Efficacy of ultrasound-guided axillary/subclavian venous approaches for pacemaker and defibrillator lead implantation: a randomized study.

PURPOSE: Subclavian access is a reliable technique for lead insertion in pacemaker and defibrillator (ICD) implantation, but it is often accompanied by complications. The aim of this study was to compare the efficacy of the ultrasound-guided axillary approach to the subclavian method. METHODS: This randomized comparative study was performed on 174 patients: as a first attempt, 116 patients underwent the ultrasound-guided axillary access and 58 patients underwent the subclavian approach. A total of 364 leads were placed. Operators were trained in ultrasound-guided vein access technique. RESULTS: Axillary access was successful in 69% of patients (32/46), in the training phase and, as a first attempt, in 91.4% of patients (106/116), in the randomized phase. When axillary approach failed, we performed the following: subclavian access in 5.2% of patients (6/116), cephalic approach in 2.6% of patients (3/116), surgical method in 0.9% of patients (1/116). The subclavian technique was effective, as a first attempt, in 55 patients (94.8%). When the subclavian access failed, the ultrasound axillary approach successfully performed in all three cases. During a mean follow-up of 18 ± 6 months, the number of lead complications was similar in the subclavian group compared to the axillary group (p = 0.664). CONCLUSIONS: As first attempt, ultrasound-guided axillary method showed similarly high-success rate than subclavian approach and well performed when the first attempt in subclavian group failed. Axillary access can be considered a safe and effective alternative technique to the conventional subclavian method for device implantation.

Long-term results of hybrid therapy in patients with atrial fibrillation who develop atrial flutter during flecainide infusion.

The flecainide infusion test has been proposed to screen candidates for hybrid pharmacological and ablation therapy. We report the long-term follow-up of 154 consecutive patients with paroxysmal or persistent atrial fibrillation (AF) who developed atrial flutter (AFL) during flecainide infusion (IC AFL), treated with inferior vena cava-tricuspid annulus isthmus catheter ablation and oral flecainide (hybrid therapy). Over a mean of 54.1 +/- 13.1 months 82 patients (53%) remained free of AF and AFL. Flecainide was discontinued because of adverse effects in 6 patients (4%). A history of persistent AF, and the documentation of >/=1 spontaneous AFL episode before the flecainide test were independent predictors of successful hybrid therapy. In patients with paroxysmal AF without documented spontaneous AFL, the long-term efficacy of hybrid therapy was 38.5% (P = 0.03). The flecainide infusion test reliably detects candidates for hybrid therapy. The efficacy of this therapy is maintained over the long-term with a high patient compliance.

Is pulmonary vein isolation necessary for curing atrial fibrillation?

BACKGROUND: Pulmonary veins (PVs) play a pivotal role in initiating and perpetuating atrial fibrillation (AF). We investigated if PV electrical isolation from the left atrium is required for curing AF. METHODS AND RESULT: Fifty-one patients with paroxysmal or persistent AF underwent circumferential radiofrequency ablation of PV ostia performed with an anatomic approach. The end point of the ablation procedure was the recording of low peak-to-peak bipolar potentials (<0.1 mV) inside the lesions. Left atrium pacing was used to assess the conduction between the PVs and the left atrium. During a mean follow-up period of 16.6+/-3.9 months, 41 patients (80.4%) were free of atrial arrhythmias. When patients with and without AF recurrence were analyzed, no significant difference was observed in the mean number of PVs in which the ablation end point was reached (3.4+/-1.2 versus 3.7+/-0.87) and PVs isolated (1.5+/-1.4 versus 1.6+/-1). We noted that, although in 29 of 41 patients (71%) without AF recurrence, the ablation end point was reached in all PVs mapped, it was only possible to demonstrate the isolation of all PVs mapped in 2 patients. On the other hand, in 7 of 10 patients (70%) with AF recurrence, the ablation end point was reached in all PVs mapped, whereas one patient had all PVs isolated. CONCLUSIONS: Our findings show that with the use of a pure anatomic approach, it is possible to prevent AF in >80% of patients undergoing catheter ablation. Moreover, the isolation of PVs is not crucial for curing AF.