1
|
Lazarus C, Sherman J, Putzel N, Sharkoski T, Zagrodzky W, Kulstad E, Ro A, Nazari J, Fisher W, Metzl M. Determination of Continuity Index Values in Atrial Fibrillation Ablation with Proactive Esophageal Cooling. J Vis Exp 2024. [PMID: 38709062 DOI: 10.3791/66688] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Radiofrequency (RF) ablation to perform pulmonary vein isolation (PVI) for the treatment of atrial fibrillation involves some risk to collateral structures, including the esophagus. Proactive esophageal cooling using a dedicated device has been granted marketing authorization by the Food and Drug Administration (FDA) to reduce the risk of ablation-related esophageal injury due to RF cardiac ablation procedures, and more recent data also suggest that esophageal cooling may contribute to improved long-term efficacy of treatment. A mechanistic underpinning explaining these findings exists through the quantification of lesion placement contiguity defined as the Continuity Index (CI). Kautzner et al. quantified the CI by the order of lesion placement, such that whenever a lesion is placed non-adjacent to the prior lesion, the CI is incremented by the number of segments the catheter tip has moved over. To facilitate real-time calculation of the CI and encourage further adoption of this instrument, we propose a modification in which the placement of non-adjacent lesions increments the CI by only one unit, avoiding the need to count potentially nebulous markers of atrial segmentation. The objective of this protocol is to describe the methods of calculating the CI both prospectively during real-time PVI cases and retrospectively using recorded case data. A comparison of the results obtained between cases that utilized proactive esophageal cooling and cases that used luminal esophageal temperature (LET) monitoring is then provided.
Collapse
Affiliation(s)
| | | | | | | | | | - Erik Kulstad
- Attune Medical; University of Texas Southwestern Medical Center
| | - Alex Ro
- NorthShore University Hospital
| | | | | | | |
Collapse
|
2
|
Lazarus C, Sherman J, Putzel N, Zagrodzky W, Sharkoski T, Ro A, Nazari J, Fisher W, Kulstad E, Metzl M. Reduced Continuity Index with Proactive Esophageal Cooling Compared to Luminal Temperature Monitoring During Radiofrequency Ablation: Improved Lesion Continuity with Esophageal Cooling. medRxiv 2024:2024.04.09.24305586. [PMID: 38645228 PMCID: PMC11030476 DOI: 10.1101/2024.04.09.24305586] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Proactive esophageal cooling is FDA cleared to reduce the likelihood of esophageal injury during radiofrequency ablation for treatment of atrial fibrillation (AF). Long-term follow-up data have also shown improved freedom from arrhythmia with proactive esophageal cooling compared to luminal esophageal temperature (LET) monitoring during pulmonary vein isolation (PVI). One hypothesized mechanism is improved lesion contiguity (as measured by the Continuity Index) with the use of cooling. We aimed to compare the Continuity Index of PVI cases using proactive esophageal cooling to those using LET monitoring. Methods Continuity Index was calculated for PVI cases at two different hospitals within the same health system using a slightly modified Continuity Index to facilitate both real-time calculation during observation of PVI cases and retrospective determination from recorded cases. The results were then compared between proactively cooled cases and those using LET monitoring. Results Continuity Indices for a total of 101 cases were obtained; 77 cases using proactive esophageal cooling and 24 cases using traditional LET monitoring. With proactive esophageal cooling, the average Continuity Index was 2.7 (1.3 on the left pulmonary vein, and 1.5 on the right pulmonary vein). With LET monitoring, the average Continuity Index was 27.3 (14.3 on the left, and 12.9 on the right), for a difference of 24.6 (p < 0.001). Conclusion Proactive esophageal cooling during PVI is associated with significantly improved lesion contiguity when compared to LET monitoring. This finding may offer a mechanism for the greater freedom from arrhythmia seen with proactive cooling in long-term follow-up.
Collapse
Affiliation(s)
| | - Jacob Sherman
- Washington University in St. Louis, St. Louis, MO, USA
| | | | | | | | - Alex Ro
- NorthShore University Hospital, Evanston, IL, USA
| | - Jose Nazari
- NorthShore University Hospital, Evanston, IL, USA
| | | | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mark Metzl
- NorthShore University Hospital, Evanston, IL, USA
| |
Collapse
|
3
|
Xia ET, Lee K, Minga I, Nazari J, Metzl MD. Concomitant treatment of sustained ventricular tachycardia and hypertrophic cardiomyopathy with transcoronary ethanol ablation: a case report. Eur Heart J Case Rep 2024; 8:ytad632. [PMID: 38239307 PMCID: PMC10794818 DOI: 10.1093/ehjcr/ytad632] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 01/22/2024]
Abstract
Background The recommended treatment for recurrent ventricular tachycardia in patients with hypertrophic cardiomyopathy that is not amenable to defibrillator implantation due to shock burden is radiofrequency ablation. In patients with deeply intramural foci of ventricular tachycardia, traditional unipolar ablation has a lower probability of success. Case summary A 66-year-old Caucasian man was admitted with ventricular tachycardia, which recurred despite antiarrhythmic drugs. On cardiac magnetic resonance imaging, he was discovered to have septal hypertrophic cardiomyopathy, which was not significant on echocardiogram. The focus of ventricular tachycardia was suspected to be buried deeply within the hypertrophic segment as localized by late gadolinium enhancement. The patient underwent transcoronary ethanol ablation, which abated the ventricular tachycardia while also completely decreasing his invasively measured left ventricular outflow tract obstruction gradient from 45 to 17 mmHg. Discussion Transcoronary ethanol ablation may be successfully applied to simultaneously treat ventricular arrhythmia superimposed within a segment of hypertrophic cardiomyopathy. Further data are needed to evaluate long-term success of this strategy vs. traditional radiofrequency ablation.
Collapse
Affiliation(s)
- Eric T Xia
- Department of Cardiology, University of Chicago Northshore University Health Systems, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Kevin Lee
- Department of Cardiology, University of Chicago Northshore University Health Systems, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Iva Minga
- Department of Cardiology, University of Chicago Northshore University Health Systems, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Jose Nazari
- Department of Cardiology, University of Chicago Northshore University Health Systems, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Mark D Metzl
- Department of Cardiology, University of Chicago Northshore University Health Systems, 2650 Ridge Avenue, Evanston, IL 60201, USA
| |
Collapse
|
4
|
Sanchez J, Woods C, Zagrodzky J, Nazari J, Singleton MJ, Schricker A, Ruppert A, Brumback B, Jenny B, Athill C, Joseph C, Shah D, Upadhyay G, Kulstad E, Cogan J, Leyton-Mange J, Cooper J, Tamirisa K, Omotoye S, Timilsina S, Perez-Verdia A, Kaplan A, Patel A, Ro A, Corsello A, Kolli A, Greet B, Willms D, Burkland D, Castillo D, Zahwe F, Nayak H, Daniels J, MacGregor J, Sackett M, Kutayli WM, Barakat M, Percell R, Akrivakis S, Hao SC, Liu T, Panico A, Ramireddy A, Dewland T, Gerstenfeld EP, Lanes DB, Sze E, Francisco G, Silva J, McHugh J, Sung K, Feldman L, Serafini N, Kawasaki R, Hongo R, Kuk R, Hayward R, Park S, Vu A, Henry C, Bailey S, Mickelsen S, Taneja T, Fisher W, Metzl M. Atrioesophageal Fistula Rates Before and After Adoption of Active Esophageal Cooling During Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2023; 9:2558-2570. [PMID: 37737773 DOI: 10.1016/j.jacep.2023.08.022] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. A formal analysis of the atrioesophageal fistula (AEF) rate with active esophageal cooling has not previously been performed. OBJECTIVES The authors aimed to compare AEF rates before and after the adoption of active esophageal cooling. METHODS This institutional review board (IRB)-approved study was a prospective analysis of retrospective data, designed before collecting and analyzing the real-world data. The number of AEFs occurring in equivalent time frames before and after adoption of cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were quantified across 25 prespecified hospital systems. AEF rates were then compared using generalized estimating equations robust to cluster correlation. RESULTS A total of 14,224 patients received active esophageal cooling during RF ablation across the 25 hospital systems, which included a total of 30 separate hospitals. In the time frames before adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In the preadoption cohort, a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates for procedures using LET monitoring. In the postadoption cohort, no AEFs were found in the prespecified sites, yielding an AEF rate of 0% (P < 0.0001). CONCLUSIONS Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.
Collapse
Affiliation(s)
| | | | | | - Jose Nazari
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Amir Schricker
- Mills-Peninsula Medical Center, Burlingame, California, USA
| | | | | | | | | | | | - Dipak Shah
- Ascension Michigan, Detroit, Michigan, USA
| | | | - Erik Kulstad
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - John Cogan
- Memorial Healthcare System, Hollywood, Florida, USA
| | | | - Julie Cooper
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | | | | | - Apoor Patel
- Houston Methodist Hospital, Houston, Texas, USA
| | - Alex Ro
- NorthShore University Health System, Evanston, Illinois, USA
| | | | | | - Brian Greet
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Danya Willms
- Sharp Memorial Hospital, San Diego, California, USA
| | | | | | | | - Hemal Nayak
- University of Texas, San Antonio, Texas, USA
| | - James Daniels
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Matthew Sackett
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | | | | | | | | | - Steven C Hao
- Sutter Pacific Medical Foundation, San Francisco, California, USA
| | - Taylor Liu
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | | | | | - Thomas Dewland
- University of California-San Fransisco, San Fransico, California, USA
| | | | | | - Edward Sze
- MaineHealth Cardiology, Portland, Maine, USA
| | | | - Jose Silva
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Julia McHugh
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Kai Sung
- Tri-City Cardiology, Mesa, Arizona, USA
| | - Leon Feldman
- Eisenhower Medical Center, Rancho Mirage, California, USA
| | | | - Raymond Kawasaki
- Northwest Community Healthcare, Arlington Heights, Illinois, USA
| | - Richard Hongo
- California Pacific Medical Center, San Francisco, California, USA
| | - Richard Kuk
- Centra Heart and Vascular Institute, Lynchburg, Virginia, USA
| | - Robert Hayward
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Shirley Park
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Andrew Vu
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | | | - Shane Bailey
- LoneStar Heart and Vascular, New Braunfels, Texas, USA
| | | | - Taresh Taneja
- Kaiser Permanente Northern California, Santa Clara, California, USA
| | - Westby Fisher
- NorthShore University Health System, Evanston, Illinois, USA
| | - Mark Metzl
- NorthShore University Health System, Evanston, Illinois, USA
| |
Collapse
|
5
|
Joseph C, Nazari J, Zagrodzky J, Brumback B, Sherman J, Zagrodzky W, Bailey S, Kulstad E, Metzl M. Improved 1-year outcomes after active cooling during left atrial radiofrequency ablation. J Interv Card Electrophysiol 2023; 66:1621-1629. [PMID: 36670327 PMCID: PMC10359433 DOI: 10.1007/s10840-023-01474-3] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Active esophageal cooling during pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF) is increasingly being utilized to reduce esophageal injury and atrioesophageal fistula formation. Randomized controlled data also show trends towards increased freedom from AF when using active cooling. This study aimed to compare 1-year arrhythmia recurrence rates between patients treated with luminal esophageal temperature (LET) monitoring versus active esophageal cooling during left atrial ablation. METHOD Data from two healthcare systems (including 3 hospitals and 4 electrophysiologists) were reviewed for patient rhythm status at 1-year follow-up after receiving PVI for the treatment of AF. Results were compared between patients receiving active esophageal cooling (ensoETM, Attune Medical, Chicago, IL) and those treated with traditional LET monitoring using Kaplan-Meier estimates. RESULTS A total of 513 patients were reviewed; 253 received LET monitoring using either single or multi-sensor temperature probes; and 260 received active cooling. The mean age was 66.8 (SD ± 10) years, and 36.8% were female. Arrhythmias were 60.1% paroxysmal AF, 34.3% persistent AF, and 5.6% long-standing persistent AF, with no significant difference between groups. At 1-year follow-up, KM estimates for freedom from AF were 58.2% for LET-monitored patients and 72.2% for actively cooled patients, for an absolute increase in freedom from AF of 14% with active esophageal cooling (p = .03). Adjustment for the confounders of patient age, gender, type of AF, and operator with an inverse probability of treatment weighted Cox proportional hazards model yielded a hazard ratio of 0.6 for the effect of cooling on AF recurrence (p = 0.045). CONCLUSIONS In this first study to date of the association between esophageal protection strategy and long-term efficacy of left atrial RF ablation, a clinically and statistically significant improvement in freedom from atrial arrhythmia at 1 year was found in patients treated with active esophageal cooling when compared to patients who received LET monitoring. More rigorous prospective studies or randomized studies are required to validate the findings of the current study.
Collapse
Affiliation(s)
| | - Jose Nazari
- NorthShore University Health System, Evanston, IL, USA
| | - Jason Zagrodzky
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, 901 W Ben White Blvd, Austin, TX, 78704, USA
| | - Babette Brumback
- Department of Biostatistics, College of Public Health & Health Professions, College of Medicine, University of Florida, Gainesville, USA
| | - Jacob Sherman
- Washington University in Saint Louis, 1 Brookings Dr, MO, 63130, St. Louis, USA
| | - William Zagrodzky
- Colorado College, 14 E Cache La Poudre St, Colorado Springs, CO, 80903, USA
| | - Shane Bailey
- Texas Cardiac Arrhythmia Institute, St. David's South Austin Medical Center, 901 W Ben White Blvd, Austin, TX, 78704, USA
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
| | - Mark Metzl
- NorthShore University Health System, Evanston, IL, USA
| |
Collapse
|
6
|
Osorio J, Zei PC, Díaz JC, Varley AL, Morales GX, Silverstein JR, Oza SR, D'Souza B, Singh D, Moretta A, Metzl MD, Hoyos C, Matos CD, Rivera E, Magnano A, Salam T, Nazari J, Thorne C, Costea A, Thosani A, Rajendra A, Romero JE. High-Frequency Low-Tidal Volume Ventilation Improves Long-Term Outcomes in AF Ablation: A Multicenter Prospective Study. JACC Clin Electrophysiol 2023; 9:1543-1554. [PMID: 37294263 DOI: 10.1016/j.jacep.2023.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND High-frequency, low-tidal-volume (HFLTV) ventilation is a safe and simple strategy to improve catheter stability and first-pass isolation during pulmonary vein (PV) isolation. However, the impact of this technique on long-term clinical outcomes has not been determined. OBJECTIVES This study sought to assess acute and long-term outcomes of HFLTV ventilation compared with standard ventilation (SV) during radiofrequency (RF) ablation of paroxysmal atrial fibrillation (PAF). METHODS In this prospective multicenter registry (REAL-AF), patients undergoing PAF ablation using either HFLTV or SV were included. The primary outcome was freedom from all-atrial arrhythmia at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and hospitalizations at 12 months. RESULTS A total of 661 patients were included. Compared with those in the SV group, patients in the HFLTV group had shorter procedural (66 [IQR: 51-88] minutes vs 80 [IQR: 61-110] minutes; P < 0.001), total RF (13.5 [IQR: 10-19] minutes vs 19.9 [IQR: 14.7-26.9] minutes; P < 0.001), and PV RF (11.1 [IQR: 8.8-14] minutes vs 15.3 [IQR: 12.4-20.4] minutes; P < 0.001) times. First-pass PV isolation was higher in the HFLTV group (66.6% vs 63.8%; P = 0.036). At 12 months, 185 of 216 (85.6%) in the HFLTV group were free from all-atrial arrhythmia, compared with 353 of 445 (79.3%) patients in the SV group (P = 0.041). HLTV was associated with a 6.3% absolute reduction in all-atrial arrhythmia recurrence, lower rate of AF-related symptoms (12.5% vs 18.9%; P = 0.046), and hospitalizations (1.4% vs 4.7%; P = 0.043). There was no significant difference in the rate of complications. CONCLUSIONS HFLTV ventilation during catheter ablation of PAF improved freedom from all-atrial arrhythmia recurrence, AF-related symptoms, and AF-related hospitalizations with shorter procedural times.
Collapse
Affiliation(s)
- Jose Osorio
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | - Paul C Zei
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juan C Díaz
- Cardiac Arrhythmia Center, Division of Cardiology, Clinica Las Vegas, Universidad CES, Medellín, Colombia
| | - Allyson L Varley
- Heart Rhythm Clinical and Research Solutions, Birmingham, Alabama, USA
| | | | | | - Saumil R Oza
- Ascension Medical Group, St Vincent's Cardiology, Jacksonville, Florida, USA
| | - Benjamin D'Souza
- Penn Heart and Vascular Center Cherry Hill, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - David Singh
- The Queens Medical Center, Honolulu, Hawaii, USA
| | | | - Mark D Metzl
- Cardiovascular Institute, NorthShore University Health System, Northbrook, Illinois, USA
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos D Matos
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Estefania Rivera
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Tariq Salam
- MultiCare Pulse Heart Institute, Tacoma, Washington, USA
| | - Jose Nazari
- Cardiovascular Institute, NorthShore University Health System, Northbrook, Illinois, USA
| | | | - Alexandru Costea
- Center for Electrophysiology, Rhythm Disorders and Electro-Mechanical Interventions, UC Heart, Lung, and Vascular Institute, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, Ohio, USA
| | - Amit Thosani
- Cardiovascular Institute, Allegheny Health Network, Baden, Pennsylvania, USA
| | - Anil Rajendra
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | - Jorge E Romero
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
7
|
Joseph C, Nazari J, Brumback B, Kulstad E, Metzl MD. INCREASED TIME TO FIRST RECURRENCE OF ARRHYTHMIA AFTER ATRIAL ABLATION WITH ACTIVE ESOPHAGEAL COOLING. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00638-1] [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: 03/06/2023]
|
8
|
Sackin H, Campbell D, Werth J, Nazari J. Sustained Suppression of Premature Ventricular Contractions by a Three-Month Pacing Adjustment. Cureus 2022; 14:e31209. [PMID: 36382325 PMCID: PMC9640207 DOI: 10.7759/cureus.31209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Premature ventricular contractions (PVCs) that comprise more than 15% of total heartbeats can induce cardiomyopathy in patients with systolic dysfunction, and cardiac ablation is frequently used to reduce PVCs in this patient group. However, cardiac ablation is not entirely without hazards. We report a noninvasive method that dramatically reduced PVCs in a cardiac pacemaker patient from 31% to 3% in seven days by increasing the lower limit pacing rate from 50 beats per minute (bpm) to 60 bpm. Not only were our patient's PVCs reduced by the initial pacing elevation, but PVC levels were maintained below 5% even after the pacemaker's lower limit was returned to its original value of 50 bpm. This irreversible suppression of PVC activity following a three-month pacing elevation is a novel result that might be caused by ventricular remodeling of the original ectopic focus.
Collapse
|
9
|
Joseph C, Nazari J, Zagrodzky J, Sherman J, Zagrodzky W, Bailey S, Ro A, Fisher W, Metzl M. Esophageal cooling during ablation of persistent atrial fibrillation is associated with improved freedom from arrhythmia at one-year follow up. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.461] [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: 11/15/2022] Open
Abstract
Abstract
Background
Various factors influence successful freedom from atrial arrhythmia after pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF). Lesion transmurality and continuity (as measured by the Continuity Index) are two important factors, and these can be worsened by pauses in RF energy application due to esophageal overheating. Proactive esophageal cooling precludes the need for premature cessation of power, avoiding partially-formed lesions and the need to “hop-scotch” in the left atrium. The resulting improvement in lesion continuity may improve long-term freedom from atrial arrhythmia after PVI, particularly in patients with persistent AF, where more posterior wall ablation is often necessary.
Purpose
Determine differences in freedom from arrhythmia at one year between patients receiving LET monitoring and those receiving esophageal cooling during PVI for persistent AF.
Methods
We reviewed data from two healthcare systems for patient rhythm status at one-year follow up after PVI for the treatment of persistent or long-standing persistent AF. We then determined Kaplan-Meier estimates of freedom from arrhythmia (AF, atrial flutter, and atrial tachycardia), and compared these between patients receiving esophageal cooling and those treated with traditional LET monitoring.
Results
A total of 252 patients received PVI for persistent or long-standing persistent AF and had data available for review. Of these, 148 received LET monitoring (with either a single or multi-sensor temperature probe), and 104 received active cooling with a dedicated esophageal cooling device. Mean age and gender for each group was similar (67.2, range 21 to 88 years, 36% female for LET monitoring, and 67.8, range 32 to 89 years, 30% female for esophageal cooling). KM estimates for freedom from AF at the one-year follow-up were 44.2% for LET monitored patients and 79.3% for actively cooled patients (P=0.01).
Conclusions
Freedom from atrial arrhythmia at one-year after PVI for persistent AF is associated with significant improvement when using active esophageal cooling rather than LET monitoring.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Attune Medical
Collapse
Affiliation(s)
- C Joseph
- University of Texas Southwestern Medical Center , Dallas , United States of America
| | - J Nazari
- NorthShore University Health System , Chicago , United States of America
| | - J Zagrodzky
- Texas cardiac Arrhythmia , Austin , United States of America
| | - J Sherman
- Washington University in St. Louis , St. Louis , United States of America
| | - W Zagrodzky
- Colorado College , Colorado Springs , United States of America
| | - S Bailey
- Texas cardiac Arrhythmia , Austin , United States of America
| | - A Ro
- NorthShore University Health System , Chicago , United States of America
| | - W Fisher
- NorthShore University Health System , Chicago , United States of America
| | - M Metzl
- NorthShore University Health System , Chicago , United States of America
| |
Collapse
|
10
|
Joseph C, Francisco G, Ruppert A, Willms D, Nazari J, Fisher W, Ro A, Sherman J, Zagrodzky J, Bailey S, Zagrodzky W, Athill C, Metzl M. Arrhythmia recurrence reduction with an active esophageal cooling device during radiofrequency ablation. Europace 2022. [DOI: 10.1093/europace/euac053.096] [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.
Background
As the burden of atrial fibrillation continues to rise with an aging population, there have been contrasting positions on the efficacy of left atrial ablation. While ablation techniques have continued to improve over the past decades, arrhythmia recurrence rates must be further reduced given the burden of ablation on patients. Since continuity of lesion sets has been associated with greater lesion durability, it has been theorized that the use of active esophageal cooling may facilitate greater freedom from arrhythmia.
Purpose
In order to investigate the association between use of active esophageal cooling and arrhythmia recurrence, we performed a multicenter retrospective study of arrhythmia recurrence rates in patients that received active cooling and compared them to those that received luminal esophageal temperature (LET) monitoring.
Methods
In this study, follow up data were collected from patients that underwent pulmonary vein isolation (PVI) at three separate large medical centers. Data were contained in a prospective hospital registry, a prospective physician registry, or the electronic health record, depending on the center. For each patient included, we recorded whether their ablation utilized LET monitoring or active esophageal cooling, along with their rhythm status at 1-year follow up. Rhythm status at follow-up was determined by either electrocardiogram, Holter monitor, or wearable heart rate monitor. Kaplan-Meier (KM) curves were created for freedom-from-arrhythmia at one year comparing those in the LET monitoring group to those in the active cooling group.
Results
Follow up data were collected from 1035 patients. There were 560 patients that received LET monitoring during their original ablation, and 475 patients that underwent active esophageal cooling. KM estimates for freedom-from-arrhythmia at one year were 42% in the LET monitored group and 65% in the actively cooled group (P<.001).
Conclusion
In this large multicenter study, there is a significant increase in freedom-from-arrhythmia at one year follow-up among patients that received active esophageal cooling as compared to those that underwent LET monitoring.
Collapse
Affiliation(s)
- C Joseph
- University of Texas Southwestern Medical Center, Dallas, United States of America
| | - G Francisco
- Sharp Memorial, San Diego, United States of America
| | - A Ruppert
- Sharp Memorial, San Diego, United States of America
| | - D Willms
- Sharp Memorial, San Diego, United States of America
| | - J Nazari
- NorthShore University Health System, Chicago, United States of America
| | - W Fisher
- NorthShore University Health System, Chicago, United States of America
| | - A Ro
- NorthShore University Health System, Chicago, United States of America
| | - J Sherman
- NorthShore University Health System, Chicago, United States of America
| | - J Zagrodzky
- Texas cardiac Arrhythmia, Austin, United States of America
| | - S Bailey
- Texas cardiac Arrhythmia, Austin, United States of America
| | - W Zagrodzky
- Texas cardiac Arrhythmia, Austin, United States of America
| | - C Athill
- Sharp Memorial, San Diego, United States of America
| | - M Metzl
- NorthShore University Health System, Chicago, United States of America
| |
Collapse
|
11
|
Joseph C, Francisco G, Ruppert A, Willms D, Metzl M, Fisher W, Nazari J, Ro A, Zagrodzky J, Zagrodzky W, Sherman J, Bailey S, Athill C. Effect of a proactive esophageal cooling device on procedure length - a multicenter comparison of persistent and paroxysmal atrial fibrillation. Europace 2022. [DOI: 10.1093/europace/euac053.086] [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: 11/15/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
During left atrial ablation for the treatment of atrial fibrillation (AF), effective esophageal protection is essential for reducing or preventing thermal injury. Traditional methods include luminal esophageal temperature (LET) monitoring that lead to frequent pauses in the procedure when temperature alarms alert operators to dangerous temperature levels. While there have been recent studies that demonstrate an association between active esophageal cooling and a reduction in procedure duration regardless of AF type, these retrospective studies have been conducted at single or joint centers which may lead to confounding from other time-saving variables that have changed over time.
Purpose
Consequently, we sought to perform a large-scale multicenter comparison to better elucidate the association between procedure length and the use of active cooling in patients with persistent and paroxysmal atrial fibrillation.
Methods
In this study, we collected data from three large hospital centers, one hospital-maintained registry, one physician-maintained registry, and one through EHR data review and aggregated in groups separated by AF type as well as whether the patients received active cooling or LET monitoring. We then compared median procedure durations in each group.
Results
There were a total of 753 patients included in this study. Of the 360 patients with paroxysmal AF, 179 received active esophageal cooling while 181 underwent LET monitoring. In the persistent AF group with 393 patients, 157 received active esophageal cooling and 236 underwent LET monitoring. Among patients with paroxysmal AF, the median mean procedure duration was 137 minutes in the LET monitored group, and 90 minutes in the actively cooled group with an overall reduction of 47 minutes (P<.001). In patients with persistent AF, the median procedure duration was 148 minutes in the LET monitored group and 94 minutes in the actively cooled group with an overall reduction of 54 minutes (P<.001). The relative reduction as a percent of total procedure time was 34%, and 36%, for paroxysmal and persistent AF cases, respectively.
Conclusion
In this large multicenter review, there is a significant reduction in procedure length when using active esophageal cooling, regardless of AF type.
Collapse
Affiliation(s)
- C Joseph
- University of Texas Southwestern Medical Center, Dallas, United States of America
| | - G Francisco
- Sharp Memorial, San Diego, United States of America
| | - A Ruppert
- Sharp Memorial, San Diego, United States of America
| | - D Willms
- Sharp Memorial, San Diego, United States of America
| | - M Metzl
- NorthShore University Health System, Chicago, United States of America
| | - W Fisher
- NorthShore University Health System, Chicago, United States of America
| | - J Nazari
- NorthShore University Health System, Chicago, United States of America
| | - A Ro
- NorthShore University Health System, Chicago, United States of America
| | - J Zagrodzky
- Texas cardiac Arrhythmia, Austin, United States of America
| | - W Zagrodzky
- Texas cardiac Arrhythmia, Austin, United States of America
| | - J Sherman
- NorthShore University Health System, Chicago, United States of America
| | - S Bailey
- Texas cardiac Arrhythmia, Austin, United States of America
| | - C Athill
- Sharp Memorial, San Diego, United States of America
| |
Collapse
|
12
|
Joseph C, Zagrodzky JD, Zagrodzky W, Sherman J, Kawasaki RN, Henry CA, Bailey SM, Ro AS, Fisher WG, Nazari J, Metzl MD. PO-681-08 REDUCED PROCEDURAL DURATION WITH PROACTIVE ESOPHAGEAL COOLING DURING LEFT ATRIAL ABLATION: A MULTICENTER ANALYSIS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.510] [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: 11/04/2022]
|
13
|
Minga I, Metzl MD, Rosenberg J, Nazari J. PO-639-03 3D MAPPING FACILITATED, INTRA-CARDIAC ECHOCARDIOGRAPHY (ICE) GUIDED LEFT ATRIAL APPENDAGE OCCLUSION (LAAO) IS FEASIBLE AND SAFE, PROVIDING SIMILAR EFFICACY WITH LESS PERSONNEL THAN TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) GUIDED PROCEDURES. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.967] [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: 11/04/2022]
|
14
|
Joseph C, Nazari J, Metzl M. Atrioesophageal fistula – a focus on preventing a devastating complication. JTCVS Tech 2022; 14:153. [PMID: 35967227 PMCID: PMC9366206 DOI: 10.1016/j.xjtc.2022.03.003] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Jose Nazari
- Department of Electrophysiology, NorthShore University Health System, Evanston, Ill
| | - Mark Metzl
- Department of Electrophysiology, NorthShore University Health System, Evanston, Ill
| |
Collapse
|
15
|
Joseph C, Sherman J, Ro A, Fisher WG, Nazari J, Metzl MD. FLUOROSCOPY REDUCTION WITH THE USE OF ACTIVE ESOPHAGEAL COOLING DURING LEFT ATRIAL ABLATION. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01106-8] [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: 11/16/2022]
|
16
|
Varley AL, Kreidieh O, Godfrey BE, Whitmire C, Thorington S, D'Souza B, Kang S, Hebsur S, Ravindran BK, Zishiri E, Gidney B, Sellers MB, Singh D, Salam T, Metzl M, Ro A, Nazari J, Fisher WG, Costea A, Magnano A, Oza S, Morales G, Rajendra A, Silverstein J, Zei PC, Osorio J. A prospective multi-site registry of real-world experience of catheter ablation for treatment of symptomatic paroxysmal and persistent atrial fibrillation (Real-AF): design and objectives. J Interv Card Electrophysiol 2021; 62:487-494. [PMID: 34212280 PMCID: PMC8249214 DOI: 10.1007/s10840-021-01031-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
Purpose Catheter ablation has become a mainstay therapy for atrial fibrillation (AF) with rapid innovation over the past decade. Variability in ablation techniques may impact efficiency, safety, and efficacy; and the ideal strategy is unknown. Real-world evidence assessing the impact of procedural variations across multiple operators may provide insight into these questions. The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal (PAF) and Persistent (PsAF) Atrial Fibrillation registry (Real-AF) is a multicenter prospective registry that will enroll patients at high volume centers, including academic institutions and private practices, with operators performing ablations primarily with low fluoroscopy when possible. The study will also evaluate the contribution of advent in technologies and workflows to real-world clinical outcomes. Methods Patients presenting at participating centers are screened for enrollment. Data are collected at the time of procedure, 10–12 weeks, and 12 months post procedure and include patient and detailed procedural characteristics, with short and long-term outcomes. Arrhythmia recurrences are monitored through standard of care practice which includes continuous rhythm monitoring at 6 and 12 months, event monitors as needed for routine care or symptoms suggestive of recurrence, EKG performed at every visit, and interrogation of implanted device or ILR when applicable. Results Enrollment began in January 2018 with a single site. Additional sites began enrollment in October 2019. Through May 2021, 1,243 patients underwent 1,269 procedures at 13 institutions. Our goal is to enroll 4000 patients. Discussion Real-AF’s multiple data sources and detailed procedural information, emphasis on high volume operators, inclusion of low fluoroscopy operators, and use of rigorous standardized follow-up methodology allow systematic documentation of clinical outcomes associated with changes in ablation workflow and technologies over time. Timely data sharing may enable real-time quality improvements in patient care and delivery. Trial registration Clinicaltrials.gov: NCT04088071 (registration date: September 12, 2019) Supplementary Information The online version contains supplementary material available at 10.1007/s10840-021-01031-w.
Collapse
Affiliation(s)
- Allyson L Varley
- Heart Rhythm Clinical and Research Solutions, LLC, AL, Birmingham, USA.
- Birmingham VA Health System, AL, Birmingham, USA.
| | - Omar Kreidieh
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, MA, Boston, USA
| | - Brigham E Godfrey
- Heart Rhythm Clinical and Research Solutions, LLC, AL, Birmingham, USA
- Arrhythmia Institute at Grandview Medical Center, AL, Birmingham, USA
| | - Carolyn Whitmire
- Grandview Medical Group Research, Grandview Medical Center, AL, Birmingham, USA
| | - Susan Thorington
- Grandview Medical Group Research, Grandview Medical Center, AL, Birmingham, USA
| | - Benjamin D'Souza
- Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania, PA, Philadelphia, USA
| | | | | | | | | | - Brett Gidney
- Santa Barbara Cottage Hospital, CA, Santa Barbara, USA
| | | | - David Singh
- Center for Heart Rhythm Disorders, The Queen's Medical Center, HI, Honolulu, USA
| | - Tariq Salam
- PulseHeart Institute, Multicare Health System, WA, Tacoma, USA
| | - Mark Metzl
- NorthShore University HealthSystem, IL, Evanston, USA
| | - Alex Ro
- NorthShore University HealthSystem, IL, Evanston, USA
| | - Jose Nazari
- NorthShore University HealthSystem, IL, Evanston, USA
| | | | - Alexandru Costea
- Division of Cardiovascular Health and Disease, University of Cincinnati, OH, Cincinnati, USA
| | - Anthony Magnano
- Department of Cardiology, Ascension St. Vincent's Health System, FL, Jacksonville, USA
| | - Saumil Oza
- Department of Cardiology, Ascension St. Vincent's Health System, FL, Jacksonville, USA
| | - Gustavo Morales
- Arrhythmia Institute at Grandview Medical Center, AL, Birmingham, USA
| | - Anil Rajendra
- Arrhythmia Institute at Grandview Medical Center, AL, Birmingham, USA
| | | | - Paul C Zei
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, MA, Boston, USA
| | - Jose Osorio
- Heart Rhythm Clinical and Research Solutions, LLC, AL, Birmingham, USA
- Arrhythmia Institute at Grandview Medical Center, AL, Birmingham, USA
| |
Collapse
|
17
|
|
18
|
Aouad P, Koktzoglou I, Milani B, Serhal A, Nazari J, Edelman RR. Radial-based acquisition strategies for pre-procedural non-contrast cardiovascular magnetic resonance angiography of the pulmonary veins. J Cardiovasc Magn Reson 2020; 22:78. [PMID: 33256791 PMCID: PMC7702691 DOI: 10.1186/s12968-020-00685-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computed tomography angiography (CTA) or contrast-enhanced (CE) cardiovascular magnetic resonance angiography (CMRA) is often obtained in patients with atrial fibrillation undergoing evaluation prior to pulmonary vein (PV) isolation. Drawbacks of CTA include radiation exposure and potential risks from iodinated contrast agent administration. Free-breathing 3D balanced steady-state free precession (bSSFP) Non-contrast CMRA is a potential imaging option, but vascular detail can be suboptimal due to ghost artifacts and blurring that tend to occur with a Cartesian k-space trajectory or, in some cases, inconsistent respiratory gating. We therefore explored the potential utility of both breath-holding and free-breathing non-contrast CMRA, using radial k-space trajectories that are known to be less sensitive to flow and motion artifacts than Cartesian. MAIN BODY Free-breathing 3D Cartesian and radial stack-of-stars acquisitions were compared in 6 healthy subjects. In addition, 27 patients underwent CTA and non-contrast CMRA for PV mapping. Three radial CMR acquisition strategies were tested: (1) breath-hold (BH) 2D radial bSSFP (BH-2D); (2) breath-hold, multiple thin-slab 3D stack-of-stars bSSFP (BH-SOS); and (3) navigator-gated free-breathing (FB) 3D stack-of-star bSSFP using a spatially non-selective RF excitation (FB-NS-SOS). A non-rigid registration algorithm was used to compensate for variations in breath-hold depth. In healthy subjects, image quality and vessel sharpness using a free-breathing 3D SOS acquisition was significantly better than free-breathing (FB) Cartesian 3D. In patients, diagnostic image quality was obtained using all three radial CMRA techniques, with BH-SOS and FB-NS-SOS outperforming BH-2D. There was overall good correlation for PV maximal diameter between BH-2D and CTA (ICC = 0.87/0.83 for the two readers), excellent correlation between BH-SOS and CTA (ICC = 0.90/0.91), and good to excellent correlation between FB-NS-SOS and CTA (ICC = 0.87/0.94). For PV area, there was overall good correlation between BH-2D and CTA (ICC = 0.79/0.83), good to excellent correlation between BH-SOS and CTA (ICC = 0.88/0.91) and excellent correlation between FB-NS-SOS and CTA (ICC = 0.90/0.95). CNR was significantly higher with BH-SOS (mean = 11.04) by comparison to BH-2D (mean = 6.02; P = 0.007) and FB-NS-SOS (mean = 5.29; P = 0.002). CONCLUSION Our results suggest that a free-breathing stack-of-stars bSSFP technique is advantageous in providing accurate depiction of PV anatomy and ostial measurements without significant degradation from off-resonance artifacts, and with better image quality than Cartesian 3D. For patients in whom respiratory gating is unsuccessful, a breath-hold thin-slab stack-of-stars technique with retrospective motion correction may be a useful alternative.
Collapse
Affiliation(s)
- Pascale Aouad
- Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Ioannis Koktzoglou
- Radiology, NorthShore University HealthSystem, Walgreen Building, G534, 2650 Ridge Avenue, Evanston, IL 60201 USA
- University of Chicago Pritzker School of Medicine, Chicago, IL USA
| | | | - Ali Serhal
- Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Jose Nazari
- Medicine, NorthShore University HealthSystem, Evanston, IL USA
| | - Robert R. Edelman
- Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
- Radiology, NorthShore University HealthSystem, Walgreen Building, G534, 2650 Ridge Avenue, Evanston, IL 60201 USA
| |
Collapse
|
19
|
Amini S, Koolivand A, Nazari J. Managerial challenges and solutions for COVID-19 outbreak: New insights for global primary healthcare system. Ethics Med Public Health 2020; 15:100567. [PMID: 32837998 PMCID: PMC7377742 DOI: 10.1016/j.jemep.2020.100567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/13/2020] [Indexed: 06/11/2023]
Affiliation(s)
- S Amini
- Health Management Department, Faculty of Health, Arak University of Medical Sciences, Arak, Iran
| | - A Koolivand
- Department of Environmental Health Engineering, Faculty of Health, Arak University of Medical Sciences, Arak, Iran
| | - J Nazari
- Department of Pediatrics, Faculty of Medicine, Arak University of Medical Sciences, Arak, Iran
| |
Collapse
|
20
|
Zagrodzky J, Gallagher MM, Leung LWM, Sharkoski T, Santangeli P, Tschabrunn C, Guerra JM, Campos B, MacGregor J, Hayat J, Clark B, Mazur A, Feher M, Arnold M, Metzl M, Nazari J, Kulstad E. Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation. J Vis Exp 2020. [PMID: 32225140 DOI: 10.3791/60733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.
Collapse
Affiliation(s)
| | - Mark M Gallagher
- St George's University Hospitals NHS Foundation Trust, St. George's, University of London
| | - Lisa W M Leung
- St George's University Hospitals NHS Foundation Trust, St. George's, University of London
| | - Tiffany Sharkoski
- Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine
| | | | | | - Jose M Guerra
- Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, CIBERCV
| | - Bieito Campos
- Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, CIBERCV
| | | | - Jamal Hayat
- St George's University Hospitals NHS Foundation Trust, St. George's, University of London
| | | | | | | | | | | | | | - Erik Kulstad
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center;
| |
Collapse
|
21
|
Bernabe E, Marcenes W, Hernandez C, Bailey J, Abreu L, Alipour V, Amini S, Arabloo J, Arefi Z, Arora A, Ayanore M, Bärnighausen T, Bijani A, Cho D, Chu D, Crowe C, Demoz G, Demsie D, Dibaji Forooshani Z, Du M, El Tantawi M, Fischer F, Folayan M, Futran N, Geramo Y, Haj-Mirzaian A, Hariyani N, Hasanzadeh A, Hassanipour S, Hay S, Hole M, Hostiuc S, Ilic M, James S, Kalhor R, Kemmer L, Keramati M, Khader Y, Kisa S, Kisa A, Koyanagi A, Lalloo R, Le Nguyen Q, London S, Manohar N, Massenburg B, Mathur M, Meles H, Mestrovic T, Mohammadian-Hafshejani A, Mohammadpourhodki R, Mokdad A, Morrison S, Nazari J, Nguyen T, Nguyen C, Nixon M, Olagunju T, Pakshir K, Pathak M, Rabiee N, Rafiei A, Ramezanzadeh K, Rios-Blancas M, Roro E, Sabour S, Samy A, Sawhney M, Schwendicke F, Shaahmadi F, Shaikh M, Stein C, Tovani-Palone M, Tran B, Unnikrishnan B, Vu G, Vukovic A, Warouw T, Zaidi Z, Zhang Z, Kassebaum N. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res 2020; 99:362-373. [PMID: 32122215 PMCID: PMC7088322 DOI: 10.1177/0022034520908533] [Citation(s) in RCA: 551] [Impact Index Per Article: 137.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank’s classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.
Collapse
Affiliation(s)
| | - E. Bernabe
- E. Bernabe, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, Bessemer Road, London, SE5 9RS, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Affiliation(s)
- Ted Feldman
- Cardiology Division, NorthShore University HealthSystem; Evanston Illinois
| | - Jose Nazari
- Cardiology Division, NorthShore University HealthSystem; Evanston Illinois
| |
Collapse
|
23
|
Edelman RR, Silvers RI, Thakrar KH, Metzl MD, Nazari J, Giri S, Koktzoglou I. Nonenhanced MR angiography of the pulmonary arteries using single-shot radial quiescent-interval slice-selective (QISS): a technical feasibility study. J Cardiovasc Magn Reson 2017; 19:48. [PMID: 28662717 PMCID: PMC5492118 DOI: 10.1186/s12968-017-0365-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [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] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/16/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND For evaluation of the pulmonary arteries in patients suspected of pulmonary embolism, CT angiography (CTA) is the first-line imaging test with contrast-enhanced MR angiography (CEMRA) a potential alternative. Disadvantages of CTA include exposure to ionizing radiation and an iodinated contrast agent, while CEMRA is sensitive to respiratory motion and requires a gadolinium-based contrast agent. The primary goal of our technical feasibility study was to evaluate pulmonary arterial conspicuity using breath-hold and free-breathing implementations of a recently-developed nonenhanced approach, single-shot radial quiescent-interval slice-selective (QISS) MRA. METHODS Breath-hold and free-breathing, navigator-gated versions of radial QISS MRA were evaluated at 1.5 Tesla in three healthy subjects and 11 patients without pulmonary embolism or arterial occlusion by CTA. Images were scored by three readers for conspicuity of the pulmonary arteries through the level of the segmental branches. In addition, one patient with pulmonary embolism was imaged. RESULTS Scan time for a 54-slice acquisition spanning the pulmonary arteries was less than 2 minutes for breath-hold QISS, and less than 3.4 min using free-breathing QISS. Pulmonary artery branches through the segmental level were conspicuous with either approach. Free-breathing scans showed only mild blurring compared with breath-hold scans. For both readers, less than 1% of pulmonary arterial segments were rated as "not seen" for breath-hold and navigator-gated QISS, respectively. In subjects with atrial fibrillation, single-shot radial QISS consistently depicted the pulmonary artery branches, whereas navigator-gated 3D balanced steady-state free precession showed motion artifacts. In one patient with pulmonary embolism, radial QISS demonstrated central pulmonary emboli comparably to CEMRA and CTA. The thrombi were highly conspicuous on radial QISS images, but appeared subtle and were not prospectively identified on scout images acquired using a single-shot bSSFP acquisition. CONCLUSIONS In this technical feasibility study, both breath-hold and free-breathing single-shot radial QISS MRA enabled rapid, consistent demonstration of the pulmonary arteries through the level of the segmental branches, with only minimal artifacts from respiratory motion and cardiac arrhythmias. Based on these promising initial results, further evaluation in patients with suspected pulmonary embolism appears warranted.
Collapse
Affiliation(s)
- Robert R. Edelman
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Robert I. Silvers
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| | - Kiran H. Thakrar
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| | - Mark D. Metzl
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| | - Jose Nazari
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| | | | - Ioannis Koktzoglou
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201 USA
- The University of Chicago Pritzker School of Medicine, Chicago, USA
| |
Collapse
|
24
|
Mykytsey A, Akbar T, Danciu S, Santos M, Razminia M, Zheutlin T, Wang T, Nazari J, Maheshwari P, Telfer E, Bauman J, Kehoe R. Efficacy of dofetilide in patients with paroxysmal atrial fibrillation and normal left ventricular function. Heart Rhythm 2005. [DOI: 10.1016/j.hrthm.2005.02.597] [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: 10/25/2022]
|
25
|
Friedman PL, Dubuc M, Green MS, Jackman WM, Keane DTJ, Marinchak RA, Nazari J, Packer DL, Skanes A, Steinberg JS, Stevenson WG, Tchou PJ, Wilber DJ, Worley SJ. Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective “frosty” trial. Heart Rhythm 2004; 1:129-38. [PMID: 15851143 DOI: 10.1016/j.hrthm.2004.02.022] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [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: 01/30/2004] [Accepted: 02/16/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To study the safety, efficacy, and mapping utility of a new cryoablation catheter. BACKGROUND The CryoCath Technologies Freezor catheter has been used successfully for cryoablation of supraventricular tachycardia (SVT), but has not been evaluated in a large clinical trial. METHODS A multicenter clinical trial to evaluate the safety, efficacy, and cryomapping utility of this cryoablation catheter was conducted in 166 subjects. The target of ablation was the slow pathway in patients with SVT due to AV nodal reentry (AVNRT, n = 103), an accessory pathway in patients with AV reentrant SVT (AVRT, n = 51) and the AV junction in patients with atrial fibrillation (AF, n = 12). RESULTS Acute procedural success (APS) was achieved in 83% of the overall group (95% CI, 76% to 88%). APS in the AVNRT group was 91% (98.3% CI, 82% to 97%), compared to 69% for AVRT (98.3% CI, 51% to 84%) and 67% for AF (98.3% CI, 29% to 93%), a highly significant difference (P < .001 by stepwise logistic regression). In patients with APS, long-term success after 6 months was 91% overall (95% CI, 86% to 96%) and 94% for AVNRT subjects (98.3% CI, 87% to 100%). None of the AVNRT or AVRT subjects required a permanent pacemaker. Cryomapping successfully identified ablation targets in 64% of patients in whom it was attempted. The electrophysiologic effects of cryomapping were completely reversible within minutes in 94% of such attempts. CONCLUSIONS Catheter cryoablation of SVT is a safe alternative to RF ablation and is clinically effective in patients with AVNRT. Cryomapping can reversibly identify targets for ablation and can help minimize the risk of inadvertent AV block during ablation.
Collapse
Affiliation(s)
- Peter L Friedman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Paydak H, Telfer EA, Kehoe RF, Balasubramanian P, Narra L, Ezri M, Zheutlin T, Maheshwari P, Nazari J, Wang T. Brugada syndrome: an unusual cause of convulsive syncope. Arch Intern Med 2002; 162:1416-9. [PMID: 12076242 DOI: 10.1001/archinte.162.12.1416] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A patient who presented with a new apparent seizure was found to have abnormal electrocardiographic findings, with classic features of the Brugada syndrome. He had spontaneous episodes of nonsustained ventricular tachycardia, easily inducible ventricular fibrillation at electrophysiological study in the absence of structural heart disease, and a negative neurological evaluation. These findings suggested that sustained ventricular arrhythmias known to be associated with the Brugada syndrome and resultant cerebral hypoperfusion, rather than a primary seizure disorder, were responsible for the event. Patients with the Brugada syndrome often present with sudden death or with syncope resulting from ventricular arrhythmias. In consideration of its variability in presentation sometimes mimicking other disorders, primary care physicians and internists should be aware of its often transient electrocardiographic features.
Collapse
Affiliation(s)
- Hakan Paydak
- Department of Medicine, Case Western Reserve University, University Hospitals of Cleveland, OH, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Gallardo I, Paydak H, Narra L, Ezri M, Maheshwari P, Telfer EA, Wang T, Zheutlin T, Kehoe RF, Nazari J. Repetitive ICD discharges during an ambulance ride: an unusual pacemaker-ICD interaction. Pacing Clin Electrophysiol 1999; 22:1680-2. [PMID: 10598973 DOI: 10.1111/j.1540-8159.1999.tb00389.x] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- I Gallardo
- Cardiac Electrophysiology Service, Illinois Masonic Medical Center, Chicago 60657, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Affiliation(s)
- T Wang
- Department of Medicine, Illinois Masonic Medical Center, Chicago 60657, USA
| | | | | | | | | | | |
Collapse
|
29
|
Roberts SA, Viana MA, Nazari J, Bauman JL. Invasive and noninvasive methods to predict the long-term efficacy of amiodarone: a compilation of clinical observations using meta-analysis. Pacing Clin Electrophysiol 1994; 17:1590-602. [PMID: 7800560 DOI: 10.1111/j.1540-8159.1994.tb02352.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [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: 01/27/2023]
Abstract
BACKGROUND The method of choice to predict the long-term efficacy of amiodarone in the treatment of complex ventricular arrhythmias is unknown. Whether electrophysiological testing or Holter monitoring better predicts long-term outcome is controversial. METHODS AND RESULTS We performed a meta-analysis of trials using electrophysiological testing or electrocardiographic monitoring to predict the efficacy of amiodarone in patients with sustained ventricular tachycardia. Arrhythmia recurrence data were combined after homogeneity testing across trials. Bayesian estimates and 95% credibility intervals were constructed to compare the arrhythmia-free probability among groups. Nine studies using electrophysiological testing (351 patients) and three using Holter monitoring (167 patients) met criteria for inclusion determined a priori. The combined arrhythmia-free probability estimate and credibility intervals were 0.86 (0.78-0.92) for patients rendered noninducible and 0.81 (0.73-0.87) for patients with abolition of ventricular tachycardia during Holter monitoring on amiodarone. With this primary analysis, there was no significant difference between the predictive value of noninducibility during electrophysiological testing and abolition of ventricular tachycardia with Holter. However, if only those electrophysiological studies using at least triple extrastimuli were included, arrhythmia-free probability for patients rendered noninducible increased to 0.96 (0.88-0.99), significantly better than noninvasive testing. CONCLUSIONS Noninducible ventricular tachycardia during electrophysiological testing and abolition of ventricular tachycardia during electrocardiographic monitoring on amiodarone appear equally predictive of long-term amiodarone success, but this conclusion seems dependent on the stimulation protocol used. Although the yield is lower (compared to Holter monitoring), ventricular tachycardia rendered noninducible with a stimulation protocol using triple extrastimuli is the most highly predictive test of long-term amiodarone efficacy.
Collapse
Affiliation(s)
- S A Roberts
- Department of Pharmacy Practice, School of Public Health, University of Illinois at Chicago 60612
| | | | | | | |
Collapse
|
30
|
Kehoe RF, MacNeil DJ, Zheutlin TA, Ezri MD, Nazari J, Spangenberg RB, Dunnington C, Lueken M. Safety and efficacy of oral sotalol for sustained ventricular tachyarrhythmias refractory to other antiarrhythmic agents. Am J Cardiol 1993; 72:56A-66A. [PMID: 8346728 DOI: 10.1016/0002-9149(93)90026-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [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: 01/30/2023]
Abstract
The safety and efficacy of oral sotalol were evaluated in 481 patients with drug-refractory sustained ventricular tachyarrhythmias (VT) in an open-label multicenter study. After drug-free baseline evaluations, therapy was initiated at 80 mg every 12 hours, with upward dose titrations of 160 mg/day being allowed at intervals of 72 hours to a maximum dose of 480 mg every 12 hours. Efficacy determinations were made by either programmed electrical stimulation (PES) or Holter monitoring responses. Of the 481 patients enrolled, 473 underwent acute-phase titration. Of the 269 patients assessable by PES, 94 (34.9%) exhibited complete response (suppression of inducible VT), with an additional 67 patients (24.9%) exhibiting partial response. Of the 109 patients assessable by Holter monitoring, 43 (39.4%) exhibited a complete response. There were no significant differences between responders and nonresponders with regard to left ventricular ejection fraction. Although response rates tended to improve as the sotalol dose was increased to 640 mg/day, efficacy was most commonly achieved at a sotalol dose of 320 mg/day. Sotalol was discontinued because of adverse effects in 42 (8.9%) of the acute-phase patients. The most common adverse effect was proarrhythmia, which was observed in 23 patients (4.9%). Proarrhythmia took the form of torsades de pointes in 12 patients and an increase in VT episodes in 11. In 3 acute-phase patients (0.6%), sotalol was discontinued because of the emergence of congestive heart failure. A total of 286 patients entered the long-term phase. Life-table estimates of the proportion of patients who remained free of recurrence of arrhythmia at 12, 18, and 27 months were 0.76, 0.72, and 0.66, respectively. There were no significant differences in time to recurrence of arrhythmia as related to PES response, Holter monitor response, baseline left ventricular ejection fraction, or history of congestive heart failure. Among the 70 patients (24.5%) in whom there was recurrence of arrhythmia, sudden death occurred in 17 and sustained VT in 41. Sotalol was discontinued owing to presumed adverse effects in 21 (7.3%) of the long-term patients, including 8 with proarrhythmia; proarrhythmia consisted of torsades de pointes in 3 patients and increased episodes of VT in 5. These findings suggest that sotalol is an effective drug for the long-term treatment of patients with drug-refractory sustained VT. Proarrhythmia was observed in only 6.4% of the study population and tended to occur during the acute titration phase. The need to discontinue therapy because of congestive heart failure was uncommon.(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
Affiliation(s)
- R F Kehoe
- Department of Clinical Cardiac Electrophysiology, Illinois Masonic Medical Center, Chicago, Illinois 60657
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
Moricizine has been touted as having a low incidence of proarrhythmic effects. We present a case of proarrhythmia from moricizine, which presented as exercise induced ventricular tachycardia, and review the literature suggesting that this antiarrhythmic drug shares the proarrhythmic profile of other agents with predominant type Ic action. We conclude that moricizine has certain clinical and electrophysiological features that resemble type Ic antiarrhythmic agents. Precautions similar to those used when prescribing other drugs of this type should be followed when prescribing moricizine, including predischarge exercise testing.
Collapse
Affiliation(s)
- J Nazari
- Department of Medicine, Illinois Masonic Medical Center, Chicago 60657
| | | | | | | | | |
Collapse
|
32
|
Tworek DA, Nazari J, Ezri M, Bauman JL. Interference by antiarrhythmic agents with function of electrical cardiac devices. Clin Pharm 1992; 11:48-56. [PMID: 1730178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The possible interference of drugs with the function of implanted electrical cardiac devices in two patients is described, and the literature on the interaction between these drugs and devices is reviewed. A 59-year-old woman had a permanent pacemaker implanted after diagnosis of tachycardia-bradycardia syndrome, and her drug regimen of digoxin, verapamil, and warfarin was supplemented with flecainide to prevent paroxysmal atrial fibrillation. A Holter monitor recording performed after five days of flecainide therapy showed the pacemaker was sensing and pacing normally. Approximately three weeks after pacemaker implantation and initiation of flecainide therapy, a Holter monitor recording showed high-grade atrioventricular block and failure of the pacemaker to capture. A chest roentgenogram showed that the pacemaker lead was properly placed. The pacemaker's pulse amplitude and pulse width were increased, and the device again functioned reliably. Six months later the pacing threshold was noted to have returned to normal. A 64-year-old man had a history of aborted sudden cardiac death from ventricular tachyarrhythmias. The patient received an automatic implanted cardioverter-defibrillator (AICD); at that time, a 15-J discharge was required to terminate induced ventricular fibrillation (VF). Three years later, the AICD was replaced; the energy required for VF termination with the new unit was 16 J. Seven months after implantation of the new unit, the patient had several episodes of ventricular tachycardia (VT). Moricizine therapy was initiated. An electrophysiologic study (EPS) three days later showed that a larger shock (28 J) was required to terminate VF and that the pacing threshold had increased.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- D A Tworek
- Department of Medicine, University of Illinois, College of Pharmacy, Chicago 60612
| | | | | | | |
Collapse
|
33
|
Affiliation(s)
- S K Chokshi
- Section of Cardiology (Department of Medicine), Northwestern University Medical School, Chicago, Illinois
| | | | | | | | | | | |
Collapse
|
34
|
Nazari J, Davison R, Kaplan K, Fintel D. Adverse reactions to thrombolytic agents. Implications for coronary reperfusion following myocardial infarction. Med Toxicol Adverse Drug Exp 1987; 2:274-86. [PMID: 3306267 DOI: 10.1007/bf03259869] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The use of thrombolytic agents to dissolve coronary artery thrombi causing acute transmural myocardial infarctions has been shown to decrease short term mortality, and improve left ventricular function, in patients with acute transmural myocardial infarction. Several thrombolytic agents are currently available which differ mainly in cost, antigenicity, and mechanism of action. Current investigations are being directed at finding safer, more effective thrombolytic agents and at developing optimal therapy following thrombolysis. The complications of thrombolytic therapy are for the most part minor and reversible. Immediate and delayed hypersensitivity to streptokinase is rare. Hypotension and arrhythmias commonly accompany myocardial reperfusion and are usually benign and self-limited. Haemorrhagic complications are the most frequent and serious problems following the use of thrombolytic agents. They can be lessened by the proper selection of patients to avoid those at high risk of bleeding. The avoidance of unnecessary arterial and venous punctures will decrease the incidence of minor but annoying local bleeding. Those agents which are activated at the site of thrombi will hopefully cause fewer bleeding episodes, but early experience with these agents has not been able to demonstrate a lower rate. With careful attention to patient selection and follow-up, thrombolytic agents can be safely and effectively used in the management of patients with acute myocardial infarction.
Collapse
|