Same-day discharge following catheter ablation and venous closure with VASCADE MVP: A postmarket registry

INTRODUCTION

Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF).

METHODS

The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure.

RESULTS

Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight.

CONCLUSION

In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.

Life cycle management of Micra transcatheter pacing system: Data from a high-volume center

BACKGROUND

Data on the management of Micra transcatheter pacing system (TPS) at the time of an upgrade or during battery depletion is limited.

OBJECTIVE

We sought to evaluate the management patterns of patients implanted with a Micra TPS during long-term follow-up.

METHODS

We retrospectively identified patients who underwent Micra implantation from April 2014 to November 2019. We identified patients who underwent extraction (n = 11) or had an abandoned Micra (n = 12).

RESULTS

We identified 302 patients who received a Micra during the period of the study. Mean age was 72.7 ± 15.4 years, 54.6% were men, and left ventricular ejection fraction was 51.9 ± 5.2%. Mean follow-up was 1105.5 ± 529.3 days. Procedural complications included pericardial tamponade (n = 1) treated with pericardiocentesis, significant rise in thresholds (n = 6) treated with reimplantation (n = 4), and major groin complications (n = 2). Indications for extraction included an upgrade to cardiac resynchronization therapy (CRT) device (n = 3), bridging after extraction of an infected transvenous system (n = 3), elevated thresholds (n = 3), and non-Micra-related bacteremia (n = 2). The median time from implantation to extraction was 78 days (interquartile range: 14-113 days), with the longest extraction occurring at 1442 days. All extractions were successful, with no procedural or long-term complications. Indications for abandonment included the need for CRT (n = 6), battery depletion (n = 2), increasing thresholds/failure to capture (n = 3), and pacemaker syndrome (n = 1). All procedures were successful, with no procedural or long-term complications.

CONCLUSION

In this large single-center study, 6% of patients implanted with a Micra required a system modification during long-term follow-up, most commonly due to the requirement for CRT pacing. These patients were managed successfully with extraction or abandonment.

Use of microelectrode near-field signals to determine catheter contact

Background

The utility of standard distal bipolar electrograms (sEGMs) for assessing catheter‐tissue contact may be obscured by the presence of far‐field signals. Microelectrode electrograms (mEGMs) may overcome this limitation.

Methods

We compared 5 mEGM characteristics (amplitude, frequency content, temporal signal variability, presence of injury current, and amplitude differential between bipoles) with the sEGM for determining tissue contact in 20 patients undergoing ablation of typical atrial flutter. Visualization of catheter‐tissue contact by intracardiac echocardiography (ICE) served as the gold standard for assessing contact. Correlation between electrograms and ICE‐verified contact level was reported as percent concordance.

Results

Three of 5 mEGM characteristics demonstrated significantly better concordance with ICE‐verified contact level than the sEGM (52% concordance with ICE): mEGM frequency content (59% concordance with ICE, P < .001 for comparison with sEGM); mEGM amplitude (concordance 59%, P < .001); and mEGM presence of injury current (56% concordance, P = .001). Concordance of amplitude differential between mEGM bipoles with ICE (49%) was not significantly different than the sEGM (P = .638) whereas mEGM temporal variability (39%) was significantly worse than the sEGM. Using a median of all 5 mEGM characteristics provided additive information (concordance with ICE 64%) and was significantly better than all of the individual mEGM characteristics except frequency content (P = .976).

Conclusion

Microelectrode EGMs (in particular frequency content, amplitude, and presence of injury current) can improve real‐time assessment of catheter contact compared to the use of standard bipolar EGMs. Broader use of mEGMs may enhance ablation efficacy.

Clinical and anatomic predictors of need for repeat atrial fibrillation ablation

AIM

To identify predictors of need for repeat procedures after initial atrial fibrillation (AF) ablation.

METHODS

We identified a cohort undergoing first time AF ablation at our institution from January 2004 to February 2014 who had cardiac magnetic resonance (CMR) imaging performed prior to ablation. Clinical variables and anatomic characteristics (determined from CMR) were assessed as predictors of need for repeat ablation. The decision regarding need for and timing of repeat ablation was at the discretion of the treating physician.

RESULTS

From a cohort of 331 patients, 142 patients (43%) underwent repeat ablation at a mean of 13.6 ± 18.4 mo after the index procedure. Both male gender (81% vs 71%, P = 0.05) and lower ejection fraction (57.4% ± 10.3% vs 59.8% ± 9.4%, P = 0.04) were associated with need for repeat ablation. On pre-ablation CMR, mean pulmonary vein (PV) diameters were significantly larger in all four PVs among patients requiring repeat procedures. In multivariate analysis, increased right superior PV diameter significantly predicted need for repeat ablation (odds ratio 1.08 per millimeter increase in diameter, 95%CI: 1.00-1.16, P = 0.05). There were also trends toward significance for increased left and right inferior PV sizes among those requiring repeat procedures.

CONCLUSION

Increased PV size predicts the need for repeat AF ablation, with each millimeter increase in PV diameter associated with an approximately 5%-10% increased risk of requiring repeat procedures.

Pulmonary Vein Remodeling Following Atrial Fibrillation Ablation: Implications For The Radiographic Diagnosis Of Pulmonary Vein Stenosis

Background: Pulmonary vein (PV) reverse remodeling has been recognized following atrial fibrillation (AF) ablation. However, the extent of physiologic reverse remodeling after AF ablation and the potential impact of reverse remodeling on the radiographic diagnosis of PV stenosis have not been well characterized. Methods: From January 2004 to February 2014, 186 patients underwent paired cardiac magnetic resonance imaging (MRI) to delineate PV orifice dimensions before and after (mean 109 ± 61 days) an initial AF ablation. Results: Negative remodeling of the PV orifice cross sectional area occurred in 67.8% of veins with a mean reduction in area of 21.0 ± 14.1%, and positive remodeling was seen in the remaining PVs with an increase in area of 22.1 ± 23.4% compared to baseline. No PVs demonstrated a reduction in cross-sectional area of > 75% (maximum reduction observed was 58%). Negative remodeling of the PV long axis dimension was observed in 55.2% of veins with a mean reduction of 14.6 ± 9.2% compared to pre-ablation and positive remodeling was observed in 25.3% of PVs with a mean increase in diameter of 14.7 ± 12.6%. Only 1 PV demonstrated a reduction in orifice diameter of > 50%. There were no clinically evident or suspected cases of PV stenosis in this cohort. Conclusions: Negative remodeling of the PV orifice area was noted in the majority of PVs following AF ablation. However, in almost all cases, the extent of negative remodeling was well below commonly used thresholds for the radiographic diagnosis of PV stenosis.

Atrial Fibrillation and Risk of Dementia/Cognitive Decline

Emerging evidence suggests a link between atrial fibrillation and subsequent development of dementia. While a majority of risk can be attributed to cardioembolic stroke secondary to atrial fibrillation, additional risk is apparent, and may be driven by vascular inflammation and changes in cerebral perfusion. Medical therapies including anticoagulation, statin therapy, and angiotensin-renin-aldosterone axis antagonists may reduce dementia risk. Procedural therapies such as atrial fibrillation catheter ablation and left atrial appendage closure may also prove to be important mediators of acute and long-term risk. In this paper, we review the data supporting a link between atrial fibrillation and dementia syndromes, pathophysiologic mechanisms and the potential roles of medical and procedural therapies at reducing such risk.

Outcomes of patients with definite and suspected isolated cardiac sarcoidosis treated with an implantable cardiac defibrillator

PURPOSE

Cardiac sarcoidosis (CS) patients are at increased risk for sudden death. Isolated CS is rare and can be difficult to diagnose.

METHODS

In this multicenter retrospective review, patients with CS and an implantable cardiac defibrillator (ICD) were identified.

RESULTS

Of 235 patients with CS and ICD, 13 (5.5 %) had isolated CS, including 7 (3.0 %) with definite isolated CS (biopsy or necropsy-proven) and 6 (2.6 %) with suspected isolated CS based on a constellation of clinical, ECG, and imaging findings. Among 13 patients with isolated CS, 10 (76.9 %) were male, mean age was 53.8 ± 7.6 years, and mean left ventricular ejection fraction was 38.3 ± 16.5. Diagnosis was made by cardiac magnetic resonance (CMR) (n = 2), biopsy (n = 3), CMR and biopsy (n = 2), CMR and positron emission tomography (PET) (n = 2), PET (n = 1), late enhanced cardiac CT (n = 1), pathology at heart transplant (n = 1), and autopsy (n = 1). Eight of 13 (61.5 %) patients with isolated CS had a secondary prevention indication (VT in 6 and VF in 2) vs. 80 of 222 (36.0 %) with sarcoidosis in other organs (p = 0.04). Over a mean of 4.2 years, 9 of 13 (69.2 %) patients with isolated CS received appropriate ICD therapy, including anti-tachycardia pacing (ATP) and/or shock, compared with 75 of 222 (33.8 %) patients with cardiac and extracardiac sarcoidosis (p = 0.0150). Six of 7 (85.7 %) patients with definite isolated CS received appropriate ICD intervention, compared with 78 of 228 patients (34.2 %) without definite isolated CS (p = 0.0192.)

CONCLUSIONS

In this retrospective study, patients with isolated CS had very high rates of appropriate ICD therapy. Prospective, long-term follow-up of consecutive patients with isolated CS is needed to determine the true natural history and rates of ventricular arrhythmias in this rare and difficult-to-diagnose disease.

Efficacy and safety of implantable cardiac defibrillators for treatment of ventricular arrhythmias in patients with cardiac sarcoidosis

AIMS

Implantable cardiac defibrillator (ICD) implantation is a class IIA recommendation for patients with cardiac sarcoidosis (CS). However, little is known about the efficacy and safety of ICDs in this population. The goal of this multicentre retrospective data review was to evaluate the efficacy and safety of ICDs in patients with CS.

METHODS AND RESULTS

Electrophysiologists at academic medical centres were asked to identify consecutive patients with CS and an ICD. Clinical information, ICD therapy history, and device complications were collected for each patient. Data were collected on 235 patients from 13 institutions, 64.7% male with mean age 55.6 ± 11.1. Over a mean follow-up of 4.2 ± 4.0 years, 85 of 234 (36.2%) patients received an appropriate ICD therapy (shocks and/or anti-tachycardia pacing) and 67 of 226 (29.7%) received an appropriate shock. Fifty-seven of 235 patients (24.3%) received a total of 222 inappropriate shocks. Forty-six adverse events occurred in 41 of 235 patients (17.4%). Patients who received appropriate ICD therapies were more likely to be male (73.8 vs. 59.6%, P = 0.0330), have a history of syncope (40.5 vs. 22.5%, P = 0.0044), lower left ventricular ejection fraction (38.1 ± 15.2 vs. 48.8 ± 14.7%, P ≤ 0.0001), ventricular pacing on baseline electrocardiogram (16.1 vs. 2.1%, P = 0.0002), and a secondary prevention indication (60.7 vs. 24.5%, P < 0.0001) compared with those who did not receive appropriate ICD therapies.

CONCLUSION

Patients with CS and ICDs are at high risk for ventricular arrhythmias. This population also has high rates of inappropriate shocks and device complications.

Prediction of new onset atrial fibrillation after cardiac revascularization surgery

The aim of this study was to create a simple risk index to predict new-onset atrial fibrillation (AF) after coronary artery bypass grafting in patients with histories of AF. AF after coronary artery bypass grafting (referred to here as AF) is associated with increased morbidity and mortality. Identifying patients at high risk for developing AF may help identify a group of patients who might benefit from strategies to prevent postoperative AF. A cohort of 18,517 patients enrolled from January 1, 1996, to December 31, 2009, was used to derive a risk index for AF prediction. A multivariate logistic regression model determined the independent predictive impact of clinical and demographic characteristics on the occurrence of AF. A subset of these variables was used to construct a risk index to predict AF. This risk index was validated in a sequential cohort of 1,378 consecutive patients who underwent coronary artery bypass grafting from January 1, 2010, to June 30, 2011. AF occurred in 3,486 patients in the calibration cohort (18.83%) and in 269 patients in the validation cohort (19.52%). After considering patients' demographics, co-morbid conditions, and severity of illness, advanced age appeared as the most powerful predictor of AF (odds ratio 1.059/year, 95% confidence interval 1.055 to 1.063). Age, height, weight, and the presence of peripheral vascular disease contributed most to the prediction model. An AF risk index including these variables had adequate discriminatory power, with a concordance index of 0.68. In conclusion, using a large cohort of patients, a simple risk index relying only on preoperative clinical variables was developed, which will help predict AF. This risk index can be used clinically to identify patients at high risk for the development of AF.

QRS duration is associated with atrial fibrillation in patients with left ventricular dysfunction

BACKGROUND

QRSduration (QRSd) is associated with higher mortality and morbidity in patients with left ventricular (LV) dysfunction. The association between QRSd and atrial fibrillation (AF) has not been studied in this patient population.

OBJECTIVES

To investigate the association between QRSd and AF in patients with LV dysfunction.

METHODS

Data were obtained from the National Registry to Advance Heart Health (ADVANCENT) registry, a prospective multicenter registry of patients with left ventricular ejection fraction (LVEF) < or = 40%. A total of 25 268 patients from 106 centers in the United States, were enrolled between June 2003 and November 2004. Demographic and clinical characteristics of patients were collected from interviews and medical records.

RESULTS

: Mean age was 66.3+/-13 years, 71.5% were males, and 81.9% were white. A total of 14 452 (57.8%) patients had a QRSd < 120 ms, 5304 (21.2%) had a QRSd between 120 and 150 ms, and 5269 (21%) had a QRSd > 150 ms. Atrial fibrillation occurred in 20.9%, 27.5%, and 35.5% of patients in the QRS groups, respectively (P < 0.0001). After adjusting for potential AF risk factors (age, gender, race, body mass index, hypertension, diabetes, renal failure, cancer, lung disease, New York Heart Association [NYHA] class, ejection fraction, etiology of cardiomyopathy) and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and lipid lowering drugs, QRS duration remained independently associated with AF (odds ratio: 1.20, 95% confidence interval: 1.14-1.25).

CONCLUSION

In this large cohort of patients, QRSd was strongly associated with AF and therefore may predict the occurrence of this arrhythmia in patients with LV dysfunction. This association persisted after adjusting for disease severity, comorbid conditions, and the use of medications known to be protective against AF.

New-onset atrial fibrillation predicts long-term mortality after coronary artery bypass graft

OBJECTIVES

We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation.

BACKGROUND

POAF predicts longer hospital stay and greater post-operative mortality.

METHODS

A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease.

RESULTS

New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up.

CONCLUSIONS

In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.

Progress in Cardiovascular Disease: Technical Considerations in Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) has been shown to improve symptoms, ventricular function, and survival in patients with left ventricular systolic dysfunction and ventricular conduction delay. Patients with moderate to severe drug-refractory heart failure symptoms along with ventricular dyssynchrony, manifested as prolongation of the QRS duration on the surface electrocardiogram, benefit from CRT. Owing to the growing awareness and application of CRT, a large number of patients have been identified as candidates for this therapy, making it necessary for clinicians involved in the care of such patients to be adequately knowledgeable of various aspects of CRT implementation. In particular, clinicians involved in the care of these patients must be aware of the practical considerations in preparing patients for the implantation procedure, careful surveillance for early or late procedure-related complications, and knowledge of the fundamental device features so as to tailor therapeutic and programming techniques to improve long-term response to CRT. This review addresses the technical considerations of the implantation procedure and device function with emphasis on the initial and long-term programming to ensure optimal delivery of CRT.

Addition of a left ventricular lead to conventional pacing systems in patients with congestive heart failure: feasibility, safety, and early results in 60 consecutive patients

Left bundle branch block worsens congestive heart failure (CHF) in patients with LV dysfunction. Asynchronous LV activation produced by RV apical pacing leads to paradoxical septal motion and inefficient ventricular contraction. Recent studies show improvement in LV function and patient symptoms with biventricular pacing in patients with CHF. The aim of this study was to determine the feasibility, safety, acute efficacy, and early effect on symptoms of the upgrade of a chronically implanted RV pacing system to a biventricular system. Sixty patients with NYHA Class III and IV underwent the upgrade procedure using commercially available leads and adapters. The procedure succeeded in 54 (90%) of 60 patients. Acute LV stimulation thresholds obtained from leads placed along the lateral LV wall via the coronary sinus compare favorably to those reported in current biventricular pacing trials. The complication rate was low (5/60, 8.3%): lead dislodgement (n = 1), pocket hematoma (n = 1), and wound infections (n = 3). During 18 months of follow-up (16.7%) of 60 patients died. Two patients that died failed the initial upgrade attempt. At 3-month follow-up, quality of life scores improved 31 +/- 28 points (n = 29), P < 0.0001). NYHA Class improved from 3.4 +/- 0.5 to 2.4 +/- 0.7 (P = < 0.0001) and ejection fraction increased from 0.23 +/- 0.8 to 0.29 +/- 0.11 (P = 0.0003). Modification of RV pacing to a biventricular system using commercially available leads and adapters can be performed effectively and safely. The early results of this study suggest patients may benefit from this procedure with improved functional status and quality of life.

Cardiac resynchronization in chronic heart failure

BACKGROUND

Previous studies have suggested that cardiac resynchronization achieved through atrial-synchronized biventricular pacing produces clinical benefits in patients with heart failure who have an intraventricular conduction delay. We conducted a double-blind trial to evaluate this therapeutic approach.

METHODS

Four hundred fifty-three patients with moderate-to-severe symptoms of heart failure associated with an ejection fraction of 35 percent or less and a QRS interval of 130 msec or more were randomly assigned to a cardiac-resynchronization group (228 patients) or to a control group (225 patients) for six months, while conventional therapy for heart failure was maintained. The primary end points were the New York Heart Association functional class, quality of life, and the distance walked in six minutes.

RESULTS

As compared with the control group, patients assigned to cardiac resynchronization experienced an improvement in the distance walked in six minutes (+39 vs. +10 m, P=0.005), functional class (P<0.001), quality of life (-18.0 vs. -9.0 points, P= 0.001), time on the treadmill during exercise testing (+81 vs. +19 sec, P=0.001), and ejection fraction (+4.6 percent vs. -0.2 percent, P<0.001). In addition, fewer patients in the group assigned to cardiac resynchronization than control patients required hospitalization (8 percent vs. 15 percent) or intravenous medications (7 percent vs. 15 percent) for the treatment of heart failure (P<0.05 for both comparisons). Implantation of the device was unsuccessful in 8 percent of patients and was complicated by refractory hypotension, bradycardia, or asystole in four patients (two of whom died) and by perforation of the coronary sinus requiring pericardiocentesis in two others.

CONCLUSIONS

Cardiac resynchronization results in significant clinical improvement in patients who have moderate-to-severe heart failure and an intraventricular conduction delay.