The relationship between the incision line and position of the latissimus dorsi muscle for subcutaneous implantable cardioverter-defibrillator intermuscular implantations.

INTRODUCTION: Intermuscular implantations of subcutaneous implantable cardioverter-defibrillators (S-ICD) have been recommended, but the position of the anterior border of the latissimus dorsi muscle (LDM) has not previously been evaluated in establishing an incision line to facilitate the intermuscular approach. The objective of this study is to evalua the position and trend of the anterior border of the LDM in patients who are candidates for implantable cardioverter-defibrillators. METHODS: The distance from the back to the anterior border of the LDM (A) and the anterior-posterior width of the chest wall (B) were measured on computed tomography retrospectively, and the ratio (=A/B) was used as the position of the anterior border of the LDM. In addition, the variability and factors affecting the values were evaluated. RESULTS: An analysis was performed on 78 patients, and the position of the anterior border of the LDM (=A/B) exhibited a normal distribution, with a mean value of 0.53 ± 0.062 (0.41-0.69). The position of the anterior border of the LDM tended to be more anterior in younger, taller, male, primary prevention, nonheart failure, low brain natriuretic peptide level, and nondiabetic patients. CONCLUSION: The position of the anterior border of the LDM varied from case to case with variable results. Conventional incisions on the midaxillary line may be inappropriate for intermuscular implantations, and the position of the anterior border of the LDM should be evaluated in each individual case to establish the incision line.

The impact of the procedural parameters on the lesion characteristics associated with AF recurrence: Late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) analysis.

BACKGROUND: Lesion gaps assessed by late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) are associated with the atrial fibrillation (AF) recurrence after pulmonary vein isolation. Animal studies have demonstrated that the catheter-contact force (CF), stability, and orientation are strongly associated with lesion formation. However, the impact of those procedural factors on the lesion characteristics associated with AF recurrence has not been well discussed. METHODS: A total of 30 patients with paroxysmal AF who underwent catheter ablation were retrospectively enrolled. Radiofrequency (RF) applications were performed with 35 W for 30 s in a point-by-point fashion under esophageal temperature monitoring. The inter-lesion distance was 4 mm. The lesions were visualized by LGE-MRI 3 months postprocedure and assessed by the LGE volume (ml), gap number (GN), and average gap length (AGL [mm]). The gaps were defined as nonenhancement sites of >4 mm. The procedural factors including the catheter-CF, stability, and orientation were calculated on the NavX system. RESULTS: Six (20%) of 30 patients had AF recurrences 12 months postablation. A univariate analysis demonstrated that the AGL was associated with AF recurrence (hazard ratio [HR]: 1.20, confidence interval [CI]: 1.03-1.42, p = .02). All AF recurrence were found in patients with an AGL of >7 mm. The catheter-CF and stability were associated with an AGL of >7 mm, but not the orientation (CF-HR: 0.62, CI: 0.39-0.97, p = .038; stability-HR: 0.8, CI: 0.66-0.98, p = .027). CONCLUSIONS: RF ablation with a low CF and poor catheter stability has a potential risk of creating large lesion gaps associated with AF recurrence.

Telehealth Follow-up Using a Real-Time Electrocardiogram Device Improves Electrocardiogram Monitoring Duration and Patient Satisfaction After Catheter Ablation.

Background: There is a strong demand for remote monitoring systems to gather health data. This study investigated the safety, usefulness, and patient satisfaction in outpatient care using telehealth with real-time electrocardiogram (ECG) monitoring after catheter ablation. Methods and Results: In all, 38 patients who underwent catheter ablation were followed up using telehealth. At the 3- and 6-month follow-up, a self-fitted Duranta ECG monitoring device was sent to the patient's home before the online consultation. Patients attached the devices themselves, and the doctors viewed the patients by video chat and performed real-time ECG monitoring. The frequency of hospital visits and the ECG monitoring duration were compared with conventional in-person follow-up data (n=102). The completion rate for telehealth follow-up was 32 of 38 patients (84%). The number of hospital visits during the 6 months was significantly lower with telehealth follow-up than with conventional follow-up (median [interquartile range] 1 [1-1] vs. 5 [3-5]; P<0.0001). However, the ECG monitoring duration was approximately 4-fold longer for the telehealth follow-up (median [interquartile range] 89 [64-117] vs. 24 [0.1-24] h; P<0.0001). No major adverse events were observed during the telehealth follow-up. Patient surveys showed high satisfaction with telehealth follow-up due to reduced hospital visits. Conclusions: A combination of telehealth follow-up with real-time ECG monitoring increased the ECG monitoring duration and patient satisfaction without any adverse events.

Rare complications of Guideplus guide-extension catheter during complex percutaneous coronary intervention.

Guide-extension catheters (GECs) are effective in providing reinforced backup support and coaxial alignment, leading to successful complex percutaneous coronary intervention (PCI). However, several GEC-associated complications have been reported, including coronary injuries, thrombotic events, and GEC fractures. The Guideplus GEC (Guideplus II ST; Nipro, Osaka, Japan) has a higher crossability due to its unique hydrophilic-coated soft cylinder, which is frequently used in complex PCI for diffuse, tortuous, and heavily calcified lesions. We describe two cases of Guideplus GEC-associated complications during complex PCI: Case 1 with a radiopaque marker dislodgement and Case 2 with a stent dislodgment. In both cases, the Guideplus GEC was used within 7-Fr guiding catheters, employing the mother-and-child technique. A large inner-catheter gap between these catheters caused by a positioning bias due to arterial bends (the aortic arch in Case 1 and brachiocephalic arterial bends in Case 2) may have caused these complications due to its interference with coronary devices (the trapping balloon in Case 1, and the scoring balloon in Case 2). Early cognition and management of these potential Guideplus GEC-associated complications are important to prevent further deterioration. Learning objectives: The Guideplus guide-extension catheter (GEC) with a hydrophilic-coated soft cylinder can deliver coronary devices to complex lesions owing to its high crossability. However, delivering coronary devices with the Guideplus GEC should be carefully performed because a large inner-catheter gap between Guideplus GEC and a guiding catheter may occur if a proximal port of the Guideplus GEC is located at an arterial bend. In such settings, Guideplus GEC-associated complications must be carefully observed, including radiopaque marker dislodgement and stent dislodgement.

Ventricular arrhythmia events in heart failure patients with cardiac resynchronization therapy with or without a defibrillator for primary prevention.

Background: It is uncertain whether cardiac resynchronization therapy with a defibrillator (CRT-D) provides better survival benefits than a CRT-pacemaker (CRT-P) in heart failure patients with a reduced ejection fraction (≦35%, HFrEF) treated with contemporary HF therapy. Methods: We retrospectively analyzed the ventricular arrhythmia (VAs; sustained ventricular tachycardia/fibrillation) events in HFrEF patients who underwent CRT without a prior history of VAs or aborted sudden cardiac death before the CRT implantation. Between January/2010 and December/2020, a CRT device was implanted in 79 HFrEF patients (mean age: 69 ± 12 years, male: 57, ischemic cardiomyopathy: 16). CRT-D and CRT-P devices were implanted in 50 and 29 patients, respectively, at each physician's discretion. CRT-Ds were indicated in younger patients than were CRT-Ps (66 ± 12 vs. 73 ± 12 years, p = 0.03), but the gender distribution did not differ (female, 24% [12 of 50] vs. 35% [10 of 29], p = 0.44). The VA events during a median follow-up of 3.5-years (interquartile range [IQR]:1.6-5.5) and their predictors were analyzed. Results: VA events occurred in 9 patients with CRT-Ds (18%) and one with a CRT-P (3%, p = 0.08). The VA event rate was significantly lower in patients without a prior non-sustained ventricular tachycardia (NSVT: ≥3 beats; rate, ≥120 bpm; lasting <30 s, HR 0.05; 95% CI 0.01-0.30; p < 0.01) and females (HR 0.11; 95% CI 0.01-0.93; p = 0.04). Of note, no female patients without a prior history of NSVT experienced VA events. Conclusion: HFrEF CRT candidates without a prior history of NSVT and females may obtain less benefit from a primary preventive defibrillator indication.

Acute Coronary and Cerebral Emboli From a Pedunculated Ascending Aorta Thrombus.

Hyperprolactinemia is a risk factor for thrombus formation. We present a rare case of a mobile ascending aorta thrombus leading to acute myocardial infarction and cerebral infarction in a patient with idiopathic hyperprolactinemia. (Level of Difficulty: Beginner.).