Transvenous revision of leads with cardiac perforation following device implantation-Safety, outcome, and complications.

INTRODUCTION: Cardiac perforation is a rare complication of cardiac implantable electronic device (CIED) implantation. Transvenous revision of perforated leads is associated with the risk of cardiac tamponade and death. Little is known about periprocedural complications and outcome of these patients. METHODS AND RESULTS: All patients referred to our department with evidence or suspicion of cardiac perforation following CIED implantation underwent chest X-ray, transthoracic echocardiography, device interrogation, and, if necessary, a cardiac computed tomography (CT)-scan to diagnose lead perforation and associated complications. Transvenous lead revision (TLR) was performed in all patients with evidence of lead perforation. Patient characteristics, procedural complications, and outcome were recorded and analyzed. Fifty-six patients (75 ± 10 years, 43% male) were diagnosed with cardiac perforation, 34 patients (61%) early within 30 days post-implantation, and 22 patients (39%) thereafter. The most frequent perforation site was the right ventricular (RV) apex (75%), followed by the RV free wall (16%) and the right atrial appendage (9%). A total of 16 patients (29%) presented with severe complications; 12 patients (21%) with pericardial effusion treated by pericardiocentesis before lead revision and four patients (7%) with hematothorax requiring drainage. Late perforations showed significantly more frequent cardiac tamponades (P = .041). TLR was performed without further complications in 54 patients (96%). None of the patients required surgical treatment or experienced in-hospital death. CONCLUSIONS: Cardiac perforation following CIED implantation is associated with severe complications in nearly one-third of the cases. Transvenous revision of the perforated lead can safely be performed with a very low complication rate.

Atrial Fibrillation and Cognitive Impairment: New Insights and Future Directions.

INTRODUCTION: Atrial fibrillation (AF) has been recognised as the most prevalent sustained arrhythmia. Recently, a growing body of evidence has suggested that AF might be involved in the progression of cognitive impairment (CIM), potentially extending into types of dementia. Accordingly, the purpose of the present study was to summarise the findings of investigations examining association between AF and cognitive function as well as highlighting the possible causes of discrepancy between the findings and reviewing the probable mechanisms of CIM in patients affected with AF. METHODS: A systematic search in the literature was conducted in the databases of PubMed, Scopus, Cochrane Library, and Google Scholar with no language restrictions, using specified search terms to identify studies published between 1 January 1990 and 1 April 2018. Then, study designs, participant information, diagnostic approaches used for cognitive assessments, and incidence/prevalence rates of CIM and/or dementia were assessed. RESULTS: Out of the initial 2,364 articles retrieved, a total number of 40 studies were selected for data collection. Most studies had suggested a significant relationship between AF and CIM. In this regard, cerebral hypo-perfusion, altered cerebral blood flow, cerebral micro-bleeds, micro-emboli, vascular inflammation, cerebral small vessel diseases, vascular inflammation, and genetic factors were considered as the possible mechanisms of CIM in patients suffering from AF. It seemed that differences in study settings and designs, variations of diagnostic tools for CIM and AF, as well as underlying conditions such as age groups, concurrent chronic diseases, and therapeutic interventions for AF might be amongst probable factors justifying the diversity of findings across the selected articles. CONCLUSION: Although evidence is much more directed towards an association between AF and CIM, the role of AF in CIM needs to be confirmed in-depth via longer prospective and cohort studies at larger scales using accurate neuropsychological and cognitive function assessments. Moreover, the mechanisms involved in the relationship between AF and Alzheimer's disease (AD) require further studies. To conclude, the effect of different therapeutic strategies of AF on CIM should be investigated in more clinical trials.

Significance of inducibility of atrial fibrillation after pulmonary vein isolation in patients with healthy left atrium substrate.

BACKGROUND: The significance of the inducibility of atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with AF remains disputable and polarizing. Therefore, we investigated the prognostic value of the inducibility of AF on long-term outcome after PVI in patients without low-voltage left atrial (LA) substrate. METHODS: Two hundred forty-five patients (mean age 59+/-9years, 72% male) without LA low-voltage areas (defined as electrogram amplitudes <0.5 mV) undergoing first PVI procedure were included in the study. Following successful PVI, inducibility was assessed by burst pacing from coronary sinus with a cycle length (CL) of 300, 250, and 200 ms or the shortest CL resulting in 1:1 atrial capture. During the follow-up period of up to 3 years, the rhythm outcome was monitored by serial 7-days Holter electrocardiogram. RESULTS: AF was induced in 38 patients (16%). Atypical atrial flutter was observed in six patients (2%), while typical flutter in three cases (1%). Within the first 3 months, early recurrence was diagnosed in 39 patients (16%), while late recurrence was detected in 58 patients (24%) after a mean AF free survival of 28 ± 1 months. While there was no impact on early recurrence, AF inducibility affected long-term recurrence (31 ± 1 vs 23 ± 3 months; P = .001). In multivariate analysis, AF inducibility (hazard ratio [HR] 2.14; 95% confidence interval [CI], 1.03-4.45; P = .041) and persistent type of AF (HR 2.17; 95%CI, 1.06-4.47; P = .034) were associated with late AF recurrence. CONCLUSION: In patients without low-voltage substrate undergoing PVI, AF inducibility is a significant predictor of long-term outcome. The pathomechanisms of this phenomenon must be further studied to be addressed by additional treatment.

Deep sedation for transvenous lead extraction: a large single-centre experience.

AIMS: Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS. METHODS AND RESULTS: Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 µg/kg, 24.3 ± 6.8 µg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses. CONCLUSION: Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

Effect of Exercise on Outcome after Ventricular Tachycardia Ablation in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy.

Competitive sports and intensive exercise are associated with adverse outcomes in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). This study aimed to assess the role of exercise on long-term results of radiofrequency catheter ablation (RFCA) therapy of ventricular tachycardia (VT) in patients with ARVD/C. Exercise participation was evaluated by telephone or in-person interviews in patients from our ARVD/C registry with previous VT ablation (38 patients, 26 males, age 52.6±14.1years). Of 38 patients, 30 were involved in sports activities before RFCA. Only the minority of our patient population (21.1%) had a sedentary lifestyle before RFCA; 42.1 and 36.8% reported recreational or competitive sports, respectively. During the follow-up period of 52.5±31.4 months, 23 of the total 38 patients with previous RFCA (60.5%) remained free from VT recurrence. In univariate and binary logistic regression analysis, only advanced age was significantly associated with VT recurrence, with a hazard ratio of 1.15, and 95% confidence interval 1.05-1.26 (p=0.004). The results of our observational study indicate that recreational sports do not impair long-term results after RFCA treatment compared with a sedentary lifestyle. Furthermore, the dynamic component of recreational exercise did not affect the outcome of VT ablation in our patient population. Recreational exercise at low to moderate intensity is not associated with an increased risk for VT recurrence after catheter ablation in patients with ARVD/C.

Predictors, management, and outcome of cardioversion failure early after atrial fibrillation ablation.

Aims: Electrical cardioversion (ECV) is frequently required for early atrial fibrillation (AF) recurrence after catheter ablation. However, in some cases, ECV is unsuccessful, and factors associated with long-term rhythm outcomes after failed ECV are unknown. This study aimed to identify possible predictors of ECV failure early after AF ablation and to analyse management and long-term rhythm outcome of these patients. Methods and results: Between 2010 and 2012, 180 consecutive patients (mean age 63.7 ± 9.4 years, male 53.3%, persistent AF 60%) underwent successful radiofrequency AF ablation but required post-procedural ECV due to early AF recurrence (≤ 7 days). Of these, 120 patients were successful (Group A, n = 120, 66.7%) and 60 failed (Group B, n = 60, 33.3%). ECV failure was associated with diabetes [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.154-4.763; P = 0.01] and lack of beta-blocker medication (OR 2.38, 95% CI 1.005-5.635; P = 0.04). In contrast, there were no significant differences in echocardiographic or procedure-related parameters. Atrial fibrillation recurrence was monitored with sequential 7 days of Holter electrocardiogram for 24 months (on average 10.8 ± 8.8 months) and was documented in 56%, n = 102 in total (Group A: 57%, n = 69 vs. Group B: 55%, n = 33; P = 0.75). Compared with successful ECV, ECV failure shortly after AF ablation had no predictive value on rhythm outcome in the long term (P = 0.98). The necessity of additional linear lesions during catheter ablation [hazard ratio (HR) 2.72, 95% CI 1.47-5.05; P = 0.001], AF duration (HR 1.08, 95% CI 1.04-1.12; P < 0.001), and a prolonged ablation time (HR 3.27, 95% CI 1.53-6.97; P = 0.002) were associated with long-term AF recurrence. Conclusion: Patients with diabetes and absence of beta-blocker medication are at higher risk for ECV failure. Early post-ablation ECV failure is not associated with long-term rhythm outcome.

Supraventricular arrhythmias in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy associate with long-term outcome after catheter ablation of ventricular tachycardias.

Aims: This study aimed to assess the impact of supraventricular tachycardia (SVT) on long-term results of radiofrequency catheter ablation therapy of ventricular tachycardia (VT) in a large cohort of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). Methods and results: Supraventricular tachycardia occurrence has been studied in patients from our ARVD/C registry (70 patients, 48 male, age 53.2 ± 14.0, 45 patients (64.3%) with previous VT ablation). SVT were diagnosed in 26 of 70 patients (37.1%). Atrial fibrillation (AF) was the most frequent atrial arrhythmia, diagnosed in 17 patients (24.3%). In univariate analysis advanced age, clinical symptoms of heart failure, enlarged right atrium, diagnosis of significant tricuspid regurgitation (TR), and inappropriate implantable cardioverters-defibrillators therapy were associated with SVT. In binary logistic regression analysis only heart failure: hazard ratio (HR) 10.89, 95% confidence interval (95% CI) 1.08-109.96 (P = 0.043) and significant TR: HR 4.79, 95% CI 1.35-16.33 (P = 0.015) remained associated with SVT. In patients with previous VT ablation Cox multiple regression survival analysis revealed older age (≥53 years): HR 4.63, 95% CI 1.51-14.24 (P = 0.008) and SVT: HR 3.01, 95% CI 1.15-7.89 (P = 0.025) as predictors for VT recurrence during the follow-up. Conclusion: SVT and older age are associated with the recurrence of VT after catheter ablation in patients with ARVD/C.

Implanted defibrillators in trouble: initial device misclassification leads to correct diagnosis-a case series.

AIMS: Supraventricular tachycardia, mistakenly diagnosed as ventricular tachycardia, may lead to inappropriate ICD therapy. Inappropriate ICD therapy associates with increased morbidity and mortality. A reduction of inappropriate therapy is therefore desired. METHODS AND RESULTS: We present three different cases that beautifully illustrate the diagnostic possibilities of stored electrograms. Initial differential diagnoses in all three patients included ventricular tachycardia, focal atrial tachycardia, atrio-ventricular re-entry tachycardia, and atrio-ventricular nodal re-entry tachycardia. The first case was diagnosed as atrio-ventricular nodal re-entry tachycardia. In the second case, atrio-ventricular re-entry tachycardia was revealed. Ectopic atrial tachycardia was the reason for inappropriate therapy in the third patient. CONCLUSION: Thorough analysis of stored electrograms yielded correct diagnosis in all cases, which subsequently was confirmed by electrophysiological study.

Vernakalant-facilitated electrical cardioversion: comparison of intravenous vernakalant and amiodarone for drug-enhanced electrical cardioversion of atrial fibrillation after failed electrical cardioversion.

AIMS: Electrical cardioversion is one cornerstone for the rhythm control strategy of atrial fibrillation (AF), which is, however, hampered by immediate AF recurrence (IRAF) or failed electrical cardioversion (FECV). We aimed to investigate the potential role of vernakalant for facilitated electrical cardioversion in cardioversion-resistant AF. METHODS AND RESULTS: The subjects of this study were 63 patients referred to the Heart Centre Leipzig between November 2011 and May 2014 for transthoracic electrical cardioversion of AF. All patients experienced after antiarrhythmic-naïve electrical cardioversion either IRAF (n = 44; 70%) or FECV (n = 19; 30%). After drug infusion, electrical cardioversion was successful in 66.7% of vernakalant-treated as opposed to 46.7% of amiodarone-treated patients (P = 0.109). Multivariate analysis revealed treatment with vernakalant (OR 0.057, 95% CI 0.006-0.540, P = 0.013), treatment with ACEI or ARB (OR 0.101, 95% CI 0.015-0.691 P = 0.019), and IRAF after initial CV (OR 0.047, 95% CI 0.004-0.498, P = 0.011) as predictors for successful, drug-facilitated electrical cardioversion. Subgroup analysis of 18 patients with previous AF ablation revealed a significantly higher success rate of electrical cardioversion after infusion of vernakalant than after infusion of amiodarone (66.7 vs. 11.1%, P = 0.016). CONCLUSION: Vernakalant may therefore be considered as a useful agent for facilitated electrical cardioversion in cardioversion-resistant AF.

Precordial QRS amplitude ratio predicts long-term outcome after catheter ablation of electrical storm due to ventricular tachycardias in patients with arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and recurrent ventricular tachycardia (VT). METHODS: This study intended to assess the long-term outcome of catheter ablation in patients with ARVC and electrical storm. The specific objective was to assess the relationship between precordial QRS amplitude ratio and outcome of catheter ablation in these patients. RESULTS: Twenty-eight patients (19 men, age 52.3±14.2years) underwent 48 catheter ablation procedures (range 1-6, six epicardial). During a mean follow-up of 18.7±15.1months, 13 patients (46.5%) experienced VT recurrence. Age >50years and ∑QRSmvV1-V3/∑QRSmvV1-V6≤0.48 but not right ventricular size and acute ablation outcome were associated with VT recurrence during the follow up. CONCLUSION: Age >50years and ∑QRSmvV1-V3/∑QRSmvV1-V6≤0.48 predict recurrence of VT after successful radiofrequency catheter ablation of VT in patients with ARVC and electrical storm.

Comparison between Remotely Supported Nurse-led Electro-Anatomic Mapping and Standard Onsite Engineer Support for Electrophysiological Procedures.

AIMS: Catheter ablations of complex cardiac arrhythmias are currently guided by electro-anatomic mapping systems. The aim of this study was to compare two different approaches: remotely supported nurse-led electro-anatomic mapping with standard onsite engineer support. METHODS AND RESULTS: In this retrospective observational study, 166 patients with complex and non-complex procedures were included. 82 patients benefited from electro-anatomic mapping with remotely supported nurse-led mapping (mean age: 62±16years), while the approach for 84 patients was with standard onsite engineer support (mean age: 56±19 years). Procedural characteristics, acute results and complication rates were compared between both groups and showed similar results.Complex and non-complex procedures were conducted in both groups, including left atrial and ventricular procedures. As ventricular tachycardia and accessory pathway ablations were more frequently conducted with standard onsite engineer support, we separately analyzed the largest subgroup, 105 patients with atrial fibrillation, left atrial flutter and left atrial tachycardia. Patients in this subgroup had comparable baseline characteristics, procedure times and procedural success. Nevertheless, there were longer ablation times and more utilization of fluoroscopy in the onsite group, most likely due to more complex procedures. CONCLUSION: Our results underline the practicality of remotely supported nurse-led electro-anatomic mapping. The latter approach proved to be a safe alternative to onsite engineer support. Due to its advantages, particularly for insular settings, it will likely play a greater role in the future.

Feasibility of remote technical support for electrophysiological ablation procedures during the current COVID-19 pandemic.

Aims: The treatment of heart rhythm disorders has been significantly impacted by direct consequences of the current COVID-19 pandemic, as well as by restrictions aimed towards constraining viral spread. Methods and results: Usually, catheter ablations of cardiac arrhythmias are guided by electro-anatomic mapping (EAM) systems. Technical staff with medical training, or medical staff with technical training, are needed to assist the operator. Travel restrictions due to the current COVID-19 pandemic have limited the in-person availability of technical support staff. To overcome these limitations, we explored the feasibility of a trans-atlantic remote technical support for EAM, with an internet-based communication platform, for complex electrophysiological ablation procedures. Conclusion: Our first experience, based on nine ablation procedures of different arrhythmias, highlights the feasibility of this approach. Remote support for EAM might therefore facilitate continuous care for patients with arrhythmias during the COVID-19 pandemic, particularly in insular settings. Beyond COVID-19-related challenges, this approach will likely play a greater role in the cardiology field in years to come, due to its significant advantages.

Characteristics of left atrial remodeling in patients with atrial fibrillation and hypertrophic cardiomyopathy in comparison to patients without hypertrophy.

Atrial fibrillation (AF) leads to remodeling characterized by changes in both size and shape of the left atrium (LA). Here we aimed to study the effect of hypertrophic cardiomyopathy (HCM) on the pattern of LA remodeling in AF-patients. HCM-patients (n = 23) undergoing AF ablation (2009-2012) were matched and compared with 125 Non-HCM patients from our prospective registry. Pre-procedural CT data were analyzed (EnSite Verismo, SJM, MN) to determine the maximal sagittal (anterior-posterior, AP), coronal (superior-inferior, SI and transversal, TV) dimensions and the sphericity index (LAS). Volume (LAV) was rendered after appendage (LAA) and pulmonary vein (PV) exclusion. A cutting plane, between PV ostia/LAA and parallel to the posterior wall, divided LAV into anterior- (LA-A) and posterior-LA (LA-P) parts. The ratio LA-A/LAV was defined as asymmetry index (ASI). HCM patients had a wider inter-ventricular septum and a smaller LV than Non-HCM patients. LA volume (LAV 166 ± 72 vs. 130 ± 36 ml, p = 0.03) and LA diameters were significantly larger in HCM patients. Anterior volume (LA-A: 112 ± 48 vs. 83 ± 26 ml, p < 0.001) differed significantly between groups, whereas the posterior volume LA-P (55 ± 28 vs. 47 ± 13 ml, p = 0.23) and LAS (75% vs. 78%, p = 0.089) was similar in both groups. As a result, ASI was significantly higher (67 ± 6 vs. 63 ± 6%, p = 0.01) in HCM than in Non-HCM patients. In conclusion, LA remodeling in patients with AF and HCM is characterized by asymmetric dilatation, driven by an anterior rather than a posterior dilatation. This can be characterized by three-dimensional imaging and could be used as surrogate of advanced atrial remodeling.

Efficacy of Catheter Ablation for Atrial Arrhythmias in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy-A Multicenter Study.

Background: Atrial arrhythmias are present in up to 20% of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Catheter ablation (CA) is an effective treatment for atrial arrhythmias in the general population. Data regarding CA for atrial arrhythmias in ARVC are scarce. Objective: To assess the safety and efficacy of CA for atrial arrhythmias in patients with ARVC. Methods: In this international collaborative effort, all patients with a definite diagnosis of ARVC undergoing CA for atrial fibrillation (AF), focal atrial tachycardia (AT), or cavotricuspid isthmus (CTI)-dependent atrial flutter (AFl) were extracted from twelve ARVC registries. Demographic, periprocedural, and long-term arrhythmic outcome data were collected. Results: Thirty-seven patients were enrolled in the study (age 50.2 ± 16.6 years, male 84%, CHA2DS2VASc 1 (1,2), HAS-BLED 0 (0-2)). The arrhythmia leading to CA was AF in 23 (62%), focal left AT in 5 (14%), and CTI-dependent AFl in 9 (24%). Acute procedural success was achieved in all procedures but one (n = 1 focal left AT; 97% acute success). The median follow-up period was 27 (13-67) months, and 96%, 74%, and 61% of patients undergoing AF ablation were free from any atrial arrhythmia recurrence after a single procedure at 6 months, 12 months, and last follow-up, respectively. After focal AT ablation, freedom from atrial arrhythmia recurrence was 80%, 80%, and 60% at 6 months, 12 months, and last follow-up, respectively. All patients undergoing CTI ablation were free from atrial arrhythmia recurrences at 6 months, with 89% single-procedural arrhythmic freedom at last follow-up. One major complication (2.7%; PV stenosis requiring PV stenting) occurred. Conclusions: CA is safe and effective in managing atrial arrhythmias in patients with ARVC, with success rates comparable to the general population.

Flecainide-Associated Cardiogenic Shock in a Patient with Atrial Fibrillation.

Flecainide is a frequently used antiarrhythmic drug, recommended by current guidelines as a first-line treatment option for restoring and maintaining sinus rhythm in patients with atrial fibrillation and no significant structural heart disease. In overdose, it can induce severe cardiogenic shock. Cardiogenic shock after a therapeutic dose of flecainide in patients without contraindication has not yet been reported in literature. Case Summary. We report a case of flecainide-associated cardiogenic shock in a 52-year-old woman with paroxysmal atrial fibrillation after a therapeutic dose of flecainide. Pharmacological cardioversion of symptomatic tachyarrhythmic atrial fibrillation with flecainide was unsuccessful and shortly after, she developed cardiogenic shock with severely reduced LVEF. Electrical cardioversion was also unsuccessful. Coronarography was unremarkable, and the cardiac MRI showed no signs of inflammation or fibrosis. After amiodarone loading, she converted to SR. This rare but severe complication despite adequate treatment could be explained by increased susceptibility to negative inotropic effect of flecainide as a consequence of marked tachycardia. Therefore, cautious monitoring after new administration of flecainide or the administration of a higher dose is advisable.