Direct current cardioversion practices following percutaneous left atrial appendage closure.

INTRODUCTION: Among patients with non-valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear. OBJECTIVE: The purpose of this study is to evaluate the real-world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre- and post-DCCV in patients with AF status post percutaneous LAAC. METHODS: This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre-DCCV, OAC use pre- and post-DCCV, incidence of left atrial thrombus (LAT) or device-related thrombus (DRT), incidence of peri-device leak (PDL), and DCCV-related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days. RESULTS: A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as "non-guideline based" due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV-related complications within 30 days. DISCUSSION: There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.

Cardiac magnetic resonance imaging for left atrial appendage closure planning.

BACKGROUND: Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. METHODS: This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland-Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. RESULTS: 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p = .229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p = .177), morphology (p = .422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland-Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR-TEE bias 0.7 mm, 95% CI [-1.1, 2.4], p = .420), but LAA depth was significantly larger with CMR versus TEE (CMR-TEE bias 7.4 mm, 95% CI [1.6, 13.2], p = .015). CONCLUSIONS: CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable.

A 10 J shock impedance in sinus rhythm correlates with a 65 J defibrillation impedance during subcutaneous defibrillator implantation using an intermuscular technique.

INTRODUCTION: Defibrillation testing (DT) is recommended during the subcutaneous defibrillator (S-ICD) placement. We sought to compare 10 J shock impedance in sinus rhythm (SR) with 65 J defibrillation impedance and evaluate device position on a postimplant chest X-ray (CXR) using an intermuscular (IM) technique. METHODS: Consecutive S-ICD implantations between 12/2019 and 12/2020 at The Ohio State University were reviewed. All implantations were performed using a two-incision IM technique. Standard DT with 65 J shock and 10 J shock in SR were performed unless contraindicated. The PRAETORIAN score was calculated based on CXR. RESULTS: A total of 37 patients (age: 47.2 ± 15.8 years old, male: n = 26 [70.3%], body mass index: 30.1 ± 6.7 kg/m2 ) underwent IM S-ICD implantation, and of those, 27 (73%) underwent both 65 J shock and 10 J shock in SR. The coefficient of determination (R2 ) between 10 J shock impedance and 65 J shock impedance was 0.84. The mean of an impedance difference was 1.6 ± 4.8 Ω (minimum - 11 and maximum 8). Postimplant CXR was available for 33 out of 37 patients (89.2%). The PRAETORIAN score was less than 90 in all patients and the mean score was 32.7 ± 8.8. CONCLUSION: We demonstrated that 10 J shock impedance in SR correlated well with 65 J defibrillation impedance during IM S-ICD implantation. An IM implantation technique provides excellent generator location on postimplant CXR. The IM technique combined with 10 J shock in SR may be sufficient to predict and ensure the defibrillation efficacy of the S-ICD.

Comprehensive strategy to reduce the incidence of lead dislodgement for cardiac implantable electronic devices.

BACKGROUND: Lead dislodgement (LD) is a well-recognized complication during implantation of cardiac implantable electronic devices (CIEDs). An intraprocedural protocol, referred to as reduction of LD protocol, was developed to reduce the risk of LD. METHODS: The protocol involved (1) inserting a straight stylet down the right atrial lead and applying forward pressure while monitoring for fluoroscopic stability, (2) visualizing all leads during deep inspiration to determine if there is adequate lead redundancy, and (3) having the patient take a deep breath and cough while pacing just at capture threshold to assess for loss of capture in each lead. Any intraprocedural change in the parameters fulfilling the predefined criteria for inadequate lead implantation prompted lead repositioning. Data regarding demographic factors, clinical characteristics, and incidence of LD in the first 30 days after implant was obtained from intramural CIED database. The preintervention (control) group spanned 27 months and consisted of a total of 4,294 leads while the postintervention (intervention) group spanned 17 months and consisted of 2,361 leads implanted. RESULTS: There was no significant difference in the demographic factors and clinical characteristics in the two groups. Protocol compliance was > 90%. There were 44 occurrences of LD (1.02%) before and 10 (0.4%) after implementation of the protocol. The protocol significantly reduced the incidence of LD during the 30 days after implant (P = 0.014). No clinical characteristic predicted the risk of LD. CONCLUSION: Intraprocedural maneuvers performed to assess the adequacy of lead implantation results in reduced risk of LD.

Implantation of subcutaneous defibrillator is feasible and safe with monitored anesthesia care.

BACKGROUND: The perioperative anesthesia care during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving. OBJECTIVE: To assess the feasibility and safety of S-ICD implantation with monitored anesthesia care (MAC) versus general anesthesia (GA) in a tertiary care center. METHODS: This is a single-center retrospective study of patients undergoing S-ICD implantation between October 2012 and May 2019. Patients were categorized into MAC and GA group based on the mode of anesthesia. Procedural success without escalation to GA was the primary endpoint of the study, whereas intraprocedural hemodynamics, need of pharmacological support for hypotension and bradycardia, length of the procedure, stay in the post-anesthesia care unit, and postoperative pain were assessed as secondary endpoints. RESULTS: The study comprises 287 patients with MAC in 111 and GA in 176 patients. Compared to MAC, patients in GA group were younger and had a higher body mass index. All patients had successful S-ICD implantation. Only one patient (0.9%) in the MAC group was converted to GA. Despite a similar baseline heart rate (HR) and mean arterial blood pressure (MAP) in both groups, patients with GA had significantly lower HR and MAP during the procedure and more frequently required pharmacological hemodynamic support. Length of the procedure, stay in the postanesthesia care unit, and postoperative pain was similar in both groups. CONCLUSION: This retrospective experience suggests that implantation of S-ICD is feasible and safe with MAC. Use of GA is associated with more frequent administration of hemodynamic drugs during S-ICD implantation.

Hypertension and Arrhythmias.

Hypertension is the most common cardiovascular risk factor and underlies heart failure, coronary artery disease, stroke, and chronic kidney disease. Hypertensive heart disease can manifest as cardiac arrhythmias. Supraventricular and ventricular arrhythmias may occur in the hypertensive patients. Atrial fibrillation and hypertension contribute to an increased risk of stroke. Some antihypertensive drugs predispose to electrolyte abnormalities, which may result in atrial and ventricular arrhythmias. A multipronged strategy involving appropriate screening, aggressive lifestyle modifications, and optimal pharmacotherapy can result in improved blood pressure control and prevent the onset or delay progression of heart failure, coronary artery disease, and cardiac arrhythmias.

Feasibility of concomitant vacuum-assisted removal of lead-related vegetations and cardiac implantable electronic device extraction.

BACKGROUND: Cardiac implantable electronic device (CIED) infections associated with large, mobile vegetation adds to the complexity of lead extraction and is associated with significant patient morbidity and mortality. OBJECTIVE: To show the feasibility of concomitant cardiovascular implantable electronic device extraction and vacuum-assisted removal of lead-related vegetations. METHODS: This is a single-center retrospective case series of consecutive patients with persistent bacteremia, sepsis, or endocarditis despite medical therapy who have vegetations >2 cm and subsequently underwent immediate CIED lead extraction after debulking with vacuum-assisted suction. RESULTS: Eight patients underwent successful removal of 17 leads immediately after debulking of vegetations with vacuum-assisted device suction. Debulking procedure was not successful in 1 patient due to inability to direct the vacuum suction device into proper position. There were no intraprocedure complications related to the vacuum-assisted debulking. One patient required open sternotomy for tear of the coronary sinus ostium related to extraction of a left ventricular pacing electrode. There was no mortality within 30 days of the procedure. CONCLUSIONS: Based upon these clinical results, it is feasible for patients with infected CIED systems that have large right-sided vegetations to undergo vacuum-assisted debulking then immediately followed by percutaneous CIED removal in whom surgical removal is considered high risk.

Incidence and temporal evolution of delayed peridevice leak after left atrial appendage closure.

BACKGROUND: Peridevice leak (PDL) after left atrial appendage closure (LAAC) portends adverse outcomes. OBJECTIVE: The purpose of this study was to assess the incidence, predictors, clinical implications, and temporal evolution of PDL after LAAC. METHODS: This single-center retrospective study included all patients who underwent LAAC with Watchman FLX and had no PDL detected at the time of implantation. The primary end point was the incidence of new PDL at initial imaging. The composite secondary end point included continued oral anticoagulation after initial imaging, device-related thrombus, stroke or transient ischemic attack, major bleeding, and need for PDL closure at longest follow-up. Temporal evolution of PDL was assessed in patients with available surveillance imaging. RESULTS: Of the 355 patients who completed imaging at 47 days (interquartile range [IQR] 6 days), 139 (39%) had new PDL with a mean leak size of 3.2 ± 1.4 mm (median 3.0 mm; IQR 2.0 mm; range 1.0-9.0 mm]. Multiple deployment attempts and larger device size were positive predictors of PDL, while increased contrast volume administration was a negative predictor of PDL. The composite secondary end point occurred in 42 (30%) and 33 (15%) patients with and without PDL, respectively (P < .001). Of the 139 patients with PDL, 43 (31%) had surveillance imaging where the leak size regressed from 3.7 ± 1.8 mm at 46 days (IQR 7 days) to 1.7 ± 2.0 mm at 189 days (IQR 127 days) (P < .001). The leak size regressed in 33 (77%), remained stable in 4 (9%), and progressed in 6 (14%) cases. CONCLUSION: Despite design improvements, LAAC with Watchman FLX demonstrates a significant incidence of PDL with meaningful clinical implications. Regardless of initial size, most leaks regressed over time.

A rare case of permanent junctional reciprocating tachycardia ablated on the roof of the left atrium.

Left-sided anteroseptal accessory pathways that course through the aortomitral fibrous continuity are some of the rarest types of accessory pathways. At this region the atrium and ventricle are separated by their greatest distance because of the intervening aortic valve. These pathways often have a long circuitous course that may involve the root and cusps of the aortic valve. Prior reports have demonstrated the feasibility of ablating these pathways along the anteroseptal mitral annulus, the left ventricular outflow tract, or in the left or noncoronary cusps of the aortic valve. We describe a case of a concealed decremental anteroseptal accessory pathway that was ablated on the roof of the left atrium remote from the mitral or aortic valve annuli. This report indicates that when an appropriate site for ablation of a left-sided anteroseptal accessory pathway is not found close to a valve annulus, these pathways may be amenable to ablation by targeting their atrial insertion site.

Risk of Adverse Outcomes Associated With Cardiac Sarcoidosis Diagnostic Schemes.

BACKGROUND: Multiple cardiac sarcoidosis (CS) diagnostic schemes have been published. OBJECTIVES: This study aims to evaluate the association of different CS diagnostic schemes with adverse outcomes. The diagnostic schemes evaluated were 1993, 2006, and 2017 Japanese criteria and the 2014 Heart Rhythm Society criteria. METHODS: Data were collected from the Cardiac Sarcoidosis Consortium, an international registry of CS patients. Outcome events were any of the following: all-cause mortality, left ventricular assist device placement, heart transplantation, and appropriate implantable cardioverter-defibrillator therapy. Logistic regression analysis evaluated the association of outcomes with each CS diagnostic scheme. RESULTS: A total of 587 subjects met the following criteria: 1993 Japanese (n = 310, 52.8%), 2006 Japanese (n = 312, 53.2%), 2014 Heart Rhythm Society (n = 480, 81.8%), and 2017 Japanese (n = 112, 19.1%). Patients who met the 1993 criteria were more likely to experience an event than patients who did not (n = 109 of 310, 35.2% vs n = 59 of 277, 21.3%; OR: 2.00; 95% CI: 1.38-2.90; P < 0.001). Similarly, patients who met the 2006 criteria were more likely to have an event than patients who did not (n = 116 of 312, 37.2% vs n = 52 of 275, 18.9%; OR: 2.54; 95% CI: 1.74-3.71; P < 0.001). There was no statistically significant association between the occurrence of an event and whether a patient met the 2014 or the 2017 criteria (OR: 1.39; 95% CI: 0.85-2.27; P = 0.18 or OR: 1.51; 95% CI: 0.97-2.33; P = 0.067, respectively). CONCLUSIONS: CS patients who met the 1993 and the 2006 criteria had higher odds of adverse clinical outcomes. Future research is needed to prospectively evaluate existing diagnostic schemes and develop new risk models for this complex disease.

Percutaneous radiofrequency catheter ablation for atrial fibrillation prior to atrial septal defect closure.

Percutaneous Radiofrequency Catheter Ablation. Patients with an atrial septal defect (ASD) commonly have atrial fibrillation (AF) and closure of the ASD rarely controls the arrhythmia. We report on the management of 4 patients with recurrent medically refractory AF in the setting of an unrepaired ASD who underwent percutaneous RFA prior to ASD closure. In 3 of the 4 patients AF was controlled after ablation without antiarrhythmic drug therapy and in the fourth patient AF was controlled with antiarrhythmic therapy after ASD closure. Based on these limited results it seems reasonable to consider RFA of medically refractory AF in patients prior to planned percutaneous ASD closure.

Resource Use and Economic Implications of Remote Monitoring With Subcutaneous Cardiac Rhythm Monitors.

OBJECTIVES: This study reports resource use and economic implications of rhythm monitoring with subcutaneous cardiac rhythm monitors (SCRMs). BACKGROUND: SCRMs generate a substantial amount of data that requires timely adjudication for appropriate clinical care. Resource use for SCRM monitoring is not known. METHODS: The study included consecutive transmissions during 4 weeks from 1,811 SCRMs. Resource use was quantified by assessment of time commitment of device clinic personnel and electrophysiologists for data adjudication. Incidence and characteristics of false positive (FP) episodes were assessed. Impact of custom programming for arrhythmia detection on incidence of FP episodes and resource use was analyzed. RESULTS: A total of 1,457 transmissions (alerts = 462; full downloads = 995) were received during study period. Average device clinic personnel time for adjudication of 1 transmission was 15 ± 6 min. This totaled to 364 h spent (2.3 full-time staff) over the 4-week period, which translated into a salary cost of $12,000 U.S. dollars (USD). Average time spent by an electrophysiologist for 1 transmission was 1.5 ± 1 min and totaled to 37 h for 4 weeks, which translated into an estimated cost of $9,600 USD. Of 1,457 total transmissions, 512 (35%) represented multiple transmissions from the same patients, which resulted in no additional reimbursement. Incidence of FP episodes in the entire cohort was 50% and was variable in alert (60%) and full download (49%) (p = 0.04) transmissions. When SCRMs with manufacturer suggested nominal programming and institutional custom programming were compared, there was a reduction in FP episodes (55% vs. 16%; p = 0.01), which translated to a 34% reduction in resource use for data adjudication. CONCLUSIONS: SCRM data adjudication requires significant resources. Custom programming for SCRMs may overcome the data deluge.

Incidence of false-positive transmissions during remote rhythm monitoring with implantable loop recorders.

BACKGROUND: Implantable loop recorder (ILR) is preferred strategy for prolonged rhythm monitoring. OBJECTIVE: The purpose of this study was to report the incidence and causes of false-positive (FP) diagnoses during remote monitoring with ILR. METHODS: During a 4-week study period, all consecutive remote transmissions in patients with ILR (Reveal LINQ, Medtronic) implanted for atrial fibrillation (AF) surveillance, cryptogenic stroke (CS), and syncope were reviewed. A nurse specializing in device management and an electrophysiologist adjudicated all transmissions. Primary endpoint of the study was incidence of FP in patients with AF, CS, and syncope. RESULTS: A total of 695 remote transmissions (scheduled downloads: 414; Alerts: 281) sent from 559 patients were adjudicated. The majority of patients had ILR for AF surveillance (n = 321), followed by CS (n =168) and syncope (n = 70) with nominal programming for rhythm diagnosis. Incidence of FP transmissions during the study period was 46%, 86%, and 71% in patients with AF, CS, and syncope, respectively. Incidence of FP transmissions was higher in patients with CS and syncope than in patients with AF (P <.001). For scheduled transmissions, primary causes of FP were signal dropout and undersensing; for alert transmissions, primary reasons for FP were premature atrial and ventricular ectopy. CONCLUSION: Incidence of FP during remote monitoring with nominal settings on this ILR was substantial, ranging from 46% to 86% depending on the indication for implantation. Adjudication of these transmissions required a considerable time commitment from electrophysiologists and device clinic personnel but would be required to avoid misdiagnosis and potential errors in clinical management.

Feasibility and safety of same day subcutaneous defibrillator implantation and send home (DASH) strategy.

PURPOSE: To assess the feasibility and safety of same-day discharge after S-ICD implantation by implementing a specific analgesia protocol and phone follow-up. METHODS: Consecutive patients presenting for outpatient S-ICD implantation were enrolled between 1/1/2018 and 4/30/2019. An analgesia protocol included pre-operative acetaminophen and oxycodone, intraoperative local bupivacaine, and limited use of oxycodone-acetaminophen at discharge. The primary outcome was successful same-day discharge. Numerical Pain Rating Scale (NPRS) on postoperative day (POD) 1, 3, 14, and 30 and any unplanned health care visits during the 1-month follow-up period were assessed. RESULTS: Out of 53 potentially eligible S-ICD patients, 49 patients (92.5%) were enrolled and successfully discharged on the same day. Mean age of these 49 patients was 47 ± 14 years. There were no acute procedural complications. Severe pain (NPRS ≥ 8) on POD 0, 1, and 3 was present in 14.3%, 14.3%, and 8.2% of patients, respectively. The total in-hospital stay was 534 ± 80 min. Four unplanned visits (8%) due to cardiac or device-related issues occurred during 1-month follow-up, including 2 patients with heart failure exacerbation, one patient with an incisional infection, and one patient with inappropriate shocks. CONCLUSIONS: With the appropriate institutional protocol including specific analgesics and phone follow-up, same-day discharge after outpatient S-ICD implantation is feasible and appears safe for most patients.. Device-related pain can be severe in the first 3 days post-implantation and can be successfully treated with limited supply of narcotic medications.

Surgical Mapping and Ablation in the Left Ventricular Summit Guided by Presurgery Pericardial Mapping.

Successful catheter ablation of ventricular arrhythmias arising from the left ventricular (LV) summit is challenging. The use of a catheter-based epicardial approach may be limited due to the proximity of the major coronary arteries and the presence of epicardial fat. Surgical cryoablation in the LV summit is a viable option for drug-refractory ventricular arrhythmias. Presurgical epicardial mapping can facilitate the surgical procedure by localizing the area of interest to allow for a more limited surgical dissection of the epicardial fat.

Perioperative management of oral anticoagulation in patients undergoing implantation of subcutaneous implantable cardioverter-defibrillator.

BACKGROUND: The perioperative anticoagulation management during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving. OBJECTIVE: The purpose of this study was to assess whether it is safe to perform S-ICD implantation with uninterrupted warfarin. METHODS: This is a single-center retrospective review of patients undergoing S-ICD implantation between October 1, 2012 and June 30, 2017. One hundred thirty-seven patients underwent successful S-ICD implantation during the study period. The most common indication for implantation was primary prevention of sudden cardiac death. In 24 (17.5%) patients, warfarin was continued without any interruption (warfarin group). In 113 (82.5%) patients, no warfarin was used in the perioperative period (nonwarfarin group). The incidence of clinically significant lateral pocket hematoma was compared in the 2 groups. RESULTS: The mean international normalized ratio was 1.83 ± 0.47 in the warfarin group and 1.09 ± 0.18 in the nonwarfarin group. A total of 8 patients developed a hematoma at the lateral pocket. No patient developed a hematoma at the parasternal pockets. Six patients (25%) in the warfarin group and 2 (1.5%) in the nonwarfarin group developed a significant lateral pocket hematoma (P = .001). The mean length of stay was longer in the warfarin group (1.23 ± 0.46 days) than in the nonwarfarin group (1.02 ± 0.18 days) (P = .0008). An international normalized ratio of >1.8 predicted the risk of hematoma. The concomitant use of dual antiplatelet therapy did not increase the risk of hematoma. None of the patients with a hematoma developed infection or required hematoma evacuation. CONCLUSION: Uninterrupted warfarin in the perioperative period during S-ICD implantation is associated with an increased risk of significant lateral pocket hematoma that results in prolonged hospital stay.