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Thind M, Oraii A, Chaumont C, Arceluz MR, Sekigawa M, Yogasundaram H, Sugrue A, Mirwais M, AlSalem AB, Zado ES, Guandalini GS, Markman TM, Deo R, Schaller RD, Dixit S, Epstein AE, Supple GE, Tschabrunn CM, Santangeli P, Callans DJ, Hyman MC, Nazarian S, Frankel DS, Marchlinski FE. Predictors of nonpulmonary vein triggers for atrial fibrillation: A clinical risk score. Heart Rhythm 2024:S1547-5271(24)00102-4. [PMID: 38296010 DOI: 10.1016/j.hrthm.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/21/2023] [Accepted: 01/24/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Targeting nonpulmonary vein triggers (NPVTs) after pulmonary vein isolation may reduce atrial fibrillation (AF) recurrence. Isoproterenol infusion and cardioversion of spontaneous or induced AF can provoke NPVTs but typically require vasopressor support and increased procedural time. OBJECTIVE The purpose of this study was to identify risk factors for the presence of NPVTs and create a risk score to identify higher-risk subgroups. METHODS Using the AF ablation registry at the Hospital of the University of Pennsylvania, we included consecutive patients who underwent AF ablation between January 2021 and December 2022. We excluded patients who did not receive NPVT provocation testing after failing to demonstrate spontaneous NPVTs. NPVTs were defined as nonpulmonary vein ectopic beats triggering AF or focal atrial tachycardia. We used risk factors associated with NPVTs with P <.1 in multivariable logistic regression model to create a risk score in a randomly split derivation set (80%) and tested its predictive accuracy in the validation set (20%). RESULTS In 1530 AF ablations included, NPVTs were observed in 235 (15.4%). In the derivation set, female sex (odds ratio [OR] 1.40; 95% confidence interval [CI] 0.96-2.03; P = .080), sinus node dysfunction (OR 1.67; 95% CI 0.98-2.87; P = .060), previous AF ablation (OR 2.50; 95% CI 1.70-3.65; P <.001), and left atrial scar (OR 2.90; 95% CI 1.94-4.36; P <.001) were risk factors associated with NPVTs. The risk score created from these risk factors (PRE2SSS2 score; [PRE]vious ablation: 2 points, female [S]ex: 1 point, [S]inus node dysfunction: 1 point, left atrial [S]car: 2 points) had good predictive accuracy in the validation cohort (area under the receiver operating characteristic curve 0.728; 95% CI 0.648-0.807). CONCLUSION A risk score incorporating predictors for NPVTs may allow provocation of triggers to be performed in patients with greatest expected yield.
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Affiliation(s)
- Munveer Thind
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alireza Oraii
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corentin Chaumont
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martín R Arceluz
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Masahiro Sekigawa
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haran Yogasundaram
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan Sugrue
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maiwand Mirwais
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmed B AlSalem
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory M Tschabrunn
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Thind M, Arceluz MR, Lucena-Padros I, Kubala M, Mirwais M, Bode W, Cerantola M, Sugrue A, Van Niekerk C, Vigdor A, Patel NA, AlSalem AB, Zado ES, Kumareswaran R, Lin D, Arkles JS, Garcia FC, Guandalini GS, Markman TM, Riley MP, Deo R, Schaller RD, Nazarian S, Dixit S, Epstein AE, Supple GE, Frankel DS, Tschabrunn CM, Santangeli P, Callans DJ, Hyman MC, Marchlinski FE. Identifying Origin of Nonpulmonary Vein Triggers Using 2 Stationary Linear Decapolar Catheters: A Novel Algorithm. JACC Clin Electrophysiol 2023; 9:2275-2287. [PMID: 37737775 DOI: 10.1016/j.jacep.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/06/2023] [Accepted: 07/15/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Targeting nonpulmonary vein triggers (NPVTs) of atrial fibrillation (AF) after pulmonary vein isolation can be challenging. NPVTs are often single ectopic beats with a surface P-wave obscured by a QRS or T-wave. OBJECTIVES The goal of this study was to construct an algorithm to regionalize the site of origin of NPVTs using only intracardiac bipolar electrograms from 2 linear decapolar catheters positioned in the posterolateral right atrium (along the crista terminalis with the distal bipole pair in the superior vena cava) and in the proximal coronary sinus (CS). METHODS After pulmonary vein isolation in 42 patients with AF, pacing from 15 typical anatomic NPVT sites was conducted. For each pacing site, the electrogram activation sequence was analyzed from the CS catheter (simultaneous/chevron/inverse chevron/distal-proximal/proximal-distal) and activation time (ie, CSCTAT) between the earliest electrograms from the 2 decapolar catheters was measured referencing the earliest CS electrogram; a negative CSCTAT value indicates the crista terminalis catheter electrogram was earlier, and a positive CSCTAT value indicates the CS catheter electrogram was earlier. A regionalization algorithm with high predictive value was defined and tested in a validation cohort with AF NPVTs localized with electroanatomic mapping. RESULTS In the study patient cohort (71% male; 43% with persistent AF, 52% with left atrial dilation), the algorithm grouped with high precision (positive predictive value 81%-99%, specificity 94%-100%, and sensitivity 30%-94%) the 15 distinct pacing sites into 9 clinically useful regions. Algorithm testing in a 98 patient validation cohort showed predictive accuracy of 91%. CONCLUSIONS An algorithm defined by the activation sequence and timing of electrograms from 2 linear multipolar catheters provided accurate regionalization of AF NPVTs to guide focused detailed mapping.
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Affiliation(s)
- Munveer Thind
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martín R Arceluz
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Irene Lucena-Padros
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maciej Kubala
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maiwand Mirwais
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Weeranun Bode
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maxime Cerantola
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan Sugrue
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christoffel Van Niekerk
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron Vigdor
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel A Patel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ahmed B AlSalem
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Arkles
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cory M Tschabrunn
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Sugrue A, Ibrahim R, Lu M, Bhatia NK, Alkukhun L, Adewumi J, Schaller RD, Marchlinski FE, D'Souza B, Nazer B, Tzou W, Merchant FM, Frankel DS. Impact of Median Sternotomy on Safety and Efficacy of the Subcutaneous Implantable Cardioverter Defibrillator. Circ Arrhythm Electrophysiol 2023; 16:468-474. [PMID: 37485688 DOI: 10.1161/circep.123.011867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/16/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Subcutaneous implantable cardioverter defibrillators (S-ICDs) are an attractive alternative to transvenous ICDs among those not requiring pacing. However, the risks of damage to the S-ICD electrode during sternotomy and adverse interactions with sternal wires remain unclear. We sought to determine the rates of damage to the S-ICD lead during sternotomy, inappropriate shocks from electrical noise due to interaction with sternal wires, and failure to terminate spontaneous or induced ventricular arrhythmias. METHODS Retrospective, multicenter study of patients undergoing sternotomy before or after S-ICD implantation. Clinical, procedural, and device-related data were collected by each center and analyzed by the coordinating center. These data were compared with a historical control cohort of nonsternotomy patients. RESULTS Of 196 identified patients (52±16 years, 47 women), 166 underwent S-ICD implantation after sternotomy and 30 sternotomy after S-ICD. There was no damage to any lead among those who underwent sternotomy after S-ICD. Defibrillation threshold testing was performed in 63% at implant, with 91% first shock success. During a median follow-up of 29 months (range, 1-188), S-ICD first shocks successfully terminated spontaneous ventricular arrhythmias in 31 of 32 patients (97%). Inappropriate shocks occurred in 22 patients, most commonly related to T wave oversensing (n=14). Compared with the nonsternotomy controls, there were no differences in rates of first shock success for induced or spontaneous arrhythmias or rate of inappropriate shocks. CONCLUSIONS Sternotomy before or after S-ICD does not confer additional risk relative to a historical control group without sternotomy.
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Affiliation(s)
- Alan Sugrue
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
| | - Rand Ibrahim
- Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, GA (R.I., M.L., N.K.B., F.M.M.)
| | - Marvin Lu
- Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, GA (R.I., M.L., N.K.B., F.M.M.)
| | - Neal K Bhatia
- Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, GA (R.I., M.L., N.K.B., F.M.M.)
| | - Laith Alkukhun
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (L.A., B.N.)
| | - Joseph Adewumi
- Division of Cardiovascular Medicine, Cardiac Electrophysiology Section, University of Colorado Anschutz Medical Campus, Aurora (J.A., W.T.)
| | - Robert D Schaller
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
| | - Francis E Marchlinski
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
| | - Benjamin D'Souza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
| | - Babak Nazer
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (L.A., B.N.)
| | - Wendy Tzou
- Division of Cardiovascular Medicine, Cardiac Electrophysiology Section, University of Colorado Anschutz Medical Campus, Aurora (J.A., W.T.)
| | - Faisal M Merchant
- Section of Cardiac Electrophysiology, Emory University School of Medicine, Atlanta, GA (R.I., M.L., N.K.B., F.M.M.)
| | - David S Frankel
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (A.S., R.D.S., F.E.M., B.D., B.N., D.S.F.)
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Sugrue A, Markman TM. Ventricular Parasystole. JACC Clin Electrophysiol 2023. [DOI: 10.1016/j.jacep.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Ladejobi A, Christopoulos G, Tan N, Ladas TP, Tri J, van Zyl M, Yasin O, Sugrue A, Khabsa M, Uecker DR, Connolly RJ, Danitz DJ, DeSimone CV, Killu AM, Maor E, Holmes D, Asirvatham SJ, Del-Carpio Munoz F. Effects of Pulsed Electric Fields on the Coronary Arteries in Swine. Circ Arrhythm Electrophysiol 2022; 15:e010668. [PMID: 36194538 DOI: 10.1161/circep.121.010668] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous animal studies have shown no significant vascular injury from pulsed electrical field (PEF) ablation. We sought to assess the effect of PEF on swine coronary arteries. METHODS We performed intracoronary and epicardial (near the coronary artery) PEF ablations in swine pretreated with dual antiplatelet and antiarrhythmic therapy. Intracoronary PEF was delivered using MapiT catheters (Biotronik, Berlin), whereas epicardial PEF was delivered using EPT catheters (Boston Scientific, MA). PEF pulse duration was microseconds (Nanoknife 3.0, Angio Dynamics, NY) or nanoseconds (CellFX, Pulse Biosciences, CA). RESULTS We performed 39 intracoronary ablations in 10 swine and 20 epicardial-pericoronary ablations in 4 separate swine. Intracoronary PEF was delivered at higher energy compared with epicardial PEF (46 [interquartile range, IQR 20-85] J versus 10 [IQR 10-11] J, P < 0.01). Reversible coronary spasm occurred in 49% intracoronary ablations and 45% epicardial ablations (P=0.80). At the end study, fixed coronary stenosis was demonstrated in 44% intracoronary ablations (80% for microsecond PEF and 18% for nanosecond PEF) and 0% epicardial ablations. Visible hemorrhagic and/or fibrotic myocardial lesions were observed at necropsy with similar frequency between intracoronary and epicardial PEF (45% versus 50%, P=0.70). Nanosecond PEF (49 ablations in 11 swine), when compared with microsecond PEF (10 intracoronary ablations in 3 swine), resulted in lower energy delivery (21 [IQR 10-46] J versus 129 [IQR 24-143] J, P=0.03) and less incidence of fixed coronary stenosis (18% versus 80%, P=0.04). CONCLUSIONS In the swine model, intracoronary PEF resulted both in significant coronary spasm and fixed coronary stenosis. Epicardial PEF, delivered at lower energy, resulted in reversible spasm but no fixed coronary stenosis.
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Affiliation(s)
- Adetola Ladejobi
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Nicholas Tan
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Jason Tri
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Omar Yasin
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Alan Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Mariam Khabsa
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Darrin R Uecker
- Pulse Biosciences Inc., Hayward, CA (D.R.U., R.J.C., D.J.D.)
| | | | - David J Danitz
- Pulse Biosciences Inc., Hayward, CA (D.R.U., R.J.C., D.J.D.)
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (E.M.)
| | - David Holmes
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN (A.L., G.C., N.T., T.P.L., J.T., M.V.Z., O.Y., A.S., M.K., C.V.D., A.M.K., D.H., S.J.A., F.D-C.M.)
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Kalluri AG, Sugrue A, Frankel DS. An Important Cause of Wide Complex Tachycardia. JAMA Intern Med 2022; 182:670-671. [PMID: 35404427 DOI: 10.1001/jamainternmed.2022.0524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Aravind G Kalluri
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alan Sugrue
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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7
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Sugrue A, Maor E, Del-Carpio Munoz F, Killu AM, Asirvatham SJ. Cardiac ablation with pulsed electric fields: principles and biophysics. Europace 2022; 24:1213-1222. [PMID: 35426908 DOI: 10.1093/europace/euac033] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/24/2022] [Indexed: 01/04/2023] Open
Abstract
Pulsed electric fields (PEFs) have emerged as an ideal cardiac ablation modality. At present numerous clinical trials in humans are exploring PEF as an ablation strategy for both atrial and ventricular arrhythmias, with early data showing significant promise. As this is a relatively new technology there is limited understanding of its principles and biophysics. Importantly, PEF biophysics and principles are starkly different to current energy modalities (radiofrequency and cryoballoon). Given the relatively novel nature of PEFs, this review aims to provide an understanding of the principles and biophysics of PEF ablation. The goal is to enhance academic research and ultimately enable optimization of ablation parameters to maximize procedure success and minimize risk.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elad Maor
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Chaim Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Freddy Del-Carpio Munoz
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ammar M Killu
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Sanborn D, Sugrue A, Amin M, Mehta R, Farwati M, Deshmukh AJ, Sridhar H, Ahmed A, Asirvatham SJ, Ou NN, Noseworthy PA, Killu AM, Mulpuru SK, Madhavan M. Outcomes of Direct Oral Anticoagulants Co-Prescribed with Common Interacting Medications. Am J Cardiol 2022; 162:80-85. [PMID: 34756422 PMCID: PMC8678337 DOI: 10.1016/j.amjcard.2021.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 01/03/2023]
Abstract
Direct oral anticoagulants (DOACs) can potentially interact with multiple prescription medications. We examined the prevalence of co-prescription of DOACs with interacting medications and its impact on outcomes in patients with atrial fibrillation (AF). Patients with AF treated with a DOAC from 2010 to 2017 at the Mayo Clinic and co-prescribed medications that are inhibitors or inducers of the P-glycoprotein and/or Cytochrome P450 3A4 pathways were identified. The outcomes of stroke, transient ischemic attack, or systemic embolism, major bleeding, and minor bleeds were compared between patients with and without an enzyme inducer. Cox proportional hazards model was used to assess the association between interacting medications and outcomes. Of 8,576 patients with AF (mean age 70 ± 12 years, 35% female) prescribed a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran), 2,610 (30.4%) were on at least 1 interacting agent: the majority were on an enzyme inhibitor (n = 2,592). Prescribed medications included non-dihydropyridine calcium channel blocker (n = 1,412; 16.5%), antiarrhythmic medication (n = 790; 9.2%), antidepressant (n = 659; 7.7%), antibiotic/antifungal (n = 77; 0.90%), antiepileptics (n = 17; 0.2%) and immunosuppressant medications (n = 19; 0.2%). Patients on an interacting medication were more likely to receive a lower dose of DOAC than indicated by the manufacturer's labeling (15.0% vs 11.4%, p <0.0001). In multivariable analysis, co-prescription of an enzyme inhibitor was not associated with risk of any bleeding (hazard ratio 0.87 [0.71 to 1.05], p = 0.15) or stroke, transient ischemic attack, or systemic embolism (hazard ratio 0.82 [0.51 to 1.31], p = 0.39). In conclusion, DOACs are co-prescribed with medications with potential interactions in 30.4% of patients with AF. Co-prescription of DOACs and these drugs are not associated with increased risk of adverse embolic or bleeding outcomes in our cohort.
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Affiliation(s)
- David Sanborn
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan Sugrue
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Mustapha Amin
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Ramila Mehta
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Medhat Farwati
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | | | - Haarini Sridhar
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Azza Ahmed
- Department of Internal Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin
| | | | - Narith N Ou
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | | | - Ammar M Killu
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Siva K Mulpuru
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Malini Madhavan
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota.
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Sugrue A, Lin D. Cutting through the fat: Relationship between comorbidities and arrhythmias in hypertrophic cardiomyopathy. J Cardiovasc Electrophysiol 2021; 33:30-31. [PMID: 34845783 DOI: 10.1111/jce.15301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alan Sugrue
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Padmanabhan D, Sugrue A, Vaidya V, Witt C, Yasin O, Naksuk N, Killu A, Foxall T, Drakulic BS, Venkatachalam KL, Asirvatham SJ. Incremental benefit of a novel signal recording system during mapping and ablation. Europace 2021; 23:130-138. [PMID: 33094311 DOI: 10.1093/europace/euaa194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 08/10/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Current electrophysiology signal recording and mapping systems have limited dynamic range (DR) and bandwidth, which causes loss of valuable information during acquisition of cardiac signals. We evaluated a novel advanced signal processing platform with the objective to obtain and assess additional information of clinical importance. METHODS AND RESULTS Over 10 canines, we compared intracardiac recordings within all cardiac chambers, in various rhythms, in pacing and during radiofrequency (RF) ablation across two platforms; a conventional system and the PURE EP™ [(PEP); Bio Sig Technologies, Inc., Los Angeles, CA, USA]. Recording cardiac signals with varying amplitudes were consistently and reproducibly observed, without loss of detail or introduction of artefact. Further the amplitude of current of injury (COI) on the unipolar signals correlated with the instantaneous contact force (CF) recorded on the sensing catheter in all the animals (r2 = 0.94 in ventricle). The maximum change in the unipolar COI correlated with the change in local electrogram amplitude during non-irrigated RF ablation (r2 = 0.61 in atrium). Reduction in artefact attributable to pacing (20 sites) and noise during ablation (48 sites) was present on the PEP system. Within the PEP system, simultaneous display of identical signals, filtered differently, aided the visualization of discrete conduction tissue signals. CONCLUSION Compared to current system, the PEP system provided incremental information including identifying conduction tissue signals, estimates of CF and a surrogate for lesion formation. This novel signal processing platform with increased DR and minimal front-end filtering may be useful in clinical practice.
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Affiliation(s)
- Deepak Padmanabhan
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Omar Yasin
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Niyada Naksuk
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ammar Killu
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Jain CC, Pedrotty D, Araoz PA, Sugrue A, Vaidya VR, Padmanabhan D, Arunachalam SP, Lerman LO, Asirvatham SJ, Borlaug BA. Sustained Improvement in Diastolic Reserve Following Percutaneous Pericardiotomy in a Porcine Model of Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2021; 14:e007530. [PMID: 33478242 DOI: 10.1161/circheartfailure.120.007530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction is increasing in prevalence, but few effective treatments are available. Elevated left ventricular (LV) diastolic filling pressures represent a key therapeutic target. Pericardial restraint contributes to elevated LV end-diastolic pressure, and acute studies have shown that pericardiotomy attenuates the rise in LV end-diastolic pressure with volume loading. However, whether these acute effects are sustained chronically remains unknown. METHODS Minimally invasive pericardiotomy was performed percutaneously using a novel device in a porcine model of heart failure with preserved ejection fraction. Hemodynamics were assessed at baseline and following volume loading with pericardium intact, acutely following pericardiotomy, and then again chronically after 4 weeks. Cardiac structure was assessed by magnetic resonance imaging. RESULTS The increase in LV end-diastolic pressure with volume loading was mitigated by 41% (95% CI, 27%-45%, P<0.0001; ΔLV end-diastolic pressure reduced from +9±3 mm Hg to +5±3 mm Hg, P=0.0003, 95% CI, -2.2 to -5.5). The effect was sustained at 4 weeks (+5±2 mm Hg, P=0.28 versus acute). There was no statistically significant effect of pericardiotomy on ventricular remodeling compared with age-matched controls. None of the animals developed hemodynamic or pathological indicators of pericardial constriction or frank systolic dysfunction. CONCLUSIONS The acute hemodynamic benefits of pericardiotomy are sustained for at least 4 weeks in a swine model of heart failure with preserved ejection fraction, without excessive chamber remodeling, pericarditis, or clinically significant systolic dysfunction. These data support trials evaluating minimally invasive pericardiotomy as a novel treatment for heart failure with preserved ejection fraction in humans.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
| | - Dawn Pedrotty
- Division of Cardiovascular Disease, Mayo Clinic Arizona (D. Pedrotty)
| | - Philip A Araoz
- Department of Radiology (P.A.A., S.P.A.), Mayo Clinic Rochester, MN
| | - Alan Sugrue
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
| | - Vaibhav R Vaidya
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
| | - Deepak Padmanabhan
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
| | | | - Lilach O Lerman
- Division of Nephrology and Hypertension (L.O.L.), Mayo Clinic Rochester, MN
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine (C.C.J., A.S., V.R.V., D. Padmanabhan, S.J.A., B.A.B.), Mayo Clinic Rochester, MN
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Yasin O, Sugrue A, Van Zyl M, Ladejobi A, Tri J, Rynbrandt J, Seifert G, Sanders R, Pedersen J, Yngsdal L, Ladewig D, Taubel R, Ritrivi C, Asirvatham S, Friedman P. A cool modality to restore sinus rhythm. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Slowing electrical conduction by cooling the myocardium can be used for defibrillation. We previously demonstrated the efficacy of a small cold device placed in oblique sinus (OS) in terminating atrial fibrillation (AF). However, the parameters needed to achieve effective atrial defibrillation are unknown.
Purpose
Assess effect of the size of cooled myocardium on frequency of AF termination in acute canine animal models.
Methods
Sternotomy was performed under general anesthesia in 10 acute canine experiments. AF was induced using rapid atrial pacing and intra-myocardial epinephrine and acetylcholine injections. Once AF sustained for at least 30s, either a cool (7–9°C) or placebo (body temperature) device was placed in the OS. Four device sizes were tested; ½X½, ¾X¾, and 1X1 inch devices and two ¾X¾ inch devices placed side by side simultaneously. Time to AF termination was recorded. Chi-squared or Fisher's exact test were used to compare the frequency of arrhythmia termination with cooling versus placebo.
Results
A total of 166 applications were performed (89 cool vs 77 placebo) in 10 animal experiments. Overall, AF terminated in 82% of the cooling applications vs. 67.5% of placebo (P=0.03, Figure 1). For the ½X½ inch device 88% of cold applications restored sinus rhythm vs. 63.6% for placebo (P=0.05). The frequency of sinus restoration for cold ¾X¾, 1X1 and two ¾X¾ side by side devices was 86.7%, 83.3% and 70% respectively. Time to sinus restoration when achieved was within three minutes was also not significantly changed.
Conclusion
Placing a cool device in the oblique sinus can terminate AF and efficacy is not affected by the size of device.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MediCool Technologies
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Affiliation(s)
- O Yasin
- Mayo Clinic, Rochester, United States of America
| | - A Sugrue
- Mayo Clinic, Rochester, United States of America
| | - M Van Zyl
- Mayo Clinic, Rochester, United States of America
| | - A Ladejobi
- Mayo Clinic, Rochester, United States of America
| | - J Tri
- Mayo Clinic, Rochester, United States of America
| | - J Rynbrandt
- Medicool Technologies Inc, Rochester, United States of America
| | - G Seifert
- Medicool Technologies Inc, Rochester, United States of America
| | - R Sanders
- Medicool Technologies Inc, Rochester, United States of America
| | - J Pedersen
- Mayo Clinic, Rochester, United States of America
| | - L Yngsdal
- Mayo Clinic, Rochester, United States of America
| | - D Ladewig
- Mayo Clinic, Rochester, United States of America
| | - R Taubel
- Mayo Clinic, Rochester, United States of America
| | - C Ritrivi
- Medicool Technologies Inc, Rochester, United States of America
| | - S Asirvatham
- Mayo Clinic, Rochester, United States of America
| | - P Friedman
- Mayo Clinic, Rochester, United States of America
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Zyl M, Pedrotty DM, Karabulut E, Kuzmenko V, Sämfors S, Livia C, Vaidya V, Sugrue A, McLeod CJ, Behfar A, Asirvatham SJ, Gatenholm P, Kapa S. Injectable conductive hydrogel restores conduction through ablated myocardium. J Cardiovasc Electrophysiol 2020; 31:3293-3301. [DOI: 10.1111/jce.14762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/18/2020] [Accepted: 08/28/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Martin Zyl
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Dawn M. Pedrotty
- Division of Cardiology, Department of Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Erdem Karabulut
- Department of Chemistry and Chemical Engineering, 3D Bioprinting and Wallenberg Wood Science Center Chalmers University Gothenburg Sweden
| | - Volodymyr Kuzmenko
- Department of Microtechnology and Nanoscience, Wallenberg Wood Science Center Chalmers University Gothenburg Sweden
| | - Sanna Sämfors
- Department of Chemistry and Chemical Engineering, 3D Bioprinting and Wallenberg Wood Science Center Chalmers University Gothenburg Sweden
| | - Christopher Livia
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Vaibhav Vaidya
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Alan Sugrue
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Christopher J. McLeod
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Atta Behfar
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
| | - Paul Gatenholm
- Department of Chemistry and Chemical Engineering, 3D Bioprinting and Wallenberg Wood Science Center Chalmers University Gothenburg Sweden
- Cellheal Sandvika Norway
| | - Suraj Kapa
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine and Science Rochester Minnesota USA
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14
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Garrott K, Laughner J, Gutbrod S, Sugrue A, Shuros A, Sulkin M, Yasin O, Bush J, Pottinger N, Meyers J, Kapa S. Combined local impedance and contact force for radiofrequency ablation assessment. Heart Rhythm 2020; 17:1371-1380. [PMID: 32240822 DOI: 10.1016/j.hrthm.2020.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The combination of contact force (CF) and local impedance (LI) may improve tissue characterization and lesion prediction during radiofrequency (RF) ablation. OBJECTIVE The purpose of this study was to evaluate the utility of LI combined with CF in assessing RF ablation efficacy. METHODS An LI catheter with CF sensing was evaluated in swine (n = 11) and in vitro (n = 14). The relationship between LI and CF in different tissue types was evaluated in vivo. Discrete lesions were created in vitro and in vivo at a range of forces, powers, and durations. Finally, an intercaval line was created in 3 groups at 30 W: 30s, Δ20Ω, and Δ30Ω. In the Δ20Ω and Δ30Ω groups, the user ablated until a 20 or 30 Ω LI drop. In the 30s group, the user was blinded to LI. RESULTS In vivo, distinction in LI was found between the blood pool and the myocardium (blood pool: 122 ± 7.02 Ω; perpendicular contact: 220 ± 29 Ω; parallel contact: 207 ± 31 Ω). LI drop correlated with lesion depth both in vitro (R = 0.84) and in vivo (R = 0.79), informing sufficient lesion creation (LI drop >20 Ω) and warning of excessive heating (LI drop >65 Ω). When creating an intercaval line, the total RF time was significantly reduced when using LI guidance (6.4 ± 2 minutes in Δ20Ω and 8.1 ± 1 minutes in Δ30Ω) compared with a standard 30-second workflow (18 ± 7 minutes). Acute conduction block was achieved in all Δ30Ω and 30s lines. CONCLUSION The addition of LI to CF provides feedback on both electrical and mechanical loads. This provides information on tissue type and catheter-tissue coupling; provides feedback on whether volumetric tissue heating is inadequate, sufficient, or excessive; and reduces ablation time.
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Affiliation(s)
- Kara Garrott
- Boston Scientific Corporation, St. Paul, Minnesota
| | | | | | - Alan Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Allan Shuros
- Boston Scientific Corporation, St. Paul, Minnesota
| | - Matt Sulkin
- Boston Scientific Corporation, St. Paul, Minnesota
| | - Omar Yasin
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jamie Bush
- Boston Scientific Corporation, St. Paul, Minnesota
| | | | - Jason Meyers
- Heart Rhythm Center, Iowa Heart Center, West Des Moines, Iowa
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.
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Abstract
To characterize cardiac activity and arrhythmias, electrophysiologists can record the electrical activity of the heart in relation to its anatomy through a process called cardiac mapping (electroanatomic mapping, EAM). A solid understanding of the basic cardiac biopotentials, called electrograms, is imperative to construct and interpret the cardiac EAM correctly. There are several mapping approaches available to the electrophysiologist, each optimized for specific arrhythmia mechanisms. This article provides an overview of the fundamentals of EAM.
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Affiliation(s)
- Thomas P Ladas
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Alan Sugrue
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - John Nan
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Vaibhav R Vaidya
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Deepak Padmanabhan
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - K L Venkatachalam
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Jacksonville, Florida, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA; Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
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16
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Zyl MV, Yasin OZ, Ladejobi A, Vaidya V, Sugrue A, Schneider N, Asirvatham R, Tri J, Friedman P, Asirvatham S. COMPLETE FOUR CHAMBER RESYNCHRONIZATION VIA NOVEL PERCUTANEOUS EPICARDIAL PACING LEAD. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30896-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Sugrue A, Vaidya VR, Livia C, Padmanabhan D, Abudan A, Isath A, Witt T, DeSimone CV, Stalboerger P, Kapa S, Asirvatham SJ, McLeod CJ. Feasibility of selective cardiac ventricular electroporation. PLoS One 2020; 15:e0229214. [PMID: 32084220 PMCID: PMC7034868 DOI: 10.1371/journal.pone.0229214] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/31/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction The application of brief high voltage electrical pulses to tissue can lead to an irreversible or reversible electroporation effect in a cell-specific manner. In the management of ventricular arrhythmias, the ability to target different tissue types, specifically cardiac conduction tissue (His-Purkinje System) vs. cardiac myocardium would be advantageous. We hypothesize that pulsed electric fields (PEFs) can be applied safely to the beating heart through a catheter-based approach, and we tested whether the superficial Purkinje cells can be targeted with PEFs without injury to underlying myocardial tissue. Methods In an acute (n = 5) and chronic canine model (n = 6), detailed electroanatomical mapping of the left ventricle identified electrical signals from myocardial and overlying Purkinje tissue. Electroporation was effected via percutaneous catheter-based Intracardiac bipolar current delivery in the anesthetized animal. Repeat Intracardiac electrical mapping of the heart was performed at acute and chronic time points; followed by histological analysis to assess effects. Results PEF demonstrated an acute dose-dependent functional effect on Purkinje, with titration of pulse duration and/or voltage associated with successful acute Purkinje damage. Electrical conduction in the insulated bundle of His (n = 2) and anterior fascicle bundle (n = 2), was not affected. At 30 days repeat cardiac mapping demonstrated resilient, normal electrical conduction throughout the targeted area with no significant change in myocardial amplitude (pre 5.9 ± 1.8 mV, 30 days 5.4 ± 1.2 mV, p = 0.92). Histopathological analysis confirmed acute Purkinje fiber targeting, with chronic studies showing normal Purkinje fibers, with minimal subendocardial myocardial fibrosis. Conclusion PEF provides a novel, safe method for non-thermal acute modulation of the Purkinje fibers without significant injury to the underlying myocardium. Future optimization of this energy delivery is required to optimize conditions so that selective electroporation can be utilized in humans the treatment of cardiac disease.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Vaibhav R. Vaidya
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher Livia
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Deepak Padmanabhan
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Anas Abudan
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Ameesh Isath
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Tyra Witt
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher V. DeSimone
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Paul Stalboerger
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental Therapeutics, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Suraj Kapa
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Samuel J. Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher J. McLeod
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
- * E-mail:
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Garrott K, Sugrue A, Laughner J, Bush J, Gutbrod S, Sulkin M, Yasin O, Meyers J, Kapa S. P2862Complementary use of contact force and local catheter impedance during RF ablation reduces ablation time in an in vivo swine model. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Catheter-tissue coupling is crucial for effective delivery of radiofrequency (RF) energy during catheter ablation. Force sensing catheters provide a metric of mechanical tissue contact and catheter stability, while local impedance has been shown to provide sensitive information on real-time tissue heating. The complementary use of force and local impedance during RF ablation procedures could provide an advantage over the use of one metric alone.
This study evaluates a prototype ablation catheter that measures both contact force (CF) using inductive sensors and local catheter impedance (LI) using only catheter electrodes. The complementary nature was assessed with discrete lesions in vitro and an intercaval line in vivo.
A force-sensing catheter with LI was evaluated in explanted swine hearts (n=14) in an in vivo swine model (n=9, 50–70kg) using investigational electroanatomical mapping software. In vitro, discrete lesions were created in ventricular tissue at a range of forces (0–40g) controlled externally. RF energy was applied at a range of powers (20W, 30W, and 40W), durations (10s-60s), and catheter orientations (0°, 45°, and 90°). Lesions were stained with TTC and measured. LI drop relative to baseline during RF in the bench studies was used to inform the in vivo study. In a separate subset of animals in vivo, an intercaval line was created in three experimental groups: LI blinded, 20Ω ΔLI, and 30Ω ΔLI. CF was maintained between 15 and 25g in all groups. All ablations were performed with a power of 30W. In the LI blinded group, all lesions were delivered for 30s. In the 20Ω ΔLI group, the investigator ablated until a 20Ω drop or 30 seconds was achieved. Likewise, in the 30Ω ΔLI, the investigator ablated until a 30Ω drop or 30 seconds was achieved.
In vitro, 137 discrete ventricular lesions were created. LI drop during ablation correlated strongly with lesion depth using a monoexponential fit (R=0.84) while force time integral (FTI) did not correlate as strongly (R=0.56). In the intercaval LI blinded group, starting LI ranged from 126–163Ω with a median of 138Ω. LI drops ranged from 13Ω-44Ω, with a median of 26Ω. In the 20Ω ΔLI group, starting LI ranged from 137–211Ω with a median of 161Ω and LI drop ranged from 7Ω-35Ω, with a median of 22Ω. In the 30Ω ΔLI group, starting LI ranged from 130–256Ω with a median of 171Ω and LI drop ranged from 20Ω-52Ω, with a median of 31Ω. Notably, RF time for the LI blinded group was 13±0.1 minutes while RF time in the 20Ω ΔLI group was 6.4±1.9 minutes and 7.5±0.7 minutes in the 30Ω ΔLI group.
A catheter incorporating CF-sensing and LI capabilities provides a powerful tool for RF ablation. Bench studies demonstrate a strong correlation between LI drop and lesion dimensions, which guided the use of LI in vivo. In vivo, the confirmation of stable mechanical contact and viewing of real-time LI drops enabled a significant reduction in RF time while creating a continuous intercaval line.
Acknowledgement/Funding
This study was funded by Boston Scientific.
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Affiliation(s)
- K Garrott
- Boston Scientific, Saint Paul, United States of America
| | - A Sugrue
- Mayo Clinic, Rochester, United States of America
| | - J Laughner
- Boston Scientific, Saint Paul, United States of America
| | - J Bush
- Boston Scientific, Saint Paul, United States of America
| | - S Gutbrod
- Boston Scientific, Saint Paul, United States of America
| | - M Sulkin
- Boston Scientific, Saint Paul, United States of America
| | - O Yasin
- Mayo Clinic, Rochester, United States of America
| | - J Meyers
- Iowa Heart Center, Des Moines, United States of America
| | - S Kapa
- Mayo Clinic, Rochester, United States of America
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19
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Abstract
Knowledge of relevant cardiac anatomy is crucial in understanding the pathophysiology and treatment of arrhythmias, and helps avoid potential complications in mapping and ablation. This article explores the anatomy, relevant to electrophysiologists, relating to atrial flutter and atrial fibrillation, ventricular tachycardia relating to the outflow tracts as well as endocardial structure, and also epicardial considerations for mapping and ablation.
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Affiliation(s)
- John Nan
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Thomas P Ladas
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Nandini Mehra
- Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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20
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Sugrue A, Vaidya V, Yasin O, Isath A, Abudan A, Padmanabhan D, Kapa S, Asirvatham SJ. Development of a novel ablation hood to prevent systemic embolization of microbubbles and particulate emboli. J Interv Card Electrophysiol 2019; 58:281-288. [PMID: 31372780 DOI: 10.1007/s10840-019-00595-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation ablation results in microbubbles and particulate emboli formation. We aimed to develop and test the early feasibility of a novel ablation hood to contain microbubbles and particulate emboli with the ultimate goal of preventing systemic embolization. METHODS In seven canines, we developed, iterated, and tested a novel retractable hood that can cover the catheter-tissue ablation site. The number and volume (nL) of microbubbles formed during ablation with and without the hood was measured using an extracorporeal circulation loop. Wilcoxon's signed-rank test was used to compare the number of bubbles detected with and without the hood. RESULTS The hood reduced systemic embolization of microbubbles in 21/28 (75%) of ablations. Both atrial and ventricular ablations showed a statistically significant reduction in bubble number (476 ± 811 without hood vs 173 ± 226 with hood, p = 0.02; 2669 ± 1623 without hood vs 1417 ± 970 with hood, p = 0.04, respectively) and bubble volume (3.3 ± 7.6 nL without hood vs 0.2 ± 0.56 nL with hood, p = 0.006; 6.1 ± 5.2 nL without hood vs 1.9 ± 1.4 nL with hood, p = 0.05, respectively). CONCLUSIONS Use of a novel hood to cover the ablation catheter at the site of catheter-tissue contact has the potential to provide a means to reduce systematic embolization of microbubbles. Further work is required to examine particulate emboli, but these data show the early feasibility of this design concept.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vaibhav Vaidya
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Omar Yasin
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ameesh Isath
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anas Abudan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deepak Padmanabhan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.
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21
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Sugrue A, Vaidya V, Witt C, DeSimone CV, Yasin O, Maor E, Killu AM, Kapa S, McLeod CJ, Miklavčič D, Asirvatham SJ. Irreversible electroporation for catheter-based cardiac ablation: a systematic review of the preclinical experience. J Interv Card Electrophysiol 2019; 55:251-265. [PMID: 31270656 DOI: 10.1007/s10840-019-00574-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/26/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Irreversible electroporation (IRE) utilizing high voltage pulses is an emerging strategy for catheter-based cardiac ablation with considerable growth in the preclinical arena. METHODS A systematic search for articles was performed from three sources (PubMed, EMBASE, and Google Scholar). The primary outcome was the efficacy of tissue ablation with characteristics of lesion formation evaluated by histologic analysis. The secondary outcome was focused on safety and damage to collateral structures. RESULTS Sixteen studies met inclusion criteria. IRE was most commonly applied to the ventricular myocardium (n = 7/16, 44%) by a LifePak 9 Defibrillator (n = 9/16, 56%), NanoKnife Generator (n = 2/16, 13%), or other custom generators (n = 5/16, 31%). There was significant heterogeneity regarding electroporation protocols. On histological analysis, IRE was successful in creating ablation lesions with variable transmurality depending on the electric pulse parameters and catheter used. CONCLUSION Preclinical studies suggest that cardiac tissue ablation using IRE shows promise in delivering efficacious, safe lesions.
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Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar Yasin
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ammar M Killu
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher J McLeod
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Damijan Miklavčič
- Faculty of Electrical Engineering, University of Ljubljana, Trzaska 25, 1000, Ljubljana, Slovenia
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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22
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Tan NY, Yasin OZ, Sugrue A, El Sabbagh A, Foley TA, Asirvatham SJ. Anatomy and Physiologic Roles of the Left Atrial Appendage: Implications for Endocardial and Epicardial Device Closure. Interv Cardiol Clin 2019. [PMID: 29526287 DOI: 10.1016/j.iccl.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The left atrial appendage has been implicated as a major nidus for thrombus formation, particularly in atrial fibrillation. This discovery has prompted substantial interest in the development of left atrial appendage exclusion devices aimed at decreasing systemic thromboembolism risk. Its deceptively simple appearance belies the remarkable complexity that characterizes its anatomy and physiology. We highlight the key anatomic features and variations of the left atrial appendage as well as its relationships with surrounding structures. We also summarize crucial anatomic factors that should be taken into account by the interventional cardiologist when planning for or performing left atrial appendage exclusion procedures.
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Affiliation(s)
- Nicholas Y Tan
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Omar Z Yasin
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Thomas A Foley
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA.
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23
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Caluori G, Wojtaszczyk A, Yasin O, Pesl M, Wolf J, Belaskova S, Crha M, Sugrue A, Vaidya VR, Naksuk N, DeSimone CV, Killu AM, Padmanabhan D, Asirvatham SJ, Stárek Z. Comparing the incidence of ventricular arrhythmias during epicardial ablation in swine versus canine models. Pacing Clin Electrophysiol 2019; 42:862-867. [PMID: 30989679 DOI: 10.1111/pace.13698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/14/2019] [Accepted: 04/11/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Choosing the appropriate animal model for development of novel technologies requires an understanding of anatomy and physiology of these different models. There are little data about the characteristics of different animal models for the study of technologies used for epicardial ablation. We aimed to compare the incidence of ventricular arrhythmias during epicardial radiofrequency ablation between swine and canine models using novel epicardial ablation catheters. METHODS We conducted a retrospective study using data obtained from epicardial ablation experiments performed on swine (Sus Scrofa) and canine (Canis familiaris) models. We compared the incidence of ventricular arrhythmias during ablation between swine and canine using multivariate regression analysis. Six swine and six canine animals underwent successful epicardial radiofrequency ablation. A total of 103 ablation applications were recorded. RESULTS Ventricular arrhythmias requiring cardioversion occurred in 13.11% of radiofrequency ablation applications in swine and 9.75% in canine (relative risk: 117.6%, 95% confidence interval [CI]: 83.97-164.69, animal-based odds ratio [OR]: .55, 95% CI: .23-61.33; P = .184). When adjusting for application position, duration of ablation and power, the odds of developing potentially lethal ventricular arrhythmia in swine increased significantly compared to canine (OR: 3.60, 95% CI: 1.35-9.55; P = .010). CONCLUSIONS The swine myocardium is more susceptible to developing ventricular arrhythmias compared to canine model during epicardial ablation. This issue should be carefully considered in future studies.
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Affiliation(s)
- Guido Caluori
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.,CEITEC, Masaryk University, Brno, Czech Republic
| | - Adam Wojtaszczyk
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.,3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Omar Yasin
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Martin Pesl
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.,First Department of Internal Medicine/Cardioangiology, St. Anne´s Hospital, Masaryk University, Brno, Czech Republic.,Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Wolf
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Silvie Belaskova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Michal Crha
- University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | - Alan Sugrue
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Vaibhav R Vaidya
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | - Niyada Naksuk
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | | | - Ammar M Killu
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
| | | | - Samuel J Asirvatham
- Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota.,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Zdeněk Stárek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.,First Department of Internal Medicine/Cardioangiology, St. Anne´s Hospital, Masaryk University, Brno, Czech Republic
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24
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Yasin OZ, Sugrue A, Seifert G, Berhow S, Sanders R, Duerr J, Pedersen J, Yngsdal L, Ladewig D, Ritrivi C, Asirvatham S, Friedman P. ATRIAL DEFIBRILLATION USING A NOVEL EPICARDIAL COOLING DEVICE: A COOL NEW SMALL TECHNOLOGY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Padmanabhan D, Naksuk N, Killu AK, Kapa S, Witt C, Sugrue A, DeSimone CV, Madhavan M, Groot JR, O'Brien B, Rabbette T, Coffey K, Asirvatham SJ. Electroporation of epicardial autonomic ganglia: Safety and efficacy in medium‐term canine models. J Cardiovasc Electrophysiol 2019; 30:607-615. [DOI: 10.1111/jce.13860] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/19/2019] [Accepted: 01/19/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Deepak Padmanabhan
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - Niyada Naksuk
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - Ammar K. Killu
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - Suraj Kapa
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - Chance Witt
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - Alan Sugrue
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | | | - Malini Madhavan
- Department of Cardiovascular MedicineAcademic Medical CenterAmsterdam The Netherlands
| | - J. R. Groot
- Heart Center, Department of Cardiology, Academic Medical CenterAmsterdam The Netherlands
| | - Barry O'Brien
- Biomedical engineering, National University of IrelandGalway Ireland
| | - Tadhg Rabbette
- Biomedical engineering, National University of IrelandGalway Ireland
| | - Kenneth Coffey
- Biomedical engineering, National University of IrelandGalway Ireland
| | - Samuel J. Asirvatham
- Division of Pediatric CardiologyAcademic Medical CenterAmsterdam The Netherlands
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26
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Abstract
The His bundle (conduction system) is an attractive target for physiologic pacing because it uses the native conduction system. Although the potential benefits of conduction system pacing were recognized in the 1970s, in the past 2 decades, it has grown in interest as a potentially preferred method of ventricular stimulation in appropriate patients. This review provides an appraisal of conduction system pacing, with focus on anatomy, physiology, tools, and techniques as well as an appraisal of current published data and thoughts on future directions.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA
| | - Subir Bhatia
- Division of Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA
| | - Vaibhav R Vaidya
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA
| | - Ugur Kucuk
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA
| | - Siva K Mulpuru
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA
| | - Samuel J Asirvatham
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street South West, Rochester, MN 55902, USA.
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27
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Shabtaie SA, Sugrue A, Tan NY, Asirvatham S, Hayes DL. Putting down the phone: the obsolescence of transtelephonic monitoring for pacemaker follow-up. J Interv Card Electrophysiol 2018; 54:135-139. [PMID: 30353376 DOI: 10.1007/s10840-018-0478-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The evolution of heart rhythm monitoring technology over the past few decades has seen a decline in the use and need of transtelephonic monitoring (TTM). We sought to establish a predicted date for the sun setting of TTM at our institution, as well as establish the current demographics of the patients still using this technology. METHODS We retrospectively reviewed all patients with permanent pacemakers receiving routine device follow-up at our institution (Mayo Clinic-Rochester) between 2015 and 2018. From this cohort, we reviewed and analyzed patients using TTM for device follow-up and utilized projected battery longevity to determine cessation date. Pacemaker implantation date, underlying arrhythmia, and most recent device interrogation reports were also collected. RESULTS As of March 2018, a total of 3543 patients with permanent pacemakers were being followed at our institution and 289 (8.2%) are using TTM for monitoring device function (147 male, mean age 79.9 ± 12.0 years). Of those currently using TTM, by January of 2020, only 122 (42.2%) are predicted to be using this technology for device follow-up, 40 (13.8%) by January 2022, with zero patients by November of 2024. CONCLUSIONS The use of TTM will continue to significantly diminish over the next few years. Based on battery longevity estimates, we predict that by the end of 2024 TTM will no longer be used for device follow-up at our institution.
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Affiliation(s)
- Samuel A Shabtaie
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alan Sugrue
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nicholas Y Tan
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel Asirvatham
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David L Hayes
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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28
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Sugrue A, Asirvatham SJ. Highlights from Heart Rhythm 2018: Innovative Techniques. J Innov Card Rhythm Manag 2018; 9:3330-3335. [PMID: 32494506 PMCID: PMC7252867 DOI: 10.19102/icrm.2018.090905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester MN, USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester MN, USA
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester MN, USA
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29
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Sugrue A, Rohatgi RK, Bos M, Vaidya VR, Asirvatham SJ, Noseworthy PA, Ackerman MJ. Clinical Significance of Early Repolarization in Long QT Syndrome. JACC Clin Electrophysiol 2018; 4:1238-1244. [DOI: 10.1016/j.jacep.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/30/2018] [Accepted: 06/07/2018] [Indexed: 11/16/2022]
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30
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Attia ZI, Sugrue A, Asirvatham SJ, Ackerman MJ, Kapa S, Friedman PA, Noseworthy PA. Noninvasive assessment of dofetilide plasma concentration using a deep learning (neural network) analysis of the surface electrocardiogram: A proof of concept study. PLoS One 2018; 13:e0201059. [PMID: 30133452 PMCID: PMC6104915 DOI: 10.1371/journal.pone.0201059] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 07/06/2018] [Indexed: 01/16/2023] Open
Abstract
Background Dofetilide is an effective antiarrhythmic medication for rhythm control in atrial fibrillation, but carries a significant risk of pro-arrhythmia and requires meticulous dosing and monitoring. The cornerstone of this monitoring, measurement of the QT/QTc interval, is an imperfect surrogate for plasma concentration, efficacy, and risk of pro-arrhythmic potential. Objective The aim of our study was to test the application of a deep learning approach (using a convolutional neural network) to assess morphological changes on the surface ECG (beyond the QT interval) in relation to dofetilide plasma concentrations. Methods We obtained publically available serial ECGs and plasma drug concentrations from 42 healthy subjects who received dofetilide or placebo in a placebo‐controlled cross‐over randomized controlled clinical trial. Three replicate 10-s ECGs were extracted at predefined time-points with simultaneous measurement of dofetilide plasma concentration We developed a deep learning algorithm to predict dofetilide plasma concentration in 30 subjects and then tested the model in the remaining 12 subjects. We compared the deep leaning approach to a linear model based only on QTc. Results Fourty two healthy subjects (21 females, 21 males) were studied with a mean age of 26.9 ± 5.5 years. A linear model of the QTc correlated reasonably well with dofetilide drug levels (r = 0.64). The best correlation to dofetilide level was achieved with the deep learning model (r = 0.85). Conclusion This proof of concept study suggests that artificial intelligence (deep learning/neural network) applied to the surface ECG is superior to analysis of the QT interval alone in predicting plasma dofetilide concentration.
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Affiliation(s)
- Zachi I. Attia
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Samuel J. Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michael J. Ackerman
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Windland Smith Rice Sudden Death Genomics Laboratory, Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Suraj Kapa
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul A. Friedman
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Peter A. Noseworthy
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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Livia C, Sugrue A, Witt T, Polkinghorne MD, Maor E, Kapa S, Lehmann HI, DeSimone CV, Behfar A, Asirvatham SJ, McLeod CJ. Elimination of Purkinje Fibers by Electroporation Reduces Ventricular Fibrillation Vulnerability. J Am Heart Assoc 2018; 7:e009070. [PMID: 30371233 PMCID: PMC6201470 DOI: 10.1161/jaha.118.009070] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/21/2018] [Indexed: 12/18/2022]
Abstract
Background The Purkinje network appears to play a pivotal role in the triggering as well as maintenance of ventricular fibrillation. Irreversible electroporation ( IRE ) using direct current has shown promise as a nonthermal ablation modality in the heart, but its ability to target and ablate the Purkinje tissue is undefined. Our aim was to investigate the potential for selective ablation of Purkinje/fascicular fibers using IRE . Methods and Results In an ex vivo Langendorff model of canine heart (n=8), direct current was delivered in a unipolar manner at various dosages from 750 to 2500 V, in 10 pulses with a 90-μs duration at a frequency of 1 Hz. The window of ventricular fibrillation vulnerability was assessed before and after delivery of electroporation energy using a shock on T-wave method. IRE consistently eradicated all Purkinje potentials at voltages between 750 and 2500 V (minimum field strength of 250-833 V/cm). The ventricular electrogram amplitude was only minimally reduced by ablation: 0.6±2.3 mV ( P=0.03). In 4 hearts after IRE delivery, ventricular fibrillation could not be reinduced. At baseline, the lower limit of vulnerability to ventricular fibrillation was 1.8±0.4 J, and the upper limit of vulnerability was 19.5±3.0 J. The window of vulnerability was 17.8±2.9 J. Delivery of electroporation energy significantly reduced the window of vulnerability to 5.7±2.9 J ( P=0.0003), with a postablation lower limit of vulnerability=7.3±2.63 J, and the upper limit of vulnerability=18.8±5.2 J. Conclusions Our study highlights that Purkinje tissue can be ablated with IRE without any evidence of underlying myocardial damage.
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Affiliation(s)
- Christopher Livia
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental TherapeuticsCenter for Regenerative MedicineMayo ClinicRochesterMN
| | - Alan Sugrue
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
| | - Tyra Witt
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental TherapeuticsCenter for Regenerative MedicineMayo ClinicRochesterMN
| | - Murray D. Polkinghorne
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
| | - Elad Maor
- Leviev Heart Center, Sheba Medical CenterSackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Suraj Kapa
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
| | - Helge I. Lehmann
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
| | - Christopher V. DeSimone
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
| | - Atta Behfar
- Department of Cardiovascular Medicine and Department of Molecular Pharmacology and Experimental TherapeuticsCenter for Regenerative MedicineMayo ClinicRochesterMN
| | - Samuel J. Asirvatham
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMN
| | - Christopher J. McLeod
- Division of Heart Rhythm ServicesDepartment of Cardiovascular DiseasesMayo ClinicRochesterMN
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Katherine Y. Le
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Patrick Dearani
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J. Asirvatham
- Division of Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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Naksuk N, Desimone C, Witt C, Sugrue A, Kella D, Noseworthy P. P5792Risks factors for dofetilide-associated torsades de pointes among hospitalized patients with atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- N Naksuk
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
| | - C Desimone
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
| | - C Witt
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
| | - A Sugrue
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
| | - D Kella
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
| | - P Noseworthy
- Mayo Clinic, Division of Cardiovascular Disease, Rochester, United States of America
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Witt CM, Sugrue A, Padmanabhan D, Vaidya V, Gruba S, Rohl J, DeSimone CV, Killu AM, Naksuk N, Pederson J, Suddendorf S, Ladewig DJ, Maor E, Holmes DR, Kapa S, Asirvatham SJ. Intrapulmonary Vein Ablation Without Stenosis: A Novel Balloon-Based Direct Current Electroporation Approach. J Am Heart Assoc 2018; 7:JAHA.118.009575. [PMID: 29987121 PMCID: PMC6064854 DOI: 10.1161/jaha.118.009575] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Current thermal ablation methods for atrial fibrillation, including radiofrequency and cryoablation, have a suboptimal success rate. To avoid pulmonary vein (PV) stenosis, ablation is performed outside of the PV, despite the importance of triggers inside the vein. We previously reported on the acute effects of a novel direct current electroporation approach with a balloon catheter to create lesions inside the PVs in addition to the antrum. In this study, we aimed to determine whether the effects created by this nonthermal ablation method were associated with irreversible lesions and whether PV stenosis or other adverse effects occurred after a survival period. Methods and Results Initial and survival studies were performed in 5 canines. At the initial study, the balloon catheter was inflated to contact the antrum and interior of the PV. Direct current energy was delivered between 2 electrodes on the catheter in ECG‐gated 100 μs pulses. A total of 10 PVs were treated demonstrating significant acute local electrogram diminution (mean amplitude decrease of 61.2±19.8%). After the survival period (mean 27 days), computed tomography imaging showed no PV stenosis. On histologic evaluation, transmural, although not circumferential, lesions were seen in each treated vein. No PV stenosis or esophageal injury was present. Conclusions Irreversible, transmural lesions can be created inside the PV without evidence of stenosis after a 27‐day survival period using this balloon‐based direct current ablation approach. These early data show promise for an ablation approach that could directly treat PV triggers in addition to traditional PV antrum ablation.
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Affiliation(s)
- Chance M Witt
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alan Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Vaibhav Vaidya
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Niyada Naksuk
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Elad Maor
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Vaidya VR, Sugrue A, Padmanabhan D, Killu AM, Naksuk N, Al‐Masry AA, Isath A, Pedersen J, Yngsdal L, Ladewig DJ, Friedman PA, Asirvatham SJ. Percutaneous epicardial pacing using a novel transverse sinus device. J Cardiovasc Electrophysiol 2018; 29:1308-1316. [DOI: 10.1111/jce.13661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Alan Sugrue
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | | | - Ammar M. Killu
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Niyada Naksuk
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | | | - Ameesh Isath
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Joanne Pedersen
- Department of Cardiovascular SurgeryMayo Clinic Rochester MN USA
| | - Lisa Yngsdal
- Department of Cardiovascular SurgeryMayo Clinic Rochester MN USA
| | | | - Paul A. Friedman
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
- Department of Pediatrics and Adolescent MedicineMayo Clinic Rochester MN USA
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Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN
| | - Jillian Mahowald
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN.
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Sugrue A, Maor E, Ivorra A, Vaidya V, Witt C, Kapa S, Asirvatham S. Irreversible electroporation for the treatment of cardiac arrhythmias. Expert Rev Cardiovasc Ther 2018; 16:349-360. [DOI: 10.1080/14779072.2018.1459185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel Asirvatham
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Abstract
Atrial fibrillation is the most common cardiac dysrhythmia encountered in the primary care setting. Although a rate control strategy is pursued by physicians for the initial treatment of atrial fibrillation, the efficacy of a rhythm control approach is often undervalued despite offering effective treatment options. There are many pharmacological therapies available to patients, with drug choice often dictated by safety concerns (toxicities and proarrhythmic adverse effects) as well as patient characteristics and comorbidities. This article presents a simplified approach to understanding the rhythm control strategy, including the advantages and disadvantages of various antiarrhythmic drugs and common drug-drug interactions encountered in the primary care setting.
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Affiliation(s)
- Subir Bhatia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Alan Sugrue
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Killu AM, Sugrue A, Munger TM, Hodge DO, Mulpuru SK, McLeod CJ, Packer DL, Asirvatham SJ, Friedman PA. Impact of sedation vs. general anaesthesia on percutaneous epicardial access safety and procedural outcomes. Europace 2018; 20:329-336. [PMID: 28339558 DOI: 10.1093/europace/euw313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 09/06/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Patient movement while under moderate/deep sedation may complicate percutaneous epicardial access (EpiAcc), mapping and ablation. We sought to compare procedural outcomes in patients undergoing EpiAcc under sedation vs. general anaesthesia (GA) for ablation. Methods and results Patients undergoing EpiAcc between January 2004 and July 2014 were included. Safety, procedural, and clinical outcomes were compared between patients undergoing EpiAcc under sedation or GA for ventricular tachycardia or premature ventricular complex ablation. Between January 2004 and July 2014, 170 patients underwent EpiAcc (mean age, 53.2 ± 15.8 years; average ejection fraction, 44.3 ± 15.3%). The majority (122 [72%] patients) were male. GA was used in 69 (40.6%). There was no difference in route of access (more often anterior, 53.0%) or the rate of successful access (96% overall) between groups. Similarly, the site of ablation (endocardial vs. epicardial vs. combined endocardial/epicardial) was similar between groups. Complications were equally seen between groups-the most frequent event/complication was pericardial effusion, occurring in 10.6% of patients. Finally, procedural and clinical success rates between GA and sedation groups were comparable (93 vs. 91% and 44 vs. 51%, respectively, P > 0.05). Conclusions Choice of anaesthesia for EpiAcc does not appear to significantly affect safety and procedural or clinical outcomes. For patients in whom anaesthesia may pose increased risk, it is reasonable to obtain epicardial access under sedation.
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Affiliation(s)
- Ammar M Killu
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas M Munger
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Siva K Mulpuru
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Christopher J McLeod
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Douglas L Packer
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Sugrue A, Siontis KC, Piccini JP, Noseworthy PA. Periprocedural Anticoagulation Management for Atrial Fibrillation Ablation: Current Knowledge and Future Directions. Curr Treat Options Cardio Med 2018; 20:3. [DOI: 10.1007/s11936-018-0600-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Sugrue A, Rohatgi RK, Noseworthy PA, Kremen V, Bos JM, Qiang B, Sapir Y, Attia ZI, Scott CG, Brady P, Asirvatham SJ, Friedman PA, Ackerman MJ. Architectural T-Wave Analysis and Identification of On-Therapy Breakthrough Arrhythmic Risk in Type 1 and Type 2 Long-QT Syndrome. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005648. [DOI: 10.1161/circep.117.005648] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/30/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Alan Sugrue
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Ram K. Rohatgi
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Peter A. Noseworthy
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Vaclav Kremen
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - J. Martijn Bos
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Bo Qiang
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Yehu Sapir
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Zachi I. Attia
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Christopher G. Scott
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Peter Brady
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Samuel J. Asirvatham
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Paul A. Friedman
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
| | - Michael J. Ackerman
- From the Division of Heart Rhythm Services, Department of Cardiovascular Diseases (A.S., P.A.N., V.K., B.Q., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine (R.K.R., J.M.B., S.J.A., M.J.A.), and Department of Molecular Pharmacology and Experimental Therapeutics (J.M.B., M.J.A.), Windland Smith Rice Sudden Death Genomics Laboratory, and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; Czech
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Sugrue A, Witt C, DeSimone CV, Padnanabhan D, Killu A, Naksuk N, Kapa S, Asirvatham SJ. Abstract 60: Inducible Arrythmogenicity of Direct Current Electroporation Ablation: Insight from a Series of Acute Canine Studies. Circ Res 2017. [DOI: 10.1161/res.121.suppl_1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The use of direct current electroporation has the potential for significant utility because of its non-thermal approach to tissue destruction. However, the fear of inducibility of cardiac arrhythmias (particular ventricular fibrillation) when using electroporation remains of concern due to membrane poration and ion flux during periods of vulnerability occurring in ventricular repolarization.
Objectives:
Critically examine the incidence of arrhythmias in a series of acute canine studies to retrospectively determine cause and safe electoporative dosing margins.
Methods:
We performed electroporation ablation in 6 acute canine studies. These were experimental studies performed at sites critical in arrhytmogenesis. Sites included the pulmonary veins, left atrial appendage, superior vena cavae, right atrium and ventricle. Electroporation was delivered using an ECG gating algorithm so that QRS complexes are tagged and direct current energy is not delivered during the vulnerable portion of the T wave.
Results:
In 6 acute canine experiments, we delivered a total of 62 electroporation applications for ablation purposes. The average electroporation dosage delivered involved an average of 1427 Volts (range 750-3000 V), Pulse length of 100 ms, and number of pulses of 20.2 (range 10-100). AF was induced in 27.4% of electroporiatve applications. Atrial flutter/tachycardia occurred in 8.1%. VF occurred in only one application at a location of the left superior pulmonary vein.
Conclusion:
These data suggest that induction of VF is relatively uncommon with ECG gating and highlight its importance when using this modality. However, the induction of AF occurs with higher frequency. The actual mechanism as to why this occurs requires further systematic study.
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Padmanabhan D, Witt C, Sugrue A, Killu A, Naksuk N, Desimone C, Ladewig D, Powers J, Suddendorf S, Asirvatham S. Abstract 55: Use of a Novel Electrogram Filter to Visualise the Conduction Tissue Signals in the Ventricle in Sinus Rhythm and Arrhythmia: Canine Studies. Circ Res 2017. [DOI: 10.1161/res.121.suppl_1.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Conduction tissue in the ventricles is closely intertwined with myocardium. Owing to high velocity of conduction, there is near simultaneous activation , making it difficult to discern. Restricted sampling rates and limited dynamic range make real time signal processing challenging for these signals in routine recording systems.
Objectives:
We aimed to use novel signal processing techniques in a new system to isolate the conduction tissue signals from the rest of the myocardial activation.
Methods:
We used the PURE-EP™ (BioSig Technologies, MN) signal processing system to record endocardial and epicardial signals from 6 anesthetized canines in an acute study setting. A novel filter based on proprietary algorithms to isolate the high frequency signal was applied at sites where the electrogram signals were thought to have a conduction tissue component to them. . In addition, ventricular fibrillation (VF) was induced at the end of the experiment and signals were then recorded from the endocardium and the conduction system.
Results:
This filter was successfully able to isolate conduction tissue signals in the myocardium from those of the ventricular muscle. It did over sense atrial signals at the basal left ventricular septum owing to the high frequency components of the atrial signal at this location. When applied to epicardial signals, it did not pick up any conduction tissue signals. In VF, we could discern signals originating from the conduction system endocardially. (Figure 1)
Conclusions:
This filter can isolate conduction tissue signals from those of the myocardium and may prove to be a useful adjunct in mapping arrhythmias originating near the conduction system.
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Rohatgi RK, Sugrue A, Bos JM, Cannon BC, Asirvatham SJ, Moir C, Owen HJ, Bos KM, Kruisselbrink T, Ackerman MJ. Contemporary Outcomes in Patients With Long QT Syndrome. J Am Coll Cardiol 2017; 70:453-462. [DOI: 10.1016/j.jacc.2017.05.046] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 11/15/2022]
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Padmanabhan D, Sugrue A, Gaba P, Asirvatham SJ. Outflow tract ventricular arrhythmias : Electrocardiographic features in relation to mapping and ablation. Herzschrittmacherther Elektrophysiol 2017; 28:177-186. [PMID: 28534205 DOI: 10.1007/s00399-017-0507-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
Ventricular arrhythmia arising from the outflow tracts can manifest itself as frequent premature ventricular complexes (PVCs), salvos of ventricular tachycardia (VT), and/or sustained VT. It is amenable to management with medication and catheter ablation without need for an intracardiac defibrillator. The electrocardiogram (ECG) is a crucial tool in the management of these patients as it is can help localize the site of origin, thereby helping guide the electrophysiologist. An appreciation of the unique anatomy of the outflow tracts as well as their relationships with the surrounding structures is essential in interpreting the ECG. In this review, we examine the ECG features of the various outflow tract arrhythmia morphologies with a focus on anatomy and provide an approach to the ablation of these abnormal rhythms.
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Affiliation(s)
- Deepak Padmanabhan
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Alan Sugrue
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Prakriti Gaba
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA.
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Sugrue A, Noseworthy PA, Kremen V, Bos JM, Qiang B, Rohatgi RK, Sapir Y, Attia ZI, Brady P, Caraballo PJ, Asirvatham SJ, Friedman PA, Ackerman MJ. Automated T-wave analysis can differentiate acquired QT prolongation from congenital long QT syndrome. Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28429460 DOI: 10.1111/anec.12455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/18/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Prolongation of the QT on the surface electrocardiogram can be due to either genetic or acquired causes. Distinguishing congenital long QT syndrome (LQTS) from acquired QT prolongation has important prognostic and management implications. We aimed to investigate if quantitative T-wave analysis could provide a tool for the physician to differentiate between congenital and acquired QT prolongation. METHODS Patients were identified through an institution-wide computer-based QT screening system which alerts the physician if the QTc ≥ 500 ms. ECGs were retrospectively analyzed with an automated T-wave analysis program. Congenital LQTS was compared in a 1:3 ratio to those with an identified acquired etiology for QT prolongation (electrolyte abnormality and/or prescription of known QT prolongation medications). Linear discriminant analysis was performed using 10-fold cross-validation to statistically test the selected features. RESULTS The 12-lead ECG of 38 patients with congenital LQTS and 114 patients with drug-induced and/or electrolyte-mediated QT prolongation were analyzed. In lead V5 , patients with acquired QT prolongation had a shallower T wave right slope (-2,322 vs. -3,593 mV/s), greater T-peak-Tend interval (109 vs. 92 ms), and smaller T wave center of gravity on the x axis (290 ms vs. 310 ms; p < .001). These features could distinguish congenital from acquired causes in 77% of cases (sensitivity 90%, specificity 58%). CONCLUSION T-wave morphological analysis on lead V5 of the surface ECG could successfully differentiate congenital from acquired causes of QT prolongation.
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Affiliation(s)
- Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Vaclav Kremen
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA.,Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
| | - J Martijn Bos
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology & Experimental Therapeutics Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Bo Qiang
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Ram K Rohatgi
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Yehu Sapir
- Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Zachi I Attia
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA.,Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Peter Brady
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.,Department of Molecular Pharmacology & Experimental Therapeutics Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
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47
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Padmanabhan D, Foxall T, Drakulic B, Witt C, Killu A, Naksuk N, Sugrue A, Venkatachalam KL, Asirvatham S. Initial Experience with the BioSig PURE EP™ Signal Recording System: An Animal Laboratory Experience. J Innov Card Rhythm Manag 2017; 8:2690-2699. [PMID: 32494447 PMCID: PMC7252935 DOI: 10.19102/icrm.2017.080407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/11/2017] [Indexed: 11/06/2022] Open
Abstract
Current signal recording and processing systems have come a long way since their initial inception and use. There is, however, still ample scope for improvement, not only in the troubleshooting of their limitations, but also in the expansion of the boundaries in the recording of intracardiac signals. Here, we recount our experience with the use of the PURE EP™ signal recording system (BioSig Technologies, Inc., Minneapolis, MN, USA) in the animal laboratory.
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Affiliation(s)
| | | | | | - Chance Witt
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ammar Killu
- Department of Electrophysiology, Brigham and Womens' Hospital, Boston, MA
| | - Niyada Naksuk
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - K L Venkatachalam
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL
| | - Samuel Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL.,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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48
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Sugrue A, Killu AM, DeSimone CV, Chahal AA, Vogt JC, Kremen V, Hai J, Hodge DO, Acker NG, Geske JB, Ackerman MJ, Ommen SR, Lin G, Noseworthy PA, Brady PA. Utility of T-wave amplitude as a non-invasive risk marker of sudden cardiac death in hypertrophic cardiomyopathy. Open Heart 2017; 4:e000561. [PMID: 28409011 PMCID: PMC5384475 DOI: 10.1136/openhrt-2016-000561] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 01/21/2023] Open
Abstract
Objective Sudden cardiac arrest (SCA) is the most devastating outcome in hypertrophic cardiomyopathy (HCM). We evaluated repolarisation features on the surface electrocardiogram (ECG) to identify the potential risk factors for SCA. Methods Data was collected from 52 patients with HCM who underwent implantable cardioverter defibrillator (ICD) implantation. Leads V2 and V5 from the ECG closest to the time of ICD implant were utilised for measuring the Tpeak-Tend interval (Tpe), QTc, Tpe/QTc, T-wave duration and T-wave amplitude. The presence of the five traditional SCA-associated risk factors was assessed, as well as the HCM risk-SCD score. Results 16 (30%) patients experienced aborted cardiac arrest over 8.5±4.1 years, with 9 receiving an ICD shock and 7 receiving ATP. On univariate analysis, T-wave amplitude was associated with appropriate ICD therapy (HR per 0.1 mV 0.79, 95% CI 0.56 to 0.96, p=0.02). Aborted SCA was not associated with a greater mean QTc duration, Tpeak-Tend interval, T-wave duration, or Tpe/QT ratio. Multivariate analysis (adjusting for cardinal HCM SCA-risk factors) showed T-wave amplitude in Lead V2 was an independent predictor of risk (adjusted HR per 0.1 mV 0.74, 95% CI 0.57 to 0.97, p=0.03). Addition of T-wave amplitude in Lead V2 to the traditional risk factors resulted in significant improvement in risk stratification (C-statistic from 0.65 to 0.75) but did not improve the performance of the HCM SCD-risk score. Conclusions T-wave amplitude is a novel marker of SCA in this high risk HCM population and may provide incremental predictive value to established risk factors. Further work is needed to define the role of repolarisation abnormalities in predicting SCA in HCM.
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Affiliation(s)
- Alan Sugrue
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ammar M Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anwar A Chahal
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Josh C Vogt
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vaclav Kremen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Graduate School of Medicine, Rochester, Minnesota, USA
| | - JoJo Hai
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy G Acker
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Specialty Registrar, Cardiology and Internal Medicine, London Deanery, University College London Partners, UK
| | - Steve R Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Brady
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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49
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Killu AM, Mulpuru SK, Al-Hijji MA, Sugrue A, Munger TM, Hodge DO, McLeod CJ, Packer DL, Kapa S, Asirvatham SJ, Friedman PA. Outcomes of Combined Endocardial-Epicardial Ablation Compared With Endocardial Ablation Alone in Patients Who Undergo Epicardial Access. Am J Cardiol 2016; 118:842-848. [PMID: 27553109 DOI: 10.1016/j.amjcard.2016.06.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 11/16/2022]
Abstract
Percutaneous epicardial access (EpiAcc) is used in an attempt to improve outcomes of ablation. We aim to report our experience in EpiAcc for management of symptomatic ventricular premature complexes (VPC) and ventricular tachycardia (VT). All patients from January 2004 to July 2014 who underwent EpiAcc as part of a VPC or VT ablation procedure were included. Outcomes between those with endocardial-only (Gp1) and endocardial/epicardial (Gp2) ablation and those for VPC and VT ablation were compared. EpiAcc for VPC or VT ablation was attempted in 173 patients; 10 patients were excluded because of failure of access (n = 7) or no ablation performed (n = 3). Of the remaining 163, 131 patients (80.4%) had undergone previous endocardial ablation. Mean age was 53.7 ± 15.7 years; 115 (71%) were men. VT ablation was the indication in 105 patients (64%). The underlying substrate was predominately nonischemic cardiomyopathy (49.1%). Epicardial ablation was performed in 115 (70.6%). Procedural and clinical success was obtained in 92.0% and 69.9% of patients, respectively, with no difference between Gp1 and Gp2. Those who underwent VPC ablation had superior clinical outcomes at 1-year follow-up. EpiAcc is feasible in almost all patients with no previous cardiac surgery and permits acute procedural success in >90% of patients, most of whom had failed previous ablation. However, epicardial ablation was not delivered in 1/3 of patients. Epicardial mapping may be helpful as in the absence of an appropriate epicardial site for ablation, and focus can be shifted to more detailed endocardial mapping and ablation.
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Affiliation(s)
- Ammar M Killu
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Siva K Mulpuru
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohammed A Al-Hijji
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan Sugrue
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas M Munger
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Christopher J McLeod
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Douglas L Packer
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Suraj Kapa
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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50
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Sugrue A, Noseworthy PA, Kremen V, Bos JM, Qiang B, Rohatgi RK, Sapir Y, Attia ZI, Brady P, Asirvatham SJ, Friedman PA, Ackerman MJ. Identification of Concealed and Manifest Long QT Syndrome Using a Novel T Wave Analysis Program. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.115.003830. [DOI: 10.1161/circep.115.003830] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 06/03/2016] [Indexed: 11/16/2022]
Abstract
Background—
Congenital long QT syndrome (LQTS) is characterized by QT prolongation. However, the QT interval itself is insufficient for diagnosis, unless the corrected QT interval is repeatedly ≥500 ms without an acquired explanation. Further, the majority of LQTS patients have a corrected QT interval below this threshold, and a significant minority has normal resting corrected QT interval values. Here, we aimed to develop and validate a novel, quantitative T wave morphological analysis program to differentiate LQTS patients from healthy controls.
Methods and Results—
We analyzed a genotyped cohort of 420 patients (22±16 years, 43% male) with either LQT1 (61%) or LQT2 (39%). ECG analysis was conducted using a novel, proprietary T wave analysis program that quantitates subtle changes in T wave morphology. The top 3 discriminating features in each ECG lead were determined and the lead with the best discrimination selected. Classification was performed using a linear discriminant classifier and validated on an untouched cohort. The top 3 features were Tpeak–Tend interval, T wave left slope, and T wave center of gravity
x
axis (last 25% of the T wave). Lead V6 had the best discrimination. It could distinguish 86.8% of LQTS patients from healthy controls. Moreover, it distinguished 83.33% of patients with concealed LQTS from controls, despite having essentially identical resting corrected QT interval values.
Conclusions—
T wave quantitative analysis on the 12-lead surface ECG provides an effective, novel tool to distinguish patients with either LQT1/LQT2 from healthy matched controls. It can provide guidance while mutation-specific genetic testing is in motion for family members.
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Affiliation(s)
- Alan Sugrue
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Peter A. Noseworthy
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Vaclav Kremen
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - J. Martijn Bos
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Bo Qiang
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Ram K. Rohatgi
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Yehu Sapir
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Zachi I. Attia
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Peter Brady
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Samuel J. Asirvatham
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Paul A. Friedman
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
| | - Michael J. Ackerman
- From the Division of Internal Medicine (A.S.), Division of Cardiovascular Diseases (P.A.N., V.K., B.Q., R.K.R., Z.I.A., P.B., S.J.A., P.A.F., M.J.A.), Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., S.J.A., M.J.A.), Mayo Clinic, Rochester, MN; Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Czech Republic (V.K.); Electrical and Computer Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel (Y.S
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