Composite Index Tagging for PVI in Paroxysmal AF: A Prospective, Multicenter Postapproval Study.

BACKGROUND: VISITAG SURPOINT (VS)-guided ablation of paroxysmal atrial fibrillation has demonstrated good short- and long-term success rates with low rates of complications in recent, predominantly European, studies. However, there is a lack of multicenter data from the United States. OBJECTIVES: This U.S. study evaluated the safety and effectiveness of VS ablation using a contact force-sensing catheter for the treatment of drug-refractory symptomatic paroxysmal atrial fibrillation. METHODS: The prospective, nonrandomized VS postapproval study was conducted at 32 U.S. sites. Ablation consisted of pulmonary vein isolation with recommended VS index targets (anterior, roof, or ridge: 550; posterior or inferior: 380). Additional non-pulmonary vein triggers were ablated at the investigators' discretion. Subjects were followed for 12 months, including a 3-month blanking period. The primary safety endpoint was the primary adverse event rate up to 7 days postablation. The primary effectiveness endpoint was 12-month freedom from atrial tachyarrhythmia recurrence and an additional set of failure modes based on stringent monitoring (weekly transtelephonic monitoring [TTM] [day 91 through month 5], monthly TTM [months 6 to 12], and any symptomatic cardiac episode using TTM, plus electrocardiogram [at discharge, 1 month, 3 months, 6 months, and 12 months] with 24-hour Holter monitoring [12 months]). RESULTS: Of 283 patients enrolled, 261 had the catheter inserted and underwent ablation (safety cohort); 246 met all eligibility criteria (effectiveness cohort). Mean fluoroscopy time was 2.2 minutes. Mean amount of catheter-delivered fluid was 671 mL; only 18.0% of patients utilized a Foley catheter. Primary safety and effectiveness endpoints were met. The raw primary adverse event rate was 4.3% (14 events, n = 11). At 12 months, the Kaplan-Meier estimate of freedom from primary effectiveness failure was 76.4%; estimates of 12-month freedom from documented atrial fibrillation, atrial tachycardia, or atrial flutter recurrence were 81.5% and 92.7% per stringent monitoring and standard-of-care monitoring (excluding TTM), respectively. The first-pass isolation rate was 83.1%, represented by no acute reconnection after the 30-minute waiting period. Freedom from repeat ablation at 12 months was 94.0%. CONCLUSIONS: The VS postapproval study confirms reproducibility of clinical safety and effectiveness of the standardized VS paroxysmal atrial fibrillation ablation workflow with >80% 12-month freedom from atrial tachyarrhythmia recurrence and first-pass isolation rate of 83.1%. Procedures were performed with minimal fluoroscopy. (Evaluation of VISITAG SURPOINT™ Module With External Processing Unit [EPU]; NCT03624881).

Leadless pacemaker implant in patients with pre-existing infections: Results from the Micra postapproval registry.

INTRODUCTION: Leadless pacemakers may provide a safe and attractive pacing option to patients with cardiac implantable electronic device (CIED) infection. We describe the characteristics and outcomes of patients with a recent CIED infection undergoing Micra implant attempt. METHODS AND RESULTS: Patients with prior CIED infection and device explant with Micra implant within 30 days, were identified from the Micra post approval registry. Procedure characteristics and outcomes were summarized. A total of 105 patients with prior CIED infection underwent Micra implant attempt ≤30 days from prior system explant (84 [80%] pacemakers and 13 [12%] ICD/CRT-D). All system components were explanted in 93% of patients and explant occurred a median of 6 days before Micra implant, with 37% occurring on the day of Micra implant. Micra was successfully implanted in 99% patients, mean follow-up duration was 8.5 ± 7.1 months (range 0-28.5). The majority of patients (91%) received IV antibiotics preimplant, while 42% of patients received IV antibiotics postprocedure. The median length of hospitalization following Micra implant was 2 days (IQR, 1-7). During follow-up, two patients died from sepsis and four patients required system upgrade, of which two patients received Micra to provide temporary pacing support. There were no Micra devices explanted due to infection. CONCLUSION: Implantation of the Micra transcatheter pacemaker is safe and feasible in patients with a recent CIED infection. No recurrent infections that required Micra device removal were seen. Leadless pacemakers appear to be a safe pacing alternative for patients with CIED infection who undergo extraction.

Focal ventricular arrhythmias originating from the left ventricle adjacent to the membranous septum.

AIMS: We report the features of focal ventricular arrhythmias (VAs) arising from the left ventricle (LV) adjacent to the membranous septum. METHODS AND RESULTS: We studied eight patients (five men, 65 ± 10 years) with (n = 2) or without structural heart disease (n = 6) who had ventricular tachycardia (n = 4) or premature ventricular contractions (n = 4) originating from the LV septum underneath the aorta. Ventricular arrhythmias exhibited a focal activation pattern, left (n = 4) or right bundle branch block (n = 4), respectively, left superior (n = 4) or inferior axis QRS morphology (n = 4), negative QRS polarity in lead III and early or no precordial transition in all. During all of these VAs, far-field electrograms in the His bundle (HB) region preceded the QRS onset. In all patients, ventricular pre-potentials were recorded during VAs while late potentials were recorded in sinus rhythm at the border of a localized low-voltage area underneath the aorta. Radiofrequency catheter ablation at the presumed sites of origin successfully eliminated VAs in five patients and was abandoned in the remaining three because the HB electrogram was recorded at that site. CONCLUSION: Focal VAs may arise from the LV adjacent to the membranous septum as a part of the LV ostium, and broadens the spectrum of LV ostium VAs.

QRS alternans during idiopathic ventricular tachycardia originating from the right coronary cusp of the aorta.

A 77-year-old man underwent electrophysiological testing for idiopathic ventricular tachycardia (VT) with QRS alternans exhibiting a left bundle branch block and left inferior axis QRS morphology. Successful radiofrequency catheter ablation was achieved at the site of the earliest ventricular activation in the right coronary cusp. Pacing at this site reproduced an excellent pace map with QRS alternans. Pacing from other sites in the ventricular outflow tracts reproduced neither an excellent pace map nor QRS alternans. This case demonstrates that VT with a single origin and multiple exits in the aortic root may exhibit QRS alternans.

Electroanatomic mapping in the catheter ablation of premature atrial contractions with a non-pulmonary vein origin.

Symptomatic premature atrial contractions (PACs) may be a target for catheter ablation. However, mapping of PACs with an atrial origin may not be easy because of erratic incidence and different sites of origin. Although the technique and efficacy of electroanatomic mapping has been established in stable arrhythmias, electroanatomic mapping of PACs in intermittent arrhythmias has not yet been reported. This article describes a manoeuvre for mapping PACs using an electroanatomic mapping system. Our experience has demonstrated that electroanatomic mapping using an auto-freeze map is feasible during PACs and may be an option for catheter ablation of PACs.

Successful catheter ablation of premature ventricular contractions originating from the tricuspid annulus using a Halo-type catheter.

A 31-year-old woman with idiopathic premature ventricular contractions originating from the tricuspid annulus (TA) underwent electrophysiological testing. Activation mapping with a 20-pole bipolar Halo-type catheter positioned along the TA revealed the earliest ventricular activation at a site between 7 and 8 o'clock along the TA. A reversal in the polarity of the local ventricular electrograms was observed between the two neighbouring electrode pairs of the TA catheter. Successful catheter ablation was achieved at the ventricular site between those electrode pairs. A Halo-type catheter may be effective for mapping and catheter ablation of ventricular arrhythmias originating from the TA.

Successful catheter ablation of atrial fibrillation in a patient with dextrocardia.

A 49-year-old woman with dextrocardia and situs inversus underwent catheter ablation of paroxysmal atrial fibrillation. A contrast injection into the left atrium revealed that the left atrial appendage (LAA) was adjacent to the right-sided (anatomic left) superior pulmonary vein (PV). After successful isolation of that PV, LAA potentials were recorded from several electrode pairs of a circular PV mapping catheter. LAA may cause similar difficulties during PVI of the right-sided superior PV in a dextrocardia patient, as during PVI of the left superior PV in a normal heart.

Duplicated coronary sinus with a connecting branch.

A 48-year-old woman with class III heart failure and left bundle branch block underwent an implantation for cardiac resynchronization therapy. Right anterior oblique (RAO) view coronary sinus (CS) venography suggested the antero- and postero-lateral branches appeared to arise from the same vessel of a duplicated CS, but the antero-lateral branch arising from a different vessel was visualized via a connecting branch by the contrast injected into the vessel with the postero-lateral branch, and the distal parts of the two vessels were superimposed in the RAO view. This unusual anomaly may have the potential risk for complications such as perforations.