Comparison of outcomes, device deployment time (DT), and total time (TT) using a single tapered Coons dilator versus sequential serial dilation for implantation of the Micra leadless pacemaker.
Micra ...leadless pacemaker placement requires a 23 French Micra introducer sheath (MIS) for percutaneous delivery. We sought to evaluate outcomes with use of a single tapered Coons dilator (CD) versus sequential serial dilatation (SD) method to facilitate insertion of the Micra introducer sheath.
35 patients were included in the SD arm and 49 in the CD arm. DT and TT were recorded in minutes and cost in dollars. Analysis was performed using independent t-test between two groups and one-way ANOVA to evaluate inter-operator variability in the CD arm.
Both DT and TT were significantly lower for the CD arm (15.1 ± 5.1 vs 23.5 ± 9.3, p < 0.0005 and 29.9 ± 14 vs 39.3 ± 13.5 min, p = 0.000374; respectively). The cost was also significantly lower using a CD versus SD. There was no inter-operator variability in the CD arm between 6 operators (p = 0.177 for DT and p = 0.304 for TT). No complications occurred in the SD arm. There were 3 vascular access site complications in the CD arm, all of which occurred early in the operator’s experience.
Coons dilator is an efficient and cost-effective method for vascular dilatation to facilitate Micra leadless pacemaker insertion. Rate of complications is low and expected to improve with greater experience.
Introduction
Left atrial appendage occlusion (LAAO) is recommended in patients with non-valvular atrial fibrillation (AF) who have contraindications to or are intolerant of long-term oral ...anticoagulants (OAC), but its impact on hospitalization rates has not been well described. The objective of our study is to describe the incidence of all-cause, bleeding-related, and thrombosis-related hospitalizations before and after LAAO.
Material and methods
We used the Nationwide Readmission Database to include patients aged ≥ 18 years with a diagnosis of AF who underwent transcatheter LAAO during the months of February-November in each year between 2016 and 2018. Patients who died during the index procedure or had missing length of hospital stay or mortality information were excluded.
Results
A total of 27,633 patients were included (median age: 77 years, 41% female) with an average pre- and post-LAAO monitoring period of 6.5 and 5.5 months respectively. Of these, 10,808 (39.1%) patients had one or more admissions prior to the procedure compared to 7,196 (26.0%) after the procedure. There was a 26% reduction in incidence of all-cause admissions (rate ratio (RR) = 0.74, 95% confidence interval (CI): 0.71–0.76; p < 0.001), 49% reduction in bleeding-related admissions (RR = 0.51, 95% CI: 0.48–0.55; p < 0.001), and 71% reduction in thrombosis-related readmissions (RR = 0.29, 95% CI: 0.26–0.33; p < 0.001) after LAAO.
Conclusions
In a contemporary, nationally representative dataset, we found that LAAO is associated with a significant decrease in all-cause, bleeding-related, and thrombosis-related admissions. These findings lend support to the current use of transcatheter LAAO in clinical practice for patients with contraindications to OAC and/or at high risk of bleeding.
Introduction: It is unclear whether early restoration of sinus rhythm in patients with persistent atrial arrhythmias after catheter ablation of atrial fibrillation (AF) facilitates reverse atrial ...remodeling and promotes long‐term maintenance of sinus rhythm. The purpose of this study was to determine the relationship between the time to restoration of sinus rhythm after a recurrence of an atrial arrhythmia and long‐term maintenance of sinus rhythm after radiofrequency catheter ablation of AF.
Methods and Results: Radiofrequency catheter ablation was performed in 384 consecutive patients (age 60 ± 9 years) for paroxysmal (215 patients) or persistent AF (169 patients). Transthoracic cardioversion was performed in all 93 patients (24%) who presented with a persistent atrial arrhythmia: AF (n = 74) or atrial flutter (n = 19) at a mean of 51 ± 53 days from the recurrence of atrial arrhythmia and 88 ± 72 days from the ablation procedure. At a mean of 16 ± 10 months after the ablation procedure, 25 of 93 patients (27%) who underwent cardioversion were in sinus rhythm without antiarrhythmic therapy. Among the 46 patients who underwent cardioversion at ≤30 days after the recurrence, 23 (50%) were in sinus rhythm without antiarrhythmic therapy. On multivariate analysis of clinical variables, time to cardioversion within 30 days after the onset of atrial arrhythmia was the only independent predictor of maintenance of sinus rhythm in the absence of antiarrhythmic drug therapy after a single ablation procedure (OR 22.5; 95% CI 4.87–103.88, P < 0.001).
Conclusion: Freedom from AF/flutter is achieved in approximately 50% of patients who undergo cardioversion within 30 days of a persistent atrial arrhythmia after catheter ablation of AF.
Abstract only Introduction: AV dyssynchrony is considered advantageous in HoCM patients requiring pacemaker therapy. The impact of physiologic pacing, particularly LBBAP, on LVOTO in HoCM remains ...unexplored. We present a patient highlighting the effect of LBBAP on LVOTO. Case: A 69-year-old female with HoCM (resting gradient ~130mmHg) and asymmetric septal hypertrophy (17mm), managed conservatively due to high surgical risk. She had persistent AF, accompanied by debilitating fatigue and palpitations. Due to unsuccessful treatment with sotalol, dofetilide, and 5 DCCV procedures, other treatment options were discussed. She opted for LBBA pacing and AV node ablation. Dual chamber device was implanted utilizing a Medtronic 3830 lead. Within 48 hours of discharge, she came to the ER with exertional dyspnea and lightheadedness, indicating ambulatory cardiogenic shock (BP: 78/66 mmHg). A stat echo showed LVEF of 75%, severe SAM, LVOT gradient of 179 mmHg, and severe MR. No pericardial effusion. Phenylephrine was initiated, and VVIR rate was decreased from 90 bpm to 60 bpm, but no BP improvement. Obstructive cardiogenic shock from worsened LVOTO was likely caused by physiologic LBBAP. To objectively demonstrate this, she underwent a brief study in the lab after informed consent. We inserted a temporary RV apical pacing lead and assessed LVOT gradients at rest and during exercise for both physiologic pacing and RV apical pacing. RV apical pacing had lower LVOT gradient at rest and exercise compared to LBBA pacing (Figure 1). LBBA lead was extracted and a CRT-P device implanted and programmed for optimal dyssynchrony. Discussion: Traditional RV apical pacing is superior to physiologic LBBAP in HoCM. Limited studies suggest biventricular pacing reduces LVOT gradient, but CRT is not superior to RV pacing. LBBA pacing may be contraindicated in LVOTO patients. Conclusion: In HCM patients with LVOTO, RV apical pacing appears superior to LBBAP, reducing LVOT gradient at rest and during exercise.
Objectives To identify and characterize ablation lesions after radiofrequency (RF) catheter ablation of ventricular arrhythmias in patients without prior myocardial infarction and to correlate the ...ablation lesions with the amount of RF energy delivered and the clinical outcome. Background Visualization of RF energy lesions after ablation of ventricular arrhythmias might help to identify reasons for ablation failure. Methods In a consecutive series of 35 patients (19 women, age: 48 ± 15 years, ejection fraction: 0.56 ± 0.12) without structural heart disease who were referred for ablation of ventricular arrhythmias, cardiac magnetic resonance imaging with delayed enhancement was performed before and after ablation. Ablation lesions were sought in the post-ablation cardiac magnetic resonance images. The endocardial area, depth, and volume of the lesions were measured. Lesion size was correlated with the type of ablation catheter used and the duration of RF energy delivered. Results In 25 of 35 patients (71%), ablation lesions were identified by delayed enhancement a mean of 22 ± 12 months after the initial ablation procedure. The mean lesion volume was 1.4 ± 1.4 cm3 , with a mean endocardial area of 3.5 ± 3.0 cm2 . The largest lesions (mean volume of 2.9 ± 2.1 cm3 with an endocardial area of 6.4 ± 3.4 cm2 ) were identified in patients in whom the arrhythmias originated in the papillary muscles. Ablation duration correlated with lesion size (r = 0.67, p < 0.001). There was no difference in lesion volume with irrigated versus nonirrigated ablation catheters (1.0 ± 0.73 vs. 2.0 ± 2.1 cm3 , p = 0.09). Identification of ablation lesions in patients with a failed procedure identified the sites where ineffective RF energy lesions were created. Conclusions RF ablation lesions can be detected long term after an ablation procedure targeting ventricular arrhythmias in patients without previous infarction. Lesion size correlates with the amount of RF energy delivered and is largest when a targeted arrhythmia originates in a papillary muscle.
Abstract only Introduction: Ablation for typical atrial flutter (AFL) traditionally involves vascular access from the femoral vein to facilitate advancing catheters through the Inferior Vena Cava ...(IVC) to the right atrium (RA). In patients with interrupted or occluded IVC, this procedure is challenging to perform. We report a case series of typical right AFL ablation using subclavian access in interrupted or occluded IVC. Cases: A 63-year-old female with typical AFL refractory to medical therapy was referred for radiofrequency ablation (RFA). She had a history of surgically corrected atrial septal defect at age 4 years with known IVC interruption draining into RA via an azygous venous extension. Another case involved a 41-year-old male with quadriplegia and typical AFL who underwent an attempted RFA from femoral access that was aborted due to massive thrombosis of IVC. Decision making: In both cases, two sheaths were placed into the left subclavian venous system using ultrasound guidance. A coronary sinus catheter and irrigated tip ablation catheter were advanced into the coronary sinus and RA respectively. Additionally, in the second case, an intracardiac echocardiography probe was inserted via separate venous access. Using the electroanatomic mapping system, entrainment and activation mapping confirmed a tricuspid isthmus-dependent AFL. RFA was performed using an open irrigated RFA catheter in a linear fashion resulting in the termination of the tachycardia to sinus rhythm. In the first case, ablation extended from the tricuspid annulus to the os of the hepatic vein at the 06:00 position. Post ablation, hemostasis was achieved using a suture-mediated closure device. At follow-up, both patients were asymptomatic without evidence of AFL on extended-duration cardiac monitoring. Conclusion: In patients with interrupted or occluded IVC, the subclavian veins can be accessed for mapping and ablation of typical AFL when traditional femoral venous access is challenging.
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