONCLUSION: The present study found DT was not associated with complications in patients undergoing ICD generator replacement but produced no clinically important information.

Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections.

BACKGROUND: Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES: The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS: The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS: A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS: CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).

Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations.

The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.

Early de-cannulation from extracorporeal membrane oxygenation following ventricular tachycardia radiofrequency ablation.

Objectives: Ventricular tachycardia ablation (VTA) with hemodynamic compromise presents a challenge. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support allows the safe completion of the procedure. There are limited data regarding the safety of weaning off VA-ECMO at the end of the procedure. We report our experience with early VA-ECMO de-cannulation after VTA. Materials and methods: All patients undergoing VA-ECMO-assisted VTA, between January 2013 and December 2020 at a large tertiary center were included. Clinical characteristics, history of arrhythmia, procedural details, and outcomes were collected. Patients weaned from VA-ECMO immediately at the end of the procedure were compared to those that were de-cannulated at a later time. Results: A total of 46 patients (93.5% male, age 62 ± 10 years) were ablated with VA-ECMO support. Most had ischemic cardiomyopathy (65%) and (70%) presented with VT storm. The clinical VT was induced in the majority of patients (76%). A total of 99 VTs were induced of which 76 (77%) were targeted and successfully ablated. Non-inducibility was achieved in 74% of cases and most patients (83%) were de-cannulated at the end of the procedure on the procedure table. Survival at 1 year was higher among early de-cannulated patients (86 vs. 38% [log-rank p-value < 0.001]). At 1-year follow-up, 91.3% of surviving patients were free of appropriate ICD shocks. Conclusion: De-cannulation from VA-ECMO may be done immediately at the conclusion of VTA in most cases. Failure to timely wean off VA-ECMO is a strong predictor of mortality.

Occluded vein as a predictor for complications in non-infectious transvenous lead extraction.

Background: The use of cardiovascular implantable electronic device (CIED) is steadily increasing, and complications include venous occlusion and fractured leads. Transvenous lead extraction (TLE) can facilitate the re-implantation of new leads. Aims: This study aims to explore predictors and complications of non-infectious TLE. Methods: This study involves a retrospective analysis and comparison of characteristics, complications, and outcomes of patients with and without occluded veins (OVs) undergoing TLE at our center. Results: In total, eighty-eight patients underwent TLE for non-infectious reasons. Indications for TLE were lead malfunction (62; 70.5%) and need for CIED upgrade (22; 25%). Fourteen patients referred due to lead malfunction had an OV observed during venography. The OV group (36 patients) were significantly older (65.7 ± 14.1 vs. 53.8 ± 15.9, p = 0.001) and had more comorbidities. Ejection fraction (EF) was significantly lower for the OV group (27.5 vs. 57.5%, p = 0.001) and had a longer lead dwelling time (3,226 ± 2,324 vs. 2,191 ± 1,355 days, p = 0.012). Major complications were exclusive for the OV group (5.5% vs. none, p = 0.17), and most minor complications occurred in the OV group as well (33.3 vs. 4.1%, p < 0.001). Laser sheath and mechanical tools for TLE were frequently used for OV as compared to the non-occluded group (94.4 vs. 73.5%, respectively, p = 0.012). Procedure success was higher in the non-occluded group compared to the OV group (98 vs. 83.3%, respectively, p = 0.047). Despite these results, periprocedural mortality was similar between groups. Conclusion: Among the TLE for non-infectious reasons, vein occlusion appears as a major predictor of complex TLE tool use, complications, and procedural success. Venography should be considered prior to non-infectious TLE to identify high-risk patients.

QTc Dynamics Following Cardioversion for Persistent Atrial Fibrillation.

Background: Cardioversion (CV) for atrial fibrillation (AF) is common. We aimed to assess changes in QTc over time following electrical CV (ECV) for persistent AF, and to compare the benefit of using continuous Holter monitoring vs. conventional follow-up by ECG. Methods: Prospective observational cohort study. We comprised 90 patients admitted to our center for elective ECV due to persistent AF who were prospectively enrolled from July 2017 to August 2018. All patients underwent 7-days Holter started prior to ECV. Baseline QTc was defined as median QTc during 1 h post ECV. The primary endpoint was QTc prolongation defined as QTc ≥500 ms, or ≥10% increase (if baseline QTc was >480 ms). Conventional monitoring was defined as 2-h ECG post ECV. Results: Mean age was 67 ± 11 years and 61% were male. Median baseline QTc was 452 ms (IQ range: 431-479 ms) as compared with a maximal median QTc of 474 ms (IQ range: 433-527 ms; p <0.001 for the change in QTc from baseline). Peak median QTc occurred 44 h post ECV. The primary endpoint was met in 3 patients (3%) using conventional monitoring, compared with 39 new patients (43%) using Holter (p <0.001 for comparison). The Holter monitoring was superior to conventional monitoring in detecting clinically significant QTc prolongation (OR = 13; p <0.001). Conclusions: ECV of patients with persistent AF was associated with increased transient risk of QTc prolongation in nearly half of the patients. Peak median QTc occurs during end of second day following ECV and prolonged ECG monitoring provides superior detection of significant QTc prolongation compared with conventional monitoring.

Pacing burden and clinical outcomes after transcatheter aortic valve replacement-A real-world registry report.

INTRODUCTION: Conflicting data exist on the prognostic significance of permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR). OBJECTIVE: The purpose of this study was to evaluate whether PPM implantation after TAVR is associated with adverse outcomes. METHODS: A retrospective analysis of a cohort comprised patients enrolled in a prospective registry between 2008 and 2019. Participants were allocated into 3 groups: patients without a prior pacemaker (n = 930 [75%]), those with previous pacemaker implantation (n = 118 [10%]), and those with pacemaker implantation after TAVR (n = 191 [15%]). The primary outcome included death and heart failure hospitalizations at 1 year. Secondary outcomes included death and heart failure hospitalizations stratified by pacing burden. RESULTS: A total of 1239 patients underwent TAVR with a median follow-up period of 2.3 years (interquartile range 1-4 years). Patients with previous and new pacemaker implantation were older (84 [80-88], 84 [80-88], and 82 [78-86] years; P = .009) and had lower baseline left ventricular ejection fraction (50% ± 15%, 55% ± 12%, and 56% ± 12%; P < .001). Patients who underwent new pacemaker implantation had higher combined outcome of death and heart failure hospitalizations (21%,12%, and 14%; P = .01). New pacemaker implantation was associated with almost twice the risk of 1-year mortality (odds ratio 1.85; 95% confidence interval 1.13-3.02; P = .014). Pacing burden, however, was not associated with the primary outcome. Furthermore, no significant difference was observed at long-term follow-up (cumulative probability to develop the primary end point at 3 years was 57% ± 2% [without PPM], 57% ± 6% [prior PPM], 54% ± 4% [new PPM]; P = .52). CONCLUSION: Pacemaker implantation after TAVR is associated with higher 1-year adverse outcome, but this attenuates over time, suggesting that competing factors may play a role. Interestingly, pacing burden is not associated with adverse clinical course.

Rare Cause of Syncope in an Athlete, Matter of Brain and Heart Electricity.

ABSTRACT: A 17-year-old elite triathlete presented with recurrent loss of consciousness events. Implantable loop recorder (ILR) documented sinus node asystoles of up to 21 seconds. She underwent cardiac neuromodulation ablation. After ablation, a generalized tonic-clonic seizure (GTCS) occurred, without concomitant asystole on the ILR. Temporal lobe seizures were diagnosed and supported by interictal epileptic activity on electroencephalogram. We assumed that the syncope episodes were ictal asystole (IA) and that the IA terminated the epileptic seizures early after their onset. The cardiac ablation prevented IA, enabling spread of seizure activity and development of GTCS. To the best of our knowledge, this is the first case of IA treated with cardiac ablation, allowing avoidance of cardiac pacing. This case raises the awareness to epileptic seizures as a cause of asystole in athletes, with an elusive and atypical presentation.

Lead fixation mechanism impacts outcome of transvenous lead extraction: data from the European Lead Extraction ConTRolled Registry.

AIMS: The aims of this study is to characterize the transvenous lead extraction (TLE) population with active (A) compared with passive fixation (PFix) leads and to compare the safety, efficacy, and ease of extracting active fixation (AFix) compared with PFix right atrial (RA) and right ventricular (RV) leads. METHODS AND RESULTS: The European Lead Extraction ConTRolled Registry (ELECTRa) was analysed. Patients were divided into three groups; those with only AFix, only PFix, and combined Fix leads. Three outcomes were defined. Difficult extraction, complete radiological, and clinical success. Multivariate model was used to analyse the independent effect of Fix mechanism on these outcomes. The study included 2815 patients, 1456 (51.7%) with only AFix leads, 982 (34.9%) with only PFix leads, and 377 (13.4%) with combined Fix leads. Patients with AFix leads were younger with shorter lead dwelling time. Infection was the leading cause for TLE among the combined Fix group with lowest rates among AFix group. No difference in complications rates was noted between patients with only AFix vs. PFix leads. Overall, there were 1689 RA (1046 AFix and 643 PFix) and 2617 RV leads (1441 AFix and 1176 PFix). Multivariate model demonstrated that PFix is independently associated with more difficult extraction for both RA and RV leads, lower radiological success in the RA but has no effect on clinical success. CONCLUSION: Mechanism of Fix impact the ease of TLE of RA and RV leads and rates of complete radiological success in the RA but not clinical success. These findings should be considered during implantation and TLE procedures.