Ultrasound guidance for femoral venous access in patients undergoing pulmonary vein isolation: A quasi-randomized study.

INTRODUCTION: Routine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized-trial data. METHODS: Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi-random allocation to either US-guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US-guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation). RESULTS: Of the 457 patients 199 were allocated to the US-guided puncture group, while the conventional, palpation-based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p < .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US-guided puncture group (5.04% vs. 1.01%, p = .032). CONCLUSION: The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi-randomized comparison strongly supports adapting routine use of US for AF ablation procedures.

Randomized trial of intracardiac echocardiography-guided slow pathway ablation.

PURPOSE: Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS: In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS: Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS: ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.

Management of cardiac implantable electronic device infection using a complete interdisciplinary approach.

Technological advances and increasing operator experience have improved the success rate of transvenous lead extraction (TLE). However, in some cases-especially with longer lead dwelling time-TLE can be highly complicated. In this case report, the authors present an unusual case of implantable cardioverter defibrillator (ICD) pocket infection diagnosed by 18F­fluorodeoxyglucose positron emission tomography/computed tomography (18F­FDG-PET/CT). Complete lead extraction required a combined transvenous and surgical approach. Contralateral reimplantation failed due to occlusion of the right brachiocephalic vein. Therefore, a subcutaneous ICD was implanted. This case highlights the importance of an interdisciplinary approach to the treatment of cardiac implantable electronic device infection.

[Echocardiographic evaluation of the right atrial appendage and its clinical consequences]. / A jobb pitvari fülcse echokardiográfiás vizsgálata és annak klinikai jelentosége.

In case of atrial fibrillation, there is a higher risk of thrombus formation, which could affect the right heart as well. Visualization of the right atrial appendage is difficult; the aim of the present review was to demonstrate the role of routine echocardiographic techniques and to show related clinical data. Orv Hetil. 2019; 160(12): 443-447.

Isolated left atrial posterior wall tachycardia.

A case of macroreentry tachycardia of the isolated posterior left atrium is presented after surgical and subsequent catheter ablation.

[Echocardiographic assessment of the left atrial appendage - transoesophageal, transthoracic and intracardiac approaches]. / A bal pitvari fülcse echokardiográfiás vizsgálata ­ transoesophagealis, transthoracalis és intracardialis lehetoségek.

Left atrial appendage is a cardiac chamber in variable shapes and sizes. Its condition is associated with atrial arrhytmias and the presence of a thrombus. Due to its difficult visualisation, the present review aimed to demonstrate the role of different echocardiographic methods in its assessment. Orv Hetil. 2018; 159(9): 335-345.

[Long-term follow-up of patients with transposition of the great arteries following Senning or Mustard operations. Results from the CSONGRAD Registry]. / A teljes nagyér-transzpozíción átesett betegek Senning- és Mustard-féle mutéti megoldásának hosszú távú utánkövetése. Eredmények a CSONGRAD Regiszterbol.

INTRODUCTION: Transposition of the great arteries is one of the most common cyanotic congenital heart diseases. AIM: The present study aimed to examine and compare long-term survival, functional grading, arrhytmologic and quality of life control in patients with transposition of the great arteries following Senning- and Mustard-operations. METHODS: The present study comprised 85 patients with transposition of the great arteries, of whom Senning-operation was performed in 37 cases and Mustard-operation in 48 subjects. Follow-up study was performed in all cases. RESULTS: The success rate of long-term follow-up proved to be 74%. Twelve out of the 31 Senning-operated and 16 out of 32 Mustard-operated patients died during the follow-up (39% vs. 50%, p = 0.45). Neither features of heart failure, nor those of arrhythmias showed differences between the groups, but parameters of quality of life and functional capacity proved to be favourable in Senning-operated patients. CONCLUSIONS: There is no significant difference in mortality and morbidity of patients with transposition of the great arteries following Mustard- and Senning-operations. Regarding to long-term follow-up quality of life and functional capacity of Senning-operated patients were more favourable.

Clinical echocardiographic indices of left ventricular diastolic function correlate poorly with pulmonary capillary wedge pressure at 1 year following heart transplantation.

Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is routinely performed following orthotopic heart transplantation (OHT). The purpose of this study was to determine whether echocardiographic indices of LV diastolic function correlate with pulmonary capillary wedge pressure (PCWP) in the transplanted heart. Patients who had OHT between June 2009 and November 2011 underwent transthoracic echocardiography and right heart catheterization (RHC) at approximately 1 year post transplantation. We retrospectively assessed 33 potential parameters of LV diastolic function using 2-dimensional, spectral Doppler and tissue Doppler echocardiography. We measured PCWP by RHC. We compared echocardiographic measures with PCWP using linear regression analysis. Ninety-five patients (mean age 49 ± 13 years, 73 males, mean LV ejection fraction 62 ± 10%) were included in the study. Overall, echocardiographic parameters of LV diastolic function demonstrated poor correlation with PCWP. By linear regression, the parameter that most strongly correlated with PCWP was left atrial (LA) minimum area in the apical 4-chamber view (p = 0.002, r(2) = 0.1). Comparing patients with PCWP ≤ 12 mmHg and those with PCWP > 12 mmHg, the parameter that demonstrated the most significant difference was LA minimum area in the apical 2-chamber view (p = 0.002), and comparing patients with PCWP ≤ 15 mmHg and those with PCWP > 15 mmHg, the most significant difference was peak early diastolic velocity of the mitral annulus (p = 0.02). In patients with cardiac allografts, clinical echocardiographic measures of LV diastolic function correlate poorly with PCWP.

Atrial tachycardias occurring late after open heart surgery.

Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant including cavotricuspid isthmus dependent atrial flutter, incisional right atrial flutter and left atrial flutter. Focal atrial tachycardias occur less frequently. The specific type of atrial tachycardia highly depends on the type of surgical incision. Catheter ablation can be very effective, however requires a thorough understanding of anatomy and surgical technique.

Echocardiographic diastolic function assessment is of modest utility in patients with persistent and longstanding persistent atrial fibrillation.

BACKGROUND: Detection of concurrent diastolic dysfunction (DD) may be beneficial in patients with persistent and longstanding persistent atrial fibrillation (AF). The role of transthoracic echocardiography (TTE) in assessing DD in patients with AF has not been well characterized. We sought to determine the utility of TTE in detecting elevated left atrial pressure (LAP) in patients with persistent and longstanding persistent non-valvular AF using directly measured LAP as the reference standard. METHODS: We retrospectively studied 157 patients with persistent AF and preserved left ventricular ejection fraction who underwent pulmonary vein isolation (PVI). LAP was determined in conjunction with trans-septal puncture at the time of catheter ablation. TTE was performed 1 day after PVI and included two dimensional, pulse wave spectral Doppler and tissue Doppler assessments. RESULTS: The clinical parameter that strongly correlated with elevated LAP is longstanding persistent AF. Four strongest TTE parameters identified to moderately correlate with LAP include 1. left atrial minimum volume (LAVmin), 2. peak velocity of early mitral diastolic inflow velocity (E), 3. pulmonary vein systolic flow velocity (PVS), and 4. ratio of early diastolic transmitral inflow velocity to mitral annular velocity at the lateral site (E/E' lateral). CONCLUSION: Accurate assessment of diastolic dysfunction in patients with persistent and longstanding persistent AF is difficult using TTE. A combination of LAVmin, PVS, and E might be helpful to determine elevated LAP.

Ventricular premature depolarization QRS duration as a new marker of risk for the development of ventricular premature depolarization-induced cardiomyopathy.

BACKGROUND: Frequent ventricular premature depolarizations (VPDs) can cause cardiomyopathy (CMP). The mechanisms underlying its development remain unclear, with VPD burden being only a weak predictor of risk. OBJECTIVE: To determine whether VPD QRS duration at the time of initial presentation could predict risk for the subsequent development of CMP in patients with normal left ventricular ejection fraction (LVEF). METHODS: From consecutive patients referred for ablation between January 1, 2006, and April 2, 2013, with ≥10% VPDs on 24-hour Holter monitoring, we identified 45 patients with normal LVEF and an electrocardiogram of the targeted VPD, who were then followed for at least 6 months (median 14 months; interquartile range [IQR] 8-32 months) before intervention. We excluded patients with structural or genetic heart disease. RESULTS: Of the 45 patients, 28 (62%) maintained normal LVEF and 17(38%) developed VPD-induced CMP. VPD burden was similar (26.5% [IQR 19.3%-39.5%] vs 26.0% [IQR 16.4%-41.0%]; P = 0.4) between the 2 groups. Patients who developed VPD-induced CMP had significantly longer VPD QRS duration (159 ms vs 142 ms; P < .001) and a longer sinus QRS duration (97 ms vs 89 ms; P = .04). A VPD QRS duration of ≥153 ms best predicted development of VPD CMP (82% sensitivity and 75% specificity). Longer VPD QRS duration and a non-outflow tract site of VPD origin were independent risk factors for left ventricular dysfunction after multivariate analysis. CONCLUSION: VPD QRS duration longer than 153 ms and a non-outflow tract site of origin might be useful predictors of the subsequent development of VPD-induced CMP.

Left atrial volume best predicts recurrence after catheter ablation in patients with persistent and longstanding persistent atrial fibrillation.

INTRODUCTION: Patients with persistent and longstanding persistent atrial fibrillation (AF) have a higher recurrence rate after antral pulmonary vein isolation (PVI). We sought to determine the clinical, invasive, and noninvasive diastolic function parameters that are associated with AF recurrence after ablation in patients with persistent and longstanding persistent nonvalvular AF. METHODS AND RESULTS: We studied 125 consecutive patients with persistent and longstanding persistent AF who underwent antral PVI at our institution between April 2009 and April 2011. Standard clinical parameters, left atrial (LA) pressure measured at transseptal puncture, and standard diastolic function parameters on transthoracic echocardiographic (TTE) parameters were assessed. TTE was performed in sinus rhythm the first day following radiofrequency catheter ablation. Ablation eliminated AF in 83 of 125 (66.4%) patients (mean age 61.3 ± 8.9, 81% male) during 17.8 ± 7.7 months of follow-up. Using logistic regression analysis, AF duration prior to ablation (P = 0.04, odds ratio [OR]: 1.03, 95% confidence interval [CI] 1.0-1.06) was found to be the only clinical parameter significantly associated with AF recurrence. According to multiple logistic regression analysis, the indexed LA minimum volume of 26 cm(3) /m(2) (P = 0.009, OR: 4.9 95% CI 1.5-16.2) was the only independent imaging parameter associated with AF recurrence. CONCLUSION: Indexed minimal LA volume is highly associated with ablation success in patients with persistent and longstanding persistent AF.

Time to recurrence of atrial fibrillation influences outcome following catheter ablation.

BACKGROUND: Outcome after atrial fibrillation (AF) recurrence after ablation remains poorly characterized. OBJECTIVE: To determine whether the time to recurrence of AF after catheter ablation impacts outcome. METHODS: Four hundred thirty-nine consecutive patients with AF after catheter ablation were categorized as early recurrence (E) (3-6 months after ablation; n = 245 patients), late (L) (6-12 months; n = 118), and very late (VL) (>12 months; n = 76). Subsequent AF frequency (defined as rare if ≤ 2 episodes or ≤ 1 cardioversion per 6-month window), response to antiarrhythmic drugs (AADs), and long-term outcome after repeat ablation were evaluated. RESULTS: Subsequent AF episodes were rare in 9% of E, 42% of L, and 68% of VL groups (P<.001). AF was eliminated with AADs in 19% patients of E, 58% of L, and 72% of VL groups in whom AADs were tried (P<.001). A repeat ablation was performed in 75% patients of E, 59% of L, and 46% of VL recurrence groups (P<.001). With>1-year follow-up after repeat ablation, 49% patients of E, 70% of L, and 89% of VL groups (P<.001) had no or rare AF. In multivariate logistic regression, time to recurrence was an independent predictor of rare AF episodes, better response to AADs, and better outcome after repeat ablation. CONCLUSIONS: In patients with AF after ablation, time to recurrence is a major determinant of outcome. Patients with later recurrences are more likely to have sporadic episodes and respond better to AADs and repeat ablation. These results not only suggest pathophysiologic differences but also have implications for counseling patients regarding anticipated outcome.

Surgical technique and the mechanism of atrial tachycardia late after open heart surgery.

INTRODUCTION: Diverse atrial tachycardias (ATs) can develop after open heart surgery. The aim of our study was to examine the determinants of the mechanism of postoperative AT. METHODS AND RESULTS: One hundred patients with AT occurring at least 3 months after open heart surgery were studied. Patients were grouped according to the atrial incision applied at the time of surgery. During 127 electrophysiology procedures, 151 ATs were studied. Eighty-eight patients had cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL), 49 patients had at least one non-CTI-dependent AFL and 11 patients had focal AT. While CTI-dependent AFL was equally prevalent across groups, the finding of a non-CTI-dependent AFL was progressively more common as more extensive atriotomy was applied (p < 0.001). Among patients who had right atrial (RA) operations, RA incisional tachycardia was the most common non-CTI-dependent circuit, while the finding of perimitral or left atrial (LA) roof-dependent AFL was associated with LA atriotomy (p = 0.002 and p = 0.041, respectively). After adjustment for possible confounders, surgical group remained independent predictor of non-CTI-dependent AFLs (p < 0.001). No predictor was identified for focal AT, which originated from typical predilection sites and in 36% from the vicinity of surgical scar. Radiofrequency ablation was highly effective for all ATs, but the recurrence rate of AFL and atrial fibrillation was high at 22% and 27%, respectively, during 19 ± 15 months of follow-up. CONCLUSION: While CTI-dependent AFL is the most common AT late after open heart surgery, atypical AFL becomes progressively more common with more extensive atriotomy. Right atrial incisional tachycardia is the dominant non-CTI-dependent AFL after opening of the RA, while a perimitral or roof-dependent LA circuit can be expected after LA operations.