360° Virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation.

AIMS: Evaluation of (i) the effects of a virtual reality (VR) preprocedural patient education video on information provision, procedure-related knowledge, satisfaction, and the level of worries in patients planned for atrial fibrillation (AF) ablation and (ii) the feasibility of a disposable cardboard VR viewer for home use in this setting. METHODS AND RESULTS: In this prospective observational cohort study, patients were alternatively assigned in a 1:1 ratio to the control or VR group. Controls received standard preprocedural information. VR group received standard information and a VR video (via in-hospital VR headset and disposable cardboard). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) together with additional questions concerning procedural experience and satisfaction was completed pre- and post-ablation. Of 134 patients [38.1% female, aged 66 (58-72) years] included, 49.2% were assigned to the control and 50.7% to the VR group. The number of patients that worried about the ablation procedure was lower in VR than in control patients (19.1% vs. 40.9%, P = 0.006). More VR females than males had worries about the procedure (34.8% vs. 11.1%, P = 0.026). The number of VR patients that were satisfied with the preprocedural information provision was higher post-ablation than pre-ablation (83.3% vs. 60.4%, P = 0.007). In total, 59.4% reported that the disposable cardboard was easy to use and led to a discussion with relatives in 68.8%. CONCLUSION: In patients scheduled for AF ablation, a VR preprocedural educational video led to better information provision and procedure-related knowledge, higher satisfaction, and less worries regarding the procedure. The disposable cardboard was feasible for home use.

Transforming a pre-existing MRI environment into an interventional cardiac MRI suite.

AIMS: To illustrate the practical and technical challenges along with the safety aspects when performing MRI-guided electrophysiological procedures in a pre-existing diagnostic magnetic resonance imaging (MRI) environment. METHODS AND RESULTS: A dedicated, well-trained multidisciplinary interventional cardiac MRI team (iCMR team), consisting of electrophysiologists, imaging cardiologists, radiologists, anaesthesiologists, MRI physicists, electrophysiological (EP) and MRI technicians, biomedical engineers, and medical instrumentation technologists is a prerequisite for a safe and feasible implementation of CMR-guided electrophysiological procedures (iCMR) in a pre-existing MRI environment. A formal dry run "mock-up" to address the entire spectrum of technical, logistic, and safety issues was performed before obtaining final approval of the Board of Directors. With this process we showed feasibility of our workflow, safety protocol, and bailout procedures during iCMR outside the conventional EP lab. The practical aspects of performing iCMR procedures in a pre-existing MRI environment were addressed and solidified. Finally, the influence on neighbouring MRI scanners was evaluated, showing no interference. CONCLUSION: Transforming a pre-existing diagnostic MRI environment into an iCMR suite is feasible and safe. However, performing iCMR procedures outside the conventional fluoroscopic lab, poses challenges with technical, practical, and safety aspects that need to be addressed by a dedicated multi-disciplinary iCMR team.

The value of the 12-lead ECG for evaluation and optimization of cardiac resynchronization therapy in daily clinical practice.

Based on existing literature and some new data we propose a simple three-step strategy using the standard 12-lead ECG for patient selection and optimal delivery of cardiac resynchronization therapy (CRT). (1) Complete LBBB with regard to the indication for CRT can probably best be identified by a QRS duration of ≥ 130 ms for women and ≥ 120 ms for men with the presence of mid-QRS notch-/slurring in ≥ 2 contiguous leads of V1, V2, V5, V6, I and aVL. (2) Left ventricular (LV) free wall pacing should result in a positive QRS complex in lead V1, with estimation of the exact LV lead position in the circumferential and apico-basal direction using lead aVF and the precordial leads, respectively. Wide and fractionated LV-paced QRS complexes may indicate pacing in scar tissue. (3) Atrioventricular and interventricular stimulation intervals may be optimized by adjusting them until precordial leads show fusion patterns between left and right ventricular activation wavefronts in the QRS complex.

Evaluation of Left Ventricular Endocardial Cardiac Resynchronization Therapy in a Non-responder with Ventricular Arrhythmias.

Approximately one third of patients treated with cardiac resynchronization therapy do not derive any detectable benefit. In these patients, acute invasive hemodynamic evaluation can be used for therapy optimization. This report describes the use of systematic invasive hemodynamic measurements for clinical decision making in a patient who experienced severe ventricular arrhythmias and clinical deterioration following a biventricular upgrade.

Better outcome at lower costs after implementing a CRT-care pathway: comprehensive evaluation of real-world data.

AIMS: Cardiac resynchronization therapy (CRT) requires intensive, complex, and multidisciplinary care for heart failure (HF) patients. Due to limitations in time, resources, and coordination of care, in current practice, this is often incomplete. We evaluated the effect of the introduction of a CRT-care pathway (CRT-CPW) on clinical outcome and costs. METHODS AND RESULTS: The CRT-CPW focused on structuring CRT patient selection, implantation, and follow-up management. To facilitate and guarantee quality, checklists were introduced. The CRT-CPW was implemented in the Maastricht University Medical Centre in 2014. Physician-led usual care was restructured to a nurse-led care pathway. A retrospective comparison of data from CRT patients receiving usual care (2012-2014, 222 patients) and patients receiving care according to CRT-CPW (2015-2018, 241 patients) was performed. The primary outcome was the composite of all-cause mortality and HF hospitalization. Hospital-related costs of cardiovascular care after CRT implantation were analysed to address cost-effectiveness of the CRT-CPW. Demographics were comparable in the usual care and CRT-CPW groups. Kaplan-Meier estimates of the occurrence of the primary endpoint showed a significant improvement in the CRT-CPW group (25.7% vs. 34.7%, hazard ratio 0.56; confidence interval 0.40-0.78; P < 0.005), at 36 months of follow-up. The total costs for cardiology-related hospitalizations were significantly reduced in the CRT-CPW group [€17 698 (14 192-21 195) vs. 19 933 (16 980-22 991), P < 0.001]. Bootstrap cost-effectiveness analyses showed that implementation of CRT-CPW would be an economically dominant strategy in 90.7% of bootstrap samples. CONCLUSIONS: The introduction of a novel multidisciplinary, nurse-led care pathway for CRT patients resulted in significant reduction of the combination of all-cause mortality and HF hospitalizations, at reduced cardiovascular-related hospital costs.

A completely subcutaneous implantable cardioverter defibrillator system functioning simultaneously with an endocardial implantable cardioverter defibrillator programmed as pacemaker.

Because of multiple ventricular lead fractures with inappropriate shocks, a 31-year-old male received a completely subcutaneous implantable cardioverter defibrillator (ICD) system with the already existing 'endocardial' ICD functioning as an atrial pacemaker.

Inappropriate implantable cardioverter-defibrillator shocks due to temporary epicardial pacing.

Oversensing of external electrical signals can cause inappropriate therapy in cardiac rhythm management devices. In this report, a patient with an implantable cardioverter-defibrillator (ICD) is presented, who received inappropriate shocks due to temporary epicardial pacing after cardiothoracic surgery.

Atrioventricular Cross-Talk Leading to Ventricular Pacing Inhibition in a Dual-Chamber ICD.

We report atrio-ventricular cross talk in a patient with a dual chamber ICD leading to ventricular pacing inhibition. This was observed in an ICD without the ventricular safety pace option, which normally is a sufficient protection against this phenomenon. Cross talk could be prevented effectively by reprogramming ventricular sensitivity to a less sensitive setting.