Racial and Ethnic Differences in Initiation and Discontinuation of Antiarrhythmic Medications in Management of Atrial Fibrillation.

Background: Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment are critical in alleviating AF disease burden. There is significant heterogeneity in patterns of AF care. It is unclear whether there are racial and ethnic differences in treatment of AF following antiarrhythmic drug (AAD) prescription. Methods: Using the Optum Clinformatics Data Mart-Socioeconomic Status database from January, 2009, through March, 2022, multivariable logistic regression techniques were used to examine the impact of race and ethnicity on rate of AAD initiation, as well as receipt of catheter ablation within two years of initiation. We compared AAD discontinuation rate by race and ethnicity groups using Cox regression models. Log-rank analyses were used to examine the rate of AF-related hospitalization. Results: Among 143,281 patients identified with newly diagnosed AF, 30,019 patients (21%) were initiated on an AAD within 90 days. Patients identified as Non-Hispanic Black (NHB) were significantly less likely to receive an AAD compared to Non-Hispanic White patients (NHW) (Odds Ratio [OR] 0.90, 95% confidence interval [CI] 0.85-0.94). Compared to NHW, Hispanic (Hazard Ratio [HR] 1.08, 95% CI 1.02-1.14) and Asian patients (HR 1.17, 95% CI 1.06-1.29) have a higher rate of AAD discontinuation. Following AAD initiation, NHB patients were significantly more likely to have an AF-related hospitalization (p < 0.01). However, NHB patients were significantly less likely to receive ablation compared to NHW (HR 0.83, 95% CI 0.70-0.97), and less likely to change AAD (p < 0.01). Conclusion: Patients identified as NHB are 10% less likely to receive an AAD for treatment of newly diagnosed AF. Compared to NHW, Hispanic and Asian patients were more likely to discontinue AAD treatment. Once initiated on an AAD, NHB patients were significantly more likely to have an AF -related hospitalization, but were 17% less likely to receive ablation compared to NHW patients. The etiology of, and interventions to reduce, these disparities require further investigation.

Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation.

Background: Cerebral thromboembolism during atrial fibrillation (AF) ablation is an infrequent (0.17%) complication in part owing to strict adherence to intraprocedural anticoagulation. Failure to maintain therapeutic anticoagulation can lead to an increase in events, including silent cerebral ischemia. Objective: To evaluate a computerized, clinical decision support system (CDSS) to dose intraprocedural anticoagulation and determine if it leads to improved intraprocedural anticoagulation outcomes during AF ablation. Methods: The Digital Intern dosing algorithm is an adaptive, rule-based CDSS for heparin dosing. The initial dose is calculated from the patient's weight, baseline activated clotting time (ACT), and outpatient anticoagulant. Subsequent recommendations adapt based on individual patient ACT changes. Outcomes from 50 cases prior to algorithm introduction were compared to 139 cases using the algorithm. Results: Procedures using the dosing algorithm reached goal ACT (over 300 seconds) faster (17.6 ± 11.1 minutes vs 33.3 ± 23.6 minutes pre-algorithm, P < .001). ACTs fell below goal while in the LA (odds ratio 0.20 [0.10-0.39], P < .001) and rose above 400 seconds less frequently (odds ratio 0.21 [0.07-0.59], P = .003). System Usability Scale scores were excellent (96 ± 5, n = 7, score >80.3 excellent). Preprocedure anticoagulant, weight, baseline ACT, age, sex, and renal function were potential predictors of heparin dose to achieve ACT >300 seconds and final infusion rate. Conclusion: A heparin dosing CDSS based on rules and adaptation to individual patient response improved maintenance of therapeutic ACT during AF ablation and was rated highly by nurses for usability.

Race, Sex, and Neighborhood Socioeconomic Disparities in Ablation of Ventricular Tachycardia Within a National Medicare Cohort.

Background Ventricular tachycardia (VT) ablation significantly improves our ability to control VT, yet little is known about whether disparities exist in delivery of this technology. Methods and Results Using a national 100% Medicare inpatient data set of beneficiaries admitted with VT from January 1, 2014, through November 30, 2014, multivariable logistic regression techniques were used to examine the sociodemographic and clinical characteristics associated with receiving ablation. Census block group-level neighborhood socioeconomic disadvantage was measured for each patient by the Area Deprivation Index, a composite measure of socioeconomic disadvantage consisting of education, income, housing, and employment factors. Among 131 645 patients admitted with VT, 2190 (1.66%) received ablation. After adjustment for comorbidities, hospital characteristics, and sociodemographics, female sex (odds ratio [OR], 0.75 [95% CI, 0.67-0.84]), identifying as Black race (OR, 0.75 [95% CI, 0.62-0.90] compared with identifying as White race), and living in a highly socioeconomically disadvantaged neighborhood (national Area Deprivation Index percentile of >85%) (OR, 0.81 [95% CI, 0.69-0.95] versus Area Deprivation Index ≤85%) were associated with significantly lower odds of receiving ablation. Conclusions Female patients, patients identifying as Black race, and patients living in the most disadvantaged neighborhoods are 19% to 25% less likely to receive ablation during hospitalization with VT. The cause of and solutions for these disparities require further investigation.

Outcomes Following Standardized Implantable Cardioverter-defibrillator Reprogramming.

Multiple randomized controlled trials have demonstrated that programming implantable cardioverter-defibrillators (ICDs) with longer detection intervals and higher detection rates results in significant reductions in the delivery of inappropriate therapy without increasing the number of adverse events. Despite these findings, however, implementation of this evidence-based programming, particularly in previously implanted ICDs, remains inconsistent throughout the United States, with significant provider-dependent variability. We developed an institutionally standardized ICD reprogramming protocol for primary prevention ICDs utilizing high detection rates and long detection intervals, then prospectively evaluated outcomes in patients programmed with this protocol compared to a historical cohort. A total of 193 patients with primary prevention ICDs underwent standardized reprogramming and were monitored over a 1-year period. A historical cohort of 254 patients with ICD with non-standardized programming implanted prior to initiation of the standardized protocol were used as a comparison group. The primary outcomes were rates of appropriate or inappropriate ICD therapy. Secondary outcomes were rates of syncope, emergency department (ED) or urgent care (UC) visits, hospitalization, and death. All patients seen in the device clinic who qualified for device standardization were reprogrammed according to the previously developed evidence-based, institutionally standardized protocol. Patients who underwent standardized reprogramming had a lower prevalence of inappropriate therapy compared to the historical cohort (0% vs. 2.4%, P = .04); the prevalence of appropriate therapy was also lower in the reprogrammed group (4.1% vs. 7.1%) but not to a statistically significant degree (P = .19). There was a lower prevalence of syncope in the reprogrammed group (0% vs. 2.8%, P = .02). No significant difference in the prevalence of ED or UC utilization (37.8% vs. 33.9%, P = .39) or mortality (4.1% vs. 3.5%, P = .74) was found. Prospective standardized reprogramming of new and previously implanted primary prevention ICDs with high-rate detection and longer detection intervals may be an effective method to obtain high adherence to evidence-based reprogramming and reduce rates of inappropriate device therapies without a significant impact on appropriate therapies or mortality.

Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology.

PURPOSE OF REVIEW: There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy. RECENT FINDINGS: Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.

Preparing for the New Joint Commission Requirements: a Model for Tracking Outcomes of an Ambulatory Antibiotic Stewardship Program in Primary Care.

Since 2007, inpatient antibiotic stewardship programs have been required for all Joint Commission-accredited hospitals in the USA. Given the frequency of ambulatory antibiotic prescribing, in June 2019, the Joint Commission released new standards for antibiotic stewardship programs in ambulatory healthcare. This report identified five elements of performance (EPs): (1) Identify an antimicrobial stewardship leader, (2) establish an annual antimicrobial stewardship goal, (3) implement evidence-based practice guidelines related to the antimicrobial stewardship goal, (4) provide clinical staff with educational resources related to the antimicrobial stewardship goal, and (5) collect, analyze, and report data related to the antimicrobial stewardship goal. We provide eight practical tips for implementing the EPs for antimicrobial stewardship: (1) Identify a collaborative leadership team, (2) partner with informatics, (3) identify national prescribing patterns, (4) perform a needs assessment based on local prescribing patterns, (5) review guidelines for diagnosis and treatment of the selected condition, (6) identify systems-level interventions to help support providers in making appropriate treatment decisions, (7) prioritize individual EPs for your institution, and (8) re-assess local data to identify areas of strength and deficiency in local practice.

Real-World Comparison of Classes IC and III Antiarrhythmic Drugs as an Initial Rhythm Control Strategy in Newly Diagnosed Atrial Fibrillation: From the TREAT-AF Study.

OBJECTIVES: In this study the authors investigated effectiveness and safety of an initial treatment strategy with class IC or class III antiarrhythmic drugs (AAD) for newly diagnosed atrial fibrillation (AF) or atrial flutter (AFL). BACKGROUND: There is limited evidence to guide optimal AAD selection for rhythm control in newly diagnosed AF/AFL. METHODS: Using data from TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF), the authors performed a retrospective cohort study of patients with AF/AFL from 2004 to 2014 and class IC or class III AAD prescription within 90 days following diagnosis. Patients with prior myocardial infarction, heart failure, or end-stage renal disease were excluded. Inverse probability treatment weighted propensity scores were used to evaluate the association of AAD class on hospitalization and cardiovascular events. To evaluate residual confounding, falsification outcomes were evaluated. RESULTS: A total of 230,762 patients developed newly diagnosed AF/AFL during the study period. Of those, 3,973 patients (1.7%) were prescribed class IC and 6,909 (3.0%) were prescribed class III AAD. Median follow-up was 4.9 years. After inverse probability treatment weighted adjustment, class IC medications were associated with lower risk of hospitalizations for AF/AFL (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.73 to 0.81), cardiovascular disease (HR: 0.78; 95% CI: 0.75 to 0.81), heart failure (HR: 0.70; 95% CI: 0.64 to 0.76), and lower incidence of ischemic stroke (HR: 0.74; 95% CI: 0.65 to 0.85). Similar results were found in CHADS2 (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism) 0 or 1 and CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) 0 or 1 subgroups. Falsification analyses for outcomes of urinary tract infection, pneumonia, and hip fracture were generally nonsignificant. CONCLUSIONS: Prescription of class IC AAD as initial treatment for newly diagnosed AF/AFL, compared with prescription of class III AAD, may be associated with lower risk of hospitalization and cardiovascular events.

Outcomes During Intended Fluoroscopy-free Ablation in Adults and Children.

Electroanatomic mapping (EAM) systems facilitate the elimination of fluoroscopy during electrophysiologic (EP) studies and ablations. The rate and predictors of fluoroscopy requirements while attempting fluoroscopy-free (FF) ablations are unclear. This study aimed (1) to investigate the rates of fluoroscopic use and acute success in patients initially referred for FF ablation and (2) to identify procedural characteristics associated with fluoroscopic use in patients in whom FF ablation was initially planned (IFF). We performed a retrospective review of all patients who underwent IFF EP study or ablation between 2010 and 2013. Patient and procedural characteristics were compared between those with successful FF procedures and those who subsequently required fluoroscopy during their procedure. An FF EP study with or without ablation was performed in 124 patients during 138 procedures for either supraventricular or idiopathic ventricular arrhythmias. Of the 138 procedures, 105 of them were performed without fluoroscopy. In the remaining 33 cases, fluoroscopy was used for an average of 1.21 minutes ± 1.18 minutes. Acute procedural success was achieved in 97% of both FF and fluoroscopy procedures. The primary reason for fluoroscopy use was as a guide for transseptal puncture. There were no significant differences between FF and fluoroscopy procedures with respect to catheter placement time or complication rate. In conclusion, in this single-center study of IFF procedures, despite careful case selection for IFF ablation, 24% of IFF cases ultimately required minimal fluoroscopy. Fluoroscopy and FF procedures had similar rates of procedural success and complications. Additional large prospective studies are required to further investigate the safety and efficacy of FF ablations.

P-Wave Amplitude and PR Changes in Patients With Inappropriate Sinus Tachycardia: Findings Supportive of a Central Mechanism.

BACKGROUND: The mechanism of inappropriate sinus tachycardia (IST) remains incompletely understood. METHODS AND RESULTS: We prospectively compared 3 patient groups: 11 patients with IST (IST Group), 9 control patients administered isoproterenol (Isuprel Group), and 15 patients with cristae terminalis atrial tachycardia (AT Group). P-wave amplitude in lead II and PR interval were measured at a lower and higher heart rate (HR1 and HR2, respectively). P-wave amplitude increased significantly with the increase in HR in the IST Group (0.16±0.07 mV at HR1=97±12 beats per minute versus 0.21±0.08 mV at HR2=135±21 beats per minute, P=0.001). The average increase in P-wave amplitude in the IST Group was similar to the Isuprel Group (P=0.26). PR interval significantly shortened with the increases in HR in the IST Group (146±15 ms at HR1 versus 128±16 ms at HR2, P<0.001). A similar decrease in the PR interval was noted in the Isuprel Group (P=0.6). In contrast, patients in the atrial tachycardia Group experienced PR lengthening during atrial tachycardia when compared with baseline normal sinus rhythm (153±25 ms at HR1=78±17 beats per minute versus 179±29 ms at HR2=140±28 beats per minute, P<0.01). CONCLUSIONS: We have shown that HR increases in patients with IST were associated with an increase in P-wave amplitude in lead II and PR shortening similar to what is seen in healthy controls following isoproterenol infusion. The increase in P-wave amplitude and absence of PR lengthening in IST support an extrinsic mechanism consistent with a state of sympatho-excitation with cephalic shift in sinus node activation and enhanced atrioventricular nodal conduction.

Machine Learning Algorithm Predicts Cardiac Resynchronization Therapy Outcomes: Lessons From the COMPANION Trial.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in heart failure patients with reduced left ventricular function and intraventricular conduction delay. However, individual outcomes vary significantly. This study sought to use a machine learning algorithm to develop a model to predict outcomes after CRT. METHODS AND RESULTS: Models were developed with machine learning algorithms to predict all-cause mortality or heart failure hospitalization at 12 months post-CRT in the COMPANION trial (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure). The best performing model was developed with the random forest algorithm. The ability of this model to predict all-cause mortality or heart failure hospitalization and all-cause mortality alone was compared with discrimination obtained using a combination of bundle branch block morphology and QRS duration. In the 595 patients with CRT-defibrillator in the COMPANION trial, 105 deaths occurred (median follow-up, 15.7 months). The survival difference across subgroups differentiated by bundle branch block morphology and QRS duration did not reach significance (P=0.08). The random forest model produced quartiles of patients with an 8-fold difference in survival between those with the highest and lowest predicted probability for events (hazard ratio, 7.96; P<0.0001). The model also discriminated the risk of the composite end point of all-cause mortality or heart failure hospitalization better than subgroups based on bundle branch block morphology and QRS duration. CONCLUSIONS: In the COMPANION trial, a machine learning algorithm produced a model that predicted clinical outcomes after CRT. Applied before device implant, this model may better differentiate outcomes over current clinical discriminators and improve shared decision-making with patients.

Long-term morbidity and mortality after implantable cardioverter-defibrillator implantation with procedural complication: A report from the National Cardiovascular Data Registry.

BACKGROUND: Long-term outcomes and predictors of mortality after implantable cardioverter-defibrillator (ICD) implantation related complication are unclear. OBJECTIVE: The purpose of this study was to determine the risk of mortality and hospitalization after complication during ICD implantation and identify predictors of adverse outcomes. METHODS: We performed a retrospective registry study of Medicare beneficiaries who were first-time ICD recipients enrolled in the National Cardiovascular Data Registry ICD Registry between January 2006 and March 2010. Mortality and hospitalization rates were examined using Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression analysis. Covariates associated with mortality 3 years after ICD implantation complication were investigated. RESULTS: The study cohort comprised 136,143 Medicare beneficiaries. Complications during the index hospitalization occurred in 7046 patients (5.18%), and complications within 90 days of device implantation occurred in 10,005 patients (7.34%). In adjusted analyses, complications within 90 days of implantation were associated with an increased risk of all-cause mortality at 1 year (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.05-1.20; P = .006) and 3 years (HR 1.09; 95% CI 1.05-1.13; P <.0001). These results were consistent for a combined endpoint of all-cause mortality or hospitalization. Patient, device, and hospital characteristics associated with 3-year mortality were similar between those with and those without complications. CONCLUSION: Among Medicare beneficiaries, the occurrence of complications within 90 days of ICD implantation was associated with increased risk of all-cause mortality and all-cause mortality or hospitalization at 1 and 3 years. Patient, procedure, and hospital characteristics associated with mortality at 3 years after implantation were similar regardless of whether acute procedural complication occurred.

Injectable loop recorder implantation in an ambulatory setting by advanced practice providers: Analysis of outcomes.

INTRODUCTION: Implantable loop recorder (ILR) insertion has historically been performed in a surgical environment such as the electrophysiology (EP) lab. The newest generation loop recorder (Medtronic Reveal LINQ™, Minneapolis, MN, USA) is injectable with potential for implantation in a non-EP lab setting by advanced practice providers (APPs) facilitating improved workflow and resource utilization. We report the safety and efficacy of injectable ILR placement in the ambulatory care setting by APPs. METHODS: A retrospective review was performed including all patients referred for injectable ILR placement from March 2014 to November 2015. All device placement procedures were performed in an ambulatory care setting using the standard manufacturer deployment kit with sterile technique and local anesthetic following a single dose of intravenous antibiotics. Acute procedural success and complication rates following injectable ILR placement in the ambulatory setting were reviewed. RESULTS: During the study period, 125 injectable ILRs were implanted. Acute procedural success with adequate sensing (R-waves ≥ 0.2 mV) occurred in 100% of patients. There were no acute procedural complications. Subacute complications occurred in two patients (1.6% of implantations), including one possible infection treated with oral antibiotics and one device removal due to pain at the implant site. CONCLUSION: In this retrospective single-center study, implantation of injectable ILR in an ambulatory care setting by APPs following a single dose of intravenous antibiotics and standard manufacturer technique yielded a low complication rate with high acute procedural success. Use of this implantation strategy may improve EP lab workflow while providing a safe and effective technique for device placement.

Concealed Accessory Pathways with a Single Ventricular and Two Discrete Atrial Insertion Sites.

BACKGROUND: Atrioventricular reciprocating tachycardia (AVRT) utilizing a concealed accessory pathway is common. It is well appreciated that some patients may have multiple accessory pathways with separate atrial and ventricular insertion sites. METHODS: We present three cases of AVRT utilizing concealed pathways with evidence that each utilizing a single ventricular insertion and two discrete atrial insertion sites. RESULTS: In case one, two discrete atrial insertion sites were mapped in two separate procedures, and only during the second ablation was the Kent potential identified. Ablation of the Kent potential at this site remote from the two atrial insertion sites resulted in the termination of the retrograde conduction in both pathways. Case two presented with supraventricular tachycardia (SVT) with alternating eccentric atrial activation patterns without alteration in the tachycardia cycle length. The two distinct atrial insertion sites during orthodromic AVRT and ventricular pacing were targeted and each of the two atrial insertion sites were successfully mapped and ablated. In case three, retrograde decremental conduction utilizing both atrial insertion sites was identified prior to ablation. After mapping and ablation of the first discrete atrial insertion site, tachycardia persisted utilizing the second atrial insertion site. Only after ablation of the second atrial insertion site was SVT noninducible, and VA conduction was no longer present. CONCLUSIONS: Concealed retrograde accessory pathways with discrete atrial insertion sites may have a common ventricular insertion site. Identification and ablation of the ventricular insertion site or the separate discrete atrial insertion sites result in successful treatment.

Survival After Secondary Prevention Implantable Cardioverter-Defibrillator Placement: An Analysis From the NCDR ICD Registry.

OBJECTIVES: This study sought to define the characteristics and risks of death of patients receiving a physician-designated secondary prevention implantable cardioverter-defibrillator (ICD) in contemporary clinical practice. BACKGROUND: Data on utilization and outcomes of ICDs for the secondary prevention of sudden cardiac death (SCD) are limited. METHODS: Patients enrolled in the National Cardiovascular Data Registry's (NCDR) ICD Registry from 2006 to 2009 with a physician-designated secondary prevention indication for ICD implantation were identified and linked to the Social Security Death Master File. Those patients with a history either of tachycardic arrest or sustained ventricular tachycardia (SCD/VT) or of syncope without SCD/VT were included. Kaplan-Meier survival analysis was used to assess mortality. Cox proportional hazards survival modeling was used to assess the risk of death in these groups, adjusting for patient characteristics. RESULTS: In the study cohort of 46,685 patients (mean age 66 ± 14 years, 73.5% male, 85% white), 78% had SCD/VT and 22% had syncope. Overall mortality was 10.4% at 1 year and 16.4% at 2 years. Compared with patients having SCD/VT, the adjusted hazard of death at 1 year was lower in the patients having syncope (hazard ratio: 0.89; 95% confidence interval: 0.83 to 0.96) but was not significantly different by 2 years (hazard ratio: 0.96; 95% confidence interval: 0.90 to 1.01). CONCLUSIONS: Nearly 9 of 10 patients receiving a secondary prevention ICD in clinical practice are alive 1 year after implantation. The risk of death varies by indication and is highest among patients who survive SCD or sustained VT in the first year after device implantation.

Effect of PR Interval on Outcomes Following Cardiac Resynchronization Therapy: A Secondary Analysis of the COMPANION Trial.

BACKGROUND: Prolonged PR intervals may impair atrioventricular mechanical coupling and adversely affect cardiac performance. We hypothesize that patients with advanced systolic heart failure, wide QRS complexes, and prolonged PR intervals will have improved survival from CRT-D regardless of whether left bundle branch block (LBBB) or non-LBBB is present. METHODS AND RESULTS: A total of 308 patients enrolled in the optimal pharmacologic therapy (OPT) and 595 patients in the cardiac resynchronization therapy with defibrillation (CRT-D) arms of the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure trial were stratified according to normal (≤230 ms) or prolonged PR interval (>230 ms). The incidence of all-cause mortality (ACM) or hospitalization (primary endpoint) and ACM (secondary endpoint) was compared using Kaplan-Meier curves. Cox proportional hazards models for the primary and secondary endpoints were fit with LBBB status and baseline PR interval. CRT-D treatment reduced both hospitalization/ACM (P = 0.002) and ACM (P = 0.003) compared to OPT. However, CRT-D was increasingly more effective in reducing ACM hazard in patients with longer baseline PR intervals (P = 0.002) regardless of LBBB status. In particular, in the prolonged baseline PR interval subgroup, ACM was reduced with CRT-D compared to OPT (P = 0.001) with little evidence of ACM reduction in the normal PR subgroup (P = 0.07). CONCLUSIONS: In patients with advanced systolic heart failure, wide QRS complexes, and prolonged PR intervals, restoration of atrioventricular mechanical coupling with CRT-D may improve survival regardless of LBBB status. In patients with non-LBBB, a benefit from CRT-D may occur with prolonged PR intervals.

Pulmonary vein and cavotricuspid isthmus ablation in situs inversus totalis.

Pulmonary vein isolation (PVI) with cavotricuspid isthmus (CTI) ablation is feasible in patients with situs inversus totalis. Orientation challenges are improved with the use of electroanatomical mapping prior to transseptal puncture. Care must be taken to note the opposing anatomic locations of important structures such as the left atrial appendage, descending aorta, and phrenic nerve.

Percutaneous mechanical assist for severe cardiogenic shock due to acute right ventricular failure.

Acute right ventricular failure can lead to severe cardiogenic shock and death. Recovery may be achieved with early supportive measures. In many patients, intravenous fluid and inotropic resuscitation is inadequate to improve cardiac output. In these cases, percutaneous mechanical assist may provide a non-surgical bridge to recovery. Herein, we describe a case series of patients with severe, refractory cardiogenic shock due to acute right ventricular failure who received a continuous flow percutaneous ventricular device primarily utilizing the right internal jugular vein for out flow cannula placement.

Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease.

OBJECTIVES: Determine if patients prefer multivessel percutaneous coronary intervention (mv-PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multivessel coronary artery disease (mv-CAD) despite high 1-year risk. BACKGROUND: Patient risk perception and preference for CABG or mv-PCI to treat medically refractory mv-CAD are poorly understood. We hypothesize that patients prefer mv-PCI instead of CABG even when quoted high mv-PCI risk. METHODS: 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv-CAD. CABG or mv-PCI was presented as treatment options. Risk scenarios included variable 1-year risks of death, stroke, and repeat procedures for mv-PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv-PCI over CABG across a range of quoted risks of death, stroke, and repeat procedures. RESULTS: For nearly all quoted risks, patients preferred mv-PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (P < 0.0001). Compared to patients, physicians chose mv-PCI less often than CABG as the risk of death and repeat procedures increased (P < 0.001 and P = 0.004, respectively). CONCLUSION: Patients favor mv-PCI over CABG to treat mv-CAD, even if 1-year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv-PCI less than patients despite similarly quoted 1-year risks.