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Pope MTB, Paisey JR, Roberts PR. Defibrillation Threshold Testing for Right-sided Device Implants: A Review to Inform Shared Decision-making, in Association with the British Heart Rhythm Society. Arrhythm Electrophysiol Rev 2023; 12:e10. [PMID: 37427305 PMCID: PMC10326664 DOI: 10.15420/aer.2022.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/27/2022] [Indexed: 07/11/2023] Open
Abstract
Prevention of sudden death using ICDs requires the reliable delivery of a high-energy shock to successfully terminate VF. Until more recently, the device implant procedure included conducting defibrillation threshold (DFT) testing involving VF induction and shock delivery to ensure efficacy. Large clinical trials, including SIMPLE and NORDIC ICD, have subsequently demonstrated that this is unnecessary, with a practice of omitting DFT testing having no impact on subsequent clinical outcomes. However, these studies specifically excluded patients requiring devices implanted on the right side, in whom the shock vector is significantly different and smaller studies suggest a higher DFT. In this review, the data regarding the use of DFT testing, focusing on right-sided implants, and the results of a survey of current UK practice are presented. In addition, a strategy of shared decision-making when it comes to deciding on the use of DFT testing during right-sided ICD implant procedures is proposed.
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Affiliation(s)
- Michael TB Pope
- Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, UK
| | - John R Paisey
- Department of Cardiology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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2
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Briosa E Gala A, Pope MTP, Leo M, Ormerod J, Field D, Balasubramaniam R, Thomas H, Gardner RS, Hunter R, Gallagher MM, Wilson D, Paisey JR, Curzen NP, Betts TR. Accuracy of AF burden detection with the new Confirm Rx with Sharp-sense technology. Europace 2022. [DOI: 10.1093/europace/euac053.173] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Implantable cardiac monitors (ICMs) are increasingly used to monitor atrial fibrillation (AF) burden following catheter ablation. AF burden recorded by the Confirm Rx™ ICM cannot be modified even after adjudication of false-positive (FP) episodes. We sought to investigate accuracy of the AF burden detection in a UK cohort.
Methods
This multicentre retrospective study included patients with Confirm Rx™ and at least one episode >6 minutes across 9 UK hospitals. Each episode had a corresponding 120-second EGM (electrogram) and heart rate scatterplot which was considered representative of the whole episode. One cardiologist adjudicated all EGMs as ‘True AF’ or ‘False positive’ and a random sample of 10% was reviewed to account for intra and interobserver variability. AF burden was computed as the duration of all episodes classified as AF by the Confirm-Rx divided by the total duration of follow-up. ‘True-AF’ burden was calculated by dividing the duration of episodes adjudicated as ‘True-AF’ by the total duration of follow-up. We also investigated the accuracy of AF burden according to implantation indication and episode duration.
Results
A total of 16,230 individual AF episodes were included from 232 consecutive patients. Overall, 26,137 hours of AF were recorded and a total follow-up 315 patient-years which equates to an AF burden of 0.95%. However, only 24,404.7 (93.3%) hours represented time in ‘True-AF’ and a ‘True-AF’ burden for the whole cohort of 0.89% (Table 1). Patients with a Confirm-Rx™ for palpitations and suspected AF had the lowest proportion of ‘True-AF’ burden and had a modest contribution to the overall AF burden (Figure 1). Conversely, patients with known AF had the highest proportion of ‘True-AF’ burden recorded. Most AF (84.5%) episodes lasted less than 1 hour with approximately a quarter adjudicated as false-positive detections, but their contribution towards overall AF burden was very small (Figure 2A-2B). In contrast, AF >3 hours accounted for 76.4% of time in AF and the proportion of ‘True-AF’ burden was 98.5%.
Conclusion
The accuracy of the estimated AF burden for the whole cohort was excellent (93.3%), driven by the high proportion of ‘True-AF’ burden in AF>3 hours.
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Affiliation(s)
- A Briosa E Gala
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - MTP Pope
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - M Leo
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - J Ormerod
- Milton Keynes University Hospital NHS Trust, Milton Keynes, United Kingdom of Great Britain & Northern Ireland
| | - D Field
- Essex Cardiothoracic Centre, Basildon, United Kingdom of Great Britain & Northern Ireland
| | - R Balasubramaniam
- University Dorset Hospital, Bournemouth, United Kingdom of Great Britain & Northern Ireland
| | - H Thomas
- Wansbeck General Hospital, Ashington, United Kingdom of Great Britain & Northern Ireland
| | - RS Gardner
- Golden Jubilee National Hospital, Glasgow, United Kingdom of Great Britain & Northern Ireland
| | - R Hunter
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - D Wilson
- Worcestershire Royal Hospital, Worcester, United Kingdom of Great Britain & Northern Ireland
| | - JR Paisey
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - NP Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - TR Betts
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
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Bates A, Paisey JR, Yue A, Banks P, Roberts PR, Ullah W. Establishing safe, effective ablation in the diseased human ventricle: an analysis of generator impedance and electrogram attenuation. Europace 2022. [DOI: 10.1093/europace/euac053.353] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Biosense Webster Inc
Background
Predictors of effective and safe lesion delivery in the human left ventricle have not been established. Generator impedance (GI) drop and electrogram (EGM) attenuation are indices which can be used as surrogates for ablation lesion parameters. Tissue pops are a complication of myocardial overheating preceded by a rise in GI and can have adverse consequences.
Purpose
To establish the relationships between Ablation Index (AI), Force Time Integral (FTI) and contact force with GI and EGM attenuation. To establish factors early in ablation that are predictive of a GI rise.
Methods
Patients undergoing ventricular tachycardia ablation were recruited. All ablations were performed with contact force sensing surround flow catheters. Electrograms were collected pre and post ablation, with GI, AI, FTI measured during. Ablations were divided into low (LVM, < 0.50mV), intermediate (IVM, 0.51 – 1.50mV) and normal voltage (NVM, > 1.50mV) based upon pre-ablation bipolar EGM amplitude. Ablations with a 5% rise in GI from maximal drop were noted and predictors of this explored.
Results
In 15 patients, 402 ablations were analysed. Filtered percentage GI drop correlated with AI and FTI, (p < 0.0005, Spearman’s ρ = 0.522 and 0.524) and reached a plateau at 763AI and 713gs, a filtered GI drop of 7.5% (Figure 1). Shallower curves occurred progressively from NVM to IVM to LVM, (p < 0.0005), (Figure 2)
The bipolar EGM significantly attenuated with ablation, (median attenuation 0.14mV, [29.3%], p <0.0005), but percentage attenuation did not correlate with AI or FTI.
Parameters associated with a GI rise during ablation were greater mean CF to maximum GI drop, (p = 0.002), greater initial percentage GI drop at 5 seconds, (p < 0.0005), power of 50W (p = 0.005), and perpendicular orientation, (p = 0.006). Percentage GI drop at 5 seconds was the best predictor of ablations with a GI rise, (AUCROC 0.773; 95% CI 0.708 – 0.838; optimal cut-off 2.44%). Mean contact force to maximum GI drop was a poor predictor of a GI rise (AUCROC 0.647; 95% CI 0.577 – 0.718, optimal cut-off 14.7g).
Conclusion
During left ventricular ablation, AI of 763 and FTI of 713gs should be targeted, with a lower impedance drop observed for more scarred myocardium. A GI drop of <2.5% at 5 seconds and contact force < 15g should be used to optimise ablation safety.
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Affiliation(s)
- A Bates
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - JR Paisey
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Yue
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Banks
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - PR Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - W Ullah
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Briosa E Gala A, Pope MTB, Leo M, Ormerod J, Field D, Balasubramaniam R, Hunter R, Thomas H, Gardner RS, Gallagher MM, Wilson D, Paisey JR, Curzen NP, Betts TR. Diagnostic accuracy of the Confirm-Rx atrial fibrillation detection algorithm in real-world patients. Europace 2022. [DOI: 10.1093/europace/euac053.174] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Continuous rhythm monitoring with implantable cardiac monitors (ICMs) is commonly used to detect and characterise atrial fibrillation (AF) episodes. The Confirm Rx™ with SharpSense™ technology offers four new discriminators and second pass analysis aimed at enhancing detection and improving accuracy for cardiac arrhythmias. This study sought to investigate the diagnostic accuracy of the Confirm Rx™ AF detection algorithm in a UK cohort of ‘real-world’ patients.
Methods
This multicentre retrospective study included patients with Confirm Rx™ and at least one episode of AF>6 minutes from August 2018 to August 2021 across 9 UK hospitals. Each episode had a corresponding 120-second electrogram (EGM) and heart rate scatterplot. One cardiologist manually adjudicated all EGMs as ‘True-AF’ or ‘False-positive. To assess for intra and inter-observer variability, 10% of the EGMs were reviewed. Diagnostic accuracy was determined by calculating the raw and patient-averaged positive predictive value (PPV) for AF episode of different durations and implant indications.
Results
During the study 232 patients met inclusion criteria with a total of 315 patient-years of follow-up. 16,320 individual AF episodes were adjudicated; intra- and interobserver variability was excellent (Cohen’s kappa 0.85 and 0.86, respectively). The rate of ‘True-AF’ detection was 3.19 episodes per month corresponding to a raw PPV of 74.5% for the whole cohort. The highest number of episodes per months was observed in patients with a Confirm-Rx for palpitations (5.1) and suspected AF (5.8) but only approximately half of these represented ‘True-AF’ episodes (Figure 1). Patients with known AF had the lowest rate of AF episodes (1.6 episodes per month) but the highest proportion of ‘True-AF’ episodes (PPV of 95.5%). A clear trend of improving diagnostic accuracy was seen with longer AF episodes (Table1). AF>3 hours had a PPV above 94% and all episodes lasting longer than 24 hours were ‘True-AF’. For AF episode of short duration, the PPV varied with the population being monitored; however, for longer AF episodes the PPV increased significantly and irrespective of implant indication (Figure 2).
Conclusion
Overall, the Confirm Rx™ ICM diagnostic accuracy was modest for all AF episodes lasting longer than 6 minutes (74.5%) but improved considerably for longer AF episodes irrespective of implant indication.
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Affiliation(s)
- A Briosa E Gala
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - MTB Pope
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - M Leo
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - J Ormerod
- Milton Keynes University Hospital NHS Trust, Milton Keynes, United Kingdom of Great Britain & Northern Ireland
| | - D Field
- Essex Cardiothoracic Centre, Basildon, United Kingdom of Great Britain & Northern Ireland
| | - R Balasubramaniam
- University Dorset Hospital, Bournemouth, United Kingdom of Great Britain & Northern Ireland
| | - R Hunter
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - H Thomas
- Wansbeck General Hospital, Ashington, United Kingdom of Great Britain & Northern Ireland
| | - RS Gardner
- Golden Jubilee National Hospital, Glasgow, United Kingdom of Great Britain & Northern Ireland
| | - MM Gallagher
- St George’s University Hospital NHS Foundation Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - D Wilson
- Worcestershire Royal Hospital, Worcester, United Kingdom of Great Britain & Northern Ireland
| | - JR Paisey
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - NP Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - TR Betts
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom of Great Britain & Northern Ireland
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5
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Boos CJ, Holdsworth D, Woods DR, O'Hara JP, Brooks N, Macconnachie L, Bakker-Dyos J, Paisey JR, Mellor A. 18Assessment of cardiac arrhythmias at extreme high altitude using an implantable cardiac monitor: REVEAL HA Study. Europace 2017. [DOI: 10.1093/europace/eux283.027] [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: 11/14/2022] Open
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6
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Wiles BM, Illingworth CA, Paisey JR, Roberts PR, Harden SP. Keeping up appearances: the radiographic evolution of cardiovascular implantable electronic devices. Br J Radiol 2017; 91:20170506. [PMID: 28936891 DOI: 10.1259/bjr.20170506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In recent years, there has been a significant evolution in the field of cardiovascular implantable electronic devices (CIEDs). Pacemakers can now be leadless, implantable cardioverter defibrillators can be entirely subcutaneous and implantable loop recorders have become miniaturized. Driven by technological advances and an ageing population implant numbers have also steadily increased. These highly prevalent systems are all radio-opaque and are frequently observed on chest radiographs, yet the devices are neither well recognized nor understood. We present a pictorial review of CIEDs; describing the chest radiograph appearances of both newer generation systems and their traditional predecessors. Furthermore, we discuss the clinical role of chest radiography in both CIED implantation and follow up, with the aim of improving understanding in this important and expanding field. Finally, we present a collection of interesting and challenging radiographs, where multiple CIED systems have been implanted.
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Affiliation(s)
- Benedict M Wiles
- 1 Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Caroline A Illingworth
- 2 Cardiothoracic Radiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John R Paisey
- 1 Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Paul R Roberts
- 1 Cardiac Rhythm Management Research Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Stephen P Harden
- 2 Cardiothoracic Radiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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7
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Wong KC, Paisey JR, Sopher M, Balasubramaniam R, Jones M, Qureshi N, Hayes CR, Ginks MR, Rajappan K, Bashir Y, Betts TR. No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation. Circ Arrhythm Electrophysiol 2015; 8:1316-24. [DOI: 10.1161/circep.114.002504] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [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: 11/18/2014] [Accepted: 07/30/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Kelvin C.K. Wong
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - John R. Paisey
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Mark Sopher
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Richard Balasubramaniam
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Michael Jones
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Norman Qureshi
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Chris R. Hayes
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Matthew R. Ginks
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Kim Rajappan
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Yaver Bashir
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
| | - Timothy R. Betts
- From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.)
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Bowers RW, Beckett D, Paisey JR, Balasubramaniam RN, Sopher SM. Successful release of an entrapped circular mapping catheter using a snare and a multidisciplinary approach. Kardiol Pol 2015; 73:462. [PMID: 26189539 DOI: 10.5603/kp.2015.0105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/18/2014] [Indexed: 11/25/2022]
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Michael KA, Veldtman GR, Paisey JR, Robinson S, Allen S, Sunni NS, Roberts PR, Morgan JM. Non-contact mapping guided cardiac resynchronization therapy for a failing systemic right ventricle. Europace 2007; 9:880-3. [PMID: 17579245 DOI: 10.1093/europace/eum076] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Progressive systemic right ventricular (sRV) dysfunction, atrial and ventricular arrhythmias and sudden cardiac death are well-recognized late sequelae of atrial redirection surgery in which the right ventricle is left connected to the systemic circulation. Although cardiac resynchronization therapy (CRT) poses an attractive therapeutic option, little is known about indications, patient selection, and technical aspects of best lead placement. METHODS AND RESULTS We undertook CRT in a 27-year-old female patient post-Mustard correction for d-transposition (d-TGA) with New York Heart Association (NYHA) grade III disability with QRS duration measuring 130 ms. There was also echocardiographic (TTE) evidence of severe sRV dysfunction. Non-contact mapping (NCM) was used to define sites of late activation within the sRV and the acute intra-arterial blood pressure (BP) response was assessed during implantation of a 4 french (F) lead onto the endocardial surface of the sRV. At 4 weeks post-implant sRV lateral wall motion had improved and the ejection fraction (EF) rose from 23 to 33%. The patient has been successfully anticoagulated and improved to NYHA II status after 6 months. CONCLUSION The use of NCM proved safe and effective and provided a qualitative assessment of electrical viability of the sRV complimenting the measurement of mechanical function provided by TTE. The favourable clinical response in the above case justifies a prospective evaluation of this strategy.
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Affiliation(s)
- Kevin A Michael
- The Wessex Cardiothoracic Unit, Division of Clinical Electrophysiology, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD, Hampshire, UK.
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10
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Michael KA, Veldtman GR, Paisey JR, Yue AM, Robinson S, Allen S, Sunni NS, Kiesewetter C, Salmon T, Roberts PR, Morgan JM. Cardiac defibrillation therapy for at risk patients with systemic right ventricular dysfunction secondary to atrial redirection surgery for dextro-transposition of the great arteries. ACTA ACUST UNITED AC 2007; 9:281-4. [PMID: 17383987 DOI: 10.1093/europace/eum001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To review techniques of implantable cardioverter-defibrillators (ICD) in patients after Mustard surgery for arterial transposition. METHODS AND RESULTS Retrospective analysis of all Mustard patients receiving ICDs at our institution. Five patients (median age 24 years, range 19-35, 3 male) with systemic right ventricular dysfunction (sRV) dysfunction and New York Heart Association (NYHA) II and III, received ICDs. Implantation was performed transvenously in three patients, epicardial patches and subcutaneous arrays at surgery in two patients. Two patients required lead extraction and baffle stent angioplasty before ICD implantation. Defibrillation vectors incorporating the anterior sRV mass [i.e., sub-pulmonary left ventricle (pLV) to generator can, and between epicardial defibrillator patches], consistently achieved a minimum 10 joule(J) safety margin during defibrillation threshold (DFT) testing. Subcutaneous arrays and endocardial vectors that included a superior vena cava (SVC) electrode were less effective. One patient developed pulmonary oedema post-procedure. At a median 20 months, all patients were alive and in NYHA class II. Follow-up over 24 months documented multiple non-sustained ventricular tachycardia (VT) in the group and one patient had recurrent VT with aborted device therapy. CONCLUSION Defibrillator implantation in Mustard patients is challenging. Sub-optimal defibrillation should be anticipated and can be overcome using vectors which integrate the RV mass and high-energy devices. A staged procedure involving pre-implant interventions or separate DFT tests, where indicated, may be better tolerated by patients.
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Affiliation(s)
- Kevin A Michael
- Department of Clinical Electrophysiology, Wessex Cardiothoracic Centre, Southampton, UK.
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11
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Paisey JR, Morgan JM, Curzen NP. What is the role for revascularisation in patients being considered for ICD therapy? EUROINTERVENTION 2006; 2:371-374. [PMID: 19755315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Patients being considered for ICD therapy are a heterogeneous group.For the vast majority, who have significant left ventricular impairment, it has become common practice to assess their coronary artery anatomy as a surrogate for ischaemia and/or viability. Such patients are therefore frequently under the care of both electrophysiologists and interventionists. The coronary anatomy often raises the dilemma about whether such patients should undergo revascularisation. If the patients present with angina or in the context of an acute myocardial infarct then this decision is clear cut. By contrast, however, a significant proportion of them have no history to suggest ongoing ischaemia or of recent MI. In conventional practice, therefore, there would be no decisive mandate to offer them revascularisation, especially PCI, in the absence of further objective evidence of ischaemia or viability. A review of the literature in our paper does not resolve this dilemma.Further observational data are required to help guide cardiologists as to which of these patients will benefit from revascularisation, since in many cases the coronary anatomy is no surrogate for the presence of ischaemia or viability.
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Affiliation(s)
- J R Paisey
- Wessex Cardiac Unit, Southampton University Hospitals NHS Trust, Southampton, United Kingdom
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12
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Paisey JR, Yue AM, Bessoule F, Roberts PR, Morgan JM. Passive electrode effect reduces defibrillation threshold in bi-filament middle cardiac vein defibrillation. ACTA ACUST UNITED AC 2006; 8:113-7. [PMID: 16627420 DOI: 10.1093/europace/euj034] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS To investigate whether a passive electrode effect decreases defibrillation threshold (DFT) in multi-filament middle cardiac vein (MCV) defibrillation. METHODS AND RESULTS Twelve pigs underwent active housing (AH) insertion, with defibrillation coils placed transvenously in right ventricular apex and superior vena cava. The MCV was cannulated, and 1.12F, 50 mm coil electrodes (Ela Medical SA, France) were deployed in its right and left branches. Lead placement was possible in 11 of 12 animals. DFT (J, mean +/- SD) was determined by three-reversal binary search and compared between the MCV monofilament (single filament deployed) and the AH (25.9 +/- 10.9) and the MCV mono + passive filaments (both filaments deployed, one connected) and the AH (19.9 +/- 11.4); 24% DFT reduction P = 0.008. CONCLUSION A bystander electrode adjacent to a monofilament electrode in the MCV reduces DFT by 24% when compared with monofilament MCV alone. Microfilament electrodes decrease DFT as auxiliary anode but not as sole anode.
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Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospitals, UK.
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13
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Paisey JR, Yue AM, White A, Moss A, Morgan JM, Roberts PR. Radiation peak skin dose to risk stratify electrophysiological procedures for deterministic skin damage. Int J Cardiovasc Imaging 2005; 20:285-8. [PMID: 15529910 DOI: 10.1023/b:caim.0000041943.73199.d3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Indexed: 11/12/2022]
Abstract
UNLABELLED Ionising radiation is has the potential to cause harm both by increasing the probability future malignancy (stochastic mechanisms) and by direct physical injury (deterministic mechanisms). Several measures have been developed to quantify radiation exposure during a procedure and cardiologists usually refer to fluoroscopic screening time (FST). FST, however, has limitations for predicting deterministic injury which is directly dependant on peak skin dose (PSD). We compared FST to PSD for a range of interventional cardiac electrophysiology procedures. METHODS All patients undergoing electrophysiology procedures during a 2-month period in our institution were studied. Demographic details, nature of procedure, FST and PSD were measured. The FST to PSD ratio was calculated and compared between patient and procedural factors. RESULTS 67 procedures on patients (23 female) with body mass index (BMI) of 28 (SD 5) Kg/m2 were studied. Screening times ranged from 0.2 to 96.6 min (median 11.2). PSD ranged from <0.1 to 1108 mGy (median 141). There was a positive correlation between PSD to FST ratio and BMI (r = 0.59, p < 0.001). The PSD to FST ratio was higher in cardiac resynchronization therapy (CRT) devices than single or dual chamber ICDs (p = 0.002). CONCLUSION FST is not a reliable predictor of deterministic skin injury and in high-risk procedures such as CRT devices and those on individuals of high BMI PSD should be measured.
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Affiliation(s)
- J R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospitals, UK.
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14
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Paisey JR, Yue AM, Treacher K, Roberts PR, Morgan JM. Implantable loop recorders detect tachyarrhythmias in symptomatic patients with negative electrophysiological studies. Int J Cardiol 2005; 98:35-8. [PMID: 15676163 DOI: 10.1016/j.ijcard.2003.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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: 03/19/2003] [Revised: 06/20/2003] [Accepted: 06/21/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) are a valuable tool in the investigation of syncope and compare favourably with non-invasive and intracardiac electrophysiological assessment of bradycardia. They are known to detect tachyarrhythmias but have not been shown to add to the diagnostic yield of electrophysiological testing in symptomatic patients. METHODS We prospectively studied the first 41 patients (aged 48+/-19 years) in whom ILR were used at our institution after negative electrophysiological studies (EPS). All patients were symptomatic with palpitations (11), syncope (22) or both (8). Nine patients had known structural heart disease (two ischaemic, four cardiomyopathy, two valvular and one congenital). Patients were assessed according to demographic factors, symptoms and investigations. Loop recordings were analysed and assessed according to conventional criteria. RESULTS Among 41 patients in whom electrophysiological studies had failed to demonstrate arrhythmias, six were found to have clinically significant tachyarrhythmias (four ventricular and two supraventricular). CONCLUSION ILR diagnose prognostically significant tachyarrhythmias in symptomatic patients with negative electrophysiological studies.
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Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospitals, Southampton SO16 6YD, UK.
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15
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Abstract
Background—
Noncontact mapping (NCM) has not been validated as a clinical technique to measure ventricular repolarization. We used NCM to determine repolarization characteristics by analysis of reconstructed unipolar electrograms (UEs) at the same sites as monophasic action potential (MAP) recordings in the human ventricle.
Methods and Results—
MAPs were recorded from a total of 355 beats at 46 sites in the left or right ventricle of 9 patients undergoing ablation of ventricular tachycardia guided by NCM (EnSite system). Measurements were made during sinus rhythm, constant right ventricular pacing, and ventricular extrastimuli during restitution-curve construction. The EnGuide locator signal was used to document MAP catheter locations on the endocardial geometry. UE-determined activation-recovery interval (ARI) measured at the maximum derivative of the T wave (Wyatt method) and the minimum derivative of the positive T wave (alternative method) was correlated with MAP measured at 90% repolarization (MAP90%) at the same sites. ARI correlated with MAP90% during steady state by the Wyatt method (
r
=0.83,
P
<0.001) and the alternative method (
r
=0.94,
P
<0.001). Restitution curves constructed from MAP and UE data exhibited the same characteristics, with a mean correlation coefficient of 0.95 (range, 0.90 to 0.99,
P
<0.001). The error between ARI and MAP90% was greater over a shorter diastolic coupling interval but was not influenced by distance of the sampling site from the multielectrode array.
Conclusions—
NCM accurately determines steady-state and dynamic endocardial repolarization in humans. Global, high-density, NCM data could be used to characterize abnormalities of human ventricular repolarization.
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Affiliation(s)
- Arthur M Yue
- Wessex Cardiac Unit, Southampton General Hospital, Southampton, England
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Paisey JR, Yue AM, Bessoule F, Allen S, Roberts PR, Morgan JM. Examination of a middle cardiac vein defibrillation coil as stand-alone anode, auxiliary anode, and bystander electrode in a transvenous defibrillation circuit. Pacing Clin Electrophysiol 2004; 27:1089-93. [PMID: 15305957 DOI: 10.1111/j.1540-8159.2004.00589.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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] [Indexed: 01/19/2023]
Abstract
In porcine studies anodes in the middle cardiac vein compare favorably with those in the RV. It has not been demonstrated whether the RV and middle cardiac vein or the middle cardiac vein alone anodes are superior when shocking to a conventional SVC and active housing cathode nor whether a bystander middle cardiac vein electrode exerts a passive electrode affect. Twelve pigs were anesthetized and had an active housing implanted in the left pectoral region and defibrillation coils placed at the RV apex and in the SVC. A custom-made defibrillation coil (Ela Medical) was advanced into the middle cardiac vein through a 9 Fr transvenous catheter. The DFT for three anodes (RV; RV and middle cardiac vein; middle cardiac vein) to the SVC and active housing was then assessed by a three reversal binary search, the order of testing was randomized. In seven animals DFT was assessed in the same way for the configuration of RV to SVC and active housing twice more, with and without a bystander middle cardiac vein coil electrode in place. The results were middle cardiac vein 7.5 +/- 1.7 J, RV and middle cardiac vein 7.3 +/- 1.7 J reduced DFT significantly compared to RV 13.8 +/- 4.2 J (both P < 0.000). There was no significant difference between the middle cardiac vein and the middle cardiac vein and RV (P = 0.67, 95% CI for difference -0.64-0.96). The DFT of RV to SVC and the active housing was the same with (13.2 +/- 4.0) and without (13.7 +/- 4.2) the middle cardiac vein bystander coil in place (P = 0.177, 95% CI for difference -0.33-1.33 J). Shocking to a SVC and active housing cathode, middle cardiac vein, and RV and middle cardiac vein anodes are equally effective in lowering DFT compared to the RV. The middle cardiac vein coil electrode does not exert a passive electrode affect on the RV to the SVC and active housing defibrillation.
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Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Center, Southampton, General Hospital, The United Kingdom.
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Paisey JR, Betts T, Allen S, Morgan JM, Roberts PR. Evaluation of body weight as a predictive factor for transvenous ventricular defibrillation characteristics. Europace 2004; 6:21-4. [PMID: 14697722 DOI: 10.1016/j.eupc.2003.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS To investigate the correlation between body weight and defibrillation threshold (DFT) for transvenous lead systems using a porcine model. METHODS AND RESULTS Twenty-eight pigs were anaesthetised and DFTs assessed in single and dual coil configurations using a four-reversal binary search method. DFT was correlated with body weight in the RV --> Can and RV --> SVC + Can configurations. A Pearson correlation coefficient and a two-sided p-value were calculated. A positive correlation exists between body weight and DFT in RV --> Can (r=0.66, p<0.000) and RV --> SVC + Can (r=0.44, p=0.018). CONCLUSION There is a significant correlation between body weight and DFT in swine. This tends to be greater in the two-electrode than in the three-electrode configuration. With these and previous human observations, one may predict a higher DFT in heavy individuals and make appropriate procedural adjustments.
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Affiliation(s)
- J R Paisey
- Wessex Cardiothoracic Centre, Southampton, UK.
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18
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Roberts PR, Paisey JR, Betts TR, Allen S, Whitman T, Bonner M, Morgan JM. Comparison of coronary venous defibrillation with conventional transvenous internal defibrillation in man. J Interv Card Electrophysiol 2003; 8:65-70. [PMID: 12652180 DOI: 10.1023/a:1022300316980] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Animal studies have shown that defibrillation in coronary veins is more effective than in the right ventricle. We aimed to assess the feasibility of placing defibrillation electrodes in the middle cardiac vein (MCV) in man and its impact on defibrillation requirements. METHODS A prospective randomised study conducted in a tertiary referral centre. 10 patients (9 male) undergoing ICD implantation (65 (12) yrs) for NASPE/BPEG indications were studied. Defibrillation thresholds (DFT) were measured, using a binary search and an external defibrillator after 10 seconds of ventricular fibrillation, for the following configurations in each patient (order of testing randomised): RV + MCV --> Can and RV --> SVC + Can. INTERVENTIONS A dual coil defibrillation electrode was placed transvenously in the right ventricle (RV) in the conventional manner. Using a guiding catheter a 3.2 Fr (67.5 mm length) electrode was placed transvenously in MCV. A test-can was placed subcutaneously in the left pectoral region. RESULTS Lead placement was possible in 8/10 pts. Time to perform a middle cardiac venogram and place the electrode was 21 (23) mins. No adverse events were observed. Defibrillation current was less (6.7 (2.7) A) with RV + MCV --> Can compared to the conventional RV --> SVC + Can configuration (8.9 (3.4) A, p = 0.03). There was no significant difference in defibrillation voltage or energy. However, shock impedance was higher in the former configuration (57 (10) v. 43 (6) Omega, p = 0.001). CONCLUSIONS In the majority of cases placement of a defibrillation lead in MCV is feasible. Defibrillation current requirements are 25% less when the shock is delivered using a MCV electrode.
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Affiliation(s)
- P R Roberts
- Southampton University Hospitals, Southampton, UK
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Paisey JR, Kalra PR, Roberts PR. Heart failure topics from NASPE 2003. Heart Fail Monit 2003; 4:75-7. [PMID: 14976989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- John R Paisey
- Wessex Cardiothoracic Centre, Southampton University Hospital, Southampton, UK.
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