Comparison of Prevalence, Presentation, and Prognosis of Acute Coronary Syndromes in ≤35 years, 36 - 54 years, and ≥ 55 years Patients.

Whether very young patients (≤35-year-old) differ in the prevalence, presentation and prognosis of ACS is not well known. Of 43,446 patients who were referred to a tertiary care cardiac catheterization laboratory between January 1, 2006 and June 30, 2017, 26,545 patients were ACS (defined as ST Elevation MI, Non-ST Elevation MI or unstable angina pectoris). Detailed chart review was performed and characteristics at baseline were compared for ages ≤35 years, ages 36 to 54 years and ages ≥55 years. A total of 291 (1.1%) were ≤35-year-old, 7,649 (28.8) were 36 to 54-year-old and 18,605 (70.1%) were ≥55-year-old. ACS patients aged ≤35-year-old, were more likely to be men, Caucasian white, smoker, obese, and have family history of coronary artery disease and less likely to have comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia compared with older patients. They were also more likely to present with elevated troponin levels than other groups. They also tended to present with late ST elevation myocardial infarction and were more likely to receive bare metal stents than older patients. The prevalence of 2- and 3-vessel disease was lower compared with older patients. They also had higher prevalence of cardiogenic shock. Compared with 36 to 54-year-old patients, ≤35-year-old were at significant higher risk of 30-day mortality in a multivariable adjusted regression model (Odds ratio 5.65, 95% confidence interval 2.49 to 12.82, p <0.001). Very young patients comprised ∼1% of all ACS cases but had much more prevalence of modifiable risk factors and significantly worse mortality. Modifying these risk factors may mitigate the risk in these patients and should be studied in the future.

Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation.

OBJECTIVES: This study reports outcomes of bailout atrial balloon septoplasty (ABS) to overcome challenging left atrial (LA) access in patients undergoing atrial fibrillation (AF) ablation. BACKGROUND: Transseptal puncture (TSP) and LA access for AF ablation can be challenging in patients with prior atrial septal surgery, percutaneous closure, or scarred septum due to multiple prior TSPs. METHODS: The study identified patients who underwent AF ablation at 2 ablation centers from 2011 to 2017 with challenging TSP in whom bailout percutaneous ABS was performed to allow LA access. Following TSP, the transseptal sheath could not be advanced to the LA despite multiple attempts or approaches including use of a stiff wire sequentially in the left and right pulmonary veins, use of a stiff pigtail exchange wire advanced in the LA or left ventricle, or sequential dilation with progressively larger diameter long dilators. ABS was performed using a noncompliant balloon (diameter 4 to 10 mm) advanced over a stiff wire deployed in the left superior pulmonary vein, allowing passage of the transseptal sheaths for completion of the AF ablation procedure. RESULTS: Fifteen patients (mean age 54.4 ± 15.5 years, 9 women) with challenging TSP (7 patients with prior surgical ASD repair, 2 with percutaneous ASD closure devices, and 13 with ≥1 previous TSP) underwent bailout ABS for AF ablation. After TSP (radiofrequency assisted in 10 cases), ABS was successful and permitted access to the LA for ablation in all patients. Mean time required to perform ABS was 21.3 ± 19.4 min, and mean total procedure time was 241.1 ± 114.6 min (fluoroscopy time 62.0 ± 29.9 min). There were no procedural complications. CONCLUSIONS: In patients undergoing AF ablation with difficult transseptal access due to scarred, surgically, or percutaneously repaired atrial septum, ABS is a safe and effective bailout strategy to obtain transseptal access.

Long-Term Outcome of Catheter Ablation for Treatment of Bundle Branch Re-Entrant Tachycardia.

OBJECTIVES: This study reports the long-term outcome of patients with bundle branch re-entrant tachycardia (BBRT) who underwent catheter ablation for ventricular tachycardia (VT). BACKGROUND: BBRT is an uncommon mechanism of VT. Data on long-term outcomes of patients with BBRT treated with catheter ablation are insufficient. METHODS: Between 2005 and 2016, 32 patients had a sustained VT due to a bundle branch re-entrant mechanism. Diagnosis of BBRT was established per standard published criteria. RESULTS: The mode of presentation was syncope in 17 patients (53%) and palpitations in 15 (47%). BBRT was inducible in all subjects, and successful ablation of the right bundle branch in 19 patients (59%) or the left bundle branch in 13 patients (41%) was performed. During follow-up of 95 ± 36 months, 6 patients (19%) died, 3 of progressive heart failure and 3 of noncardiac causes. Recurrent VT due to BBRT did not occur in any patient. At baseline, 25 patients (78%) had a prolonged HV interval (>55 ms) and 7 (22%) had a normal HV interval (≤55 ms). In patients with a normal HV interval, there was only 1 death (due to malignancy), and no one developed heart block during 90 ± 36 months of follow-up. Ten patients (31%) had normal left ventricular (LV) function (LV ejection fraction ≥50%), and 22 (69%) had depressed LV function (LV ejection fraction <50%). No deaths were recorded in patients with normal LV function (5 with no implantable cardioverter-defibrillator) compared with 6 deaths among patients with depressed LV function (n = 22; p = 0.07). CONCLUSIONS: Radiofrequency ablation of the bundle branch is an effective therapy for treatment of BBRT. Sustained BBRT can be seen in patients with normal LV systolic function and HV interval with excellent long-term outcomes after ablation.

Impact of timing of recurrence following catheter ablation of scar-related ventricular tachycardia on subsequent mortality.

BACKGROUND: Catheter ablation (CA) has an established role in scar-related ventricular tachycardia (VT), but the risk of recurrences is substantial and the appropriate intensity of postablation monitoring unknown. The implication of timing of postablation VT recurrence has not been adequately investigated. METHODS: We studied 120 consecutive patients with scar-related VT (age 60 ± 15 years, left ventricular ejection fraction 39 ± 16%, 52% ischemic etiology) with at least 2 years of follow-up. Timing of VT recurrence was classified as very early (<1 month), early (1-6 months), or late (>6 months). RESULTS: At 24 months follow-up, 53 (44%) patients had recurrent VT, with eight (15%) having very early recurrence, 17 (32%) early recurrence, and 28 (53%) late recurrence. Mortality rates at 2 years were significantly higher in patients with very early VT recurrence (38%) compared to those with early (12%), late (7%), and no (3%) recurrences (log-rank P < 0.001). Very early VT recurrence was associated with an increased risk of death (odds ratio = 5.68, 95% confidence interval = 1.06-30.62, P = 0.04), while recurrent VT beyond 6 months was not associated with increased risk of mortality (P = 0.94). CONCLUSIONS: Timing of VT recurrence following CA of scar-related VT impacts subsequent risk of mortality. Patients experiencing VT recurrence within 1-6 months from the procedure are at particularly high risk. These data support the importance of intense postablation monitoring for at least 6 months after the procedure to identify patients with early VT recurrence who may benefit from additional therapeutic interventions to improve outcomes.