Background Sutureless self-expandable aortic bioprostheses rely on radial forces for stabilization, raising concern that these devices may increase the risk of postoperative conduction disease. The ...purpose of this study was to determine the incidence of conduction disorders after sutureless aortic valve replacement (AVR) with the Perceval S (Sorin Group, Saluggia, Italy) bioprosthesis. Methods Between June 2011 and March 2013, 108 consecutive patients underwent sutureless AVR with the Perceval S prosthesis. Six patients (6%) had a permanent pacemaker (PPM) preoperatively and were excluded from the present study. Mean electrocardiographic follow-up was 14.6 ± 6.0 months. Results Mean age was 79.2 ± 4.8 years (52% female). During the postoperative period, 34 patients (34%) had first-degree atrioventricular block, 2 (2%) had Mobitz-II atrioventricular block, and 16 (16%) had complete atrioventricular block. New-onset left bundle branch block and right bundle branch block were observed in 33 patients (33%) and 22 patients (22%), respectively. Inhospital postoperative PPM implantation was required in 23 patients (23%). Preoperative aortic valve area, age more than 85 years, and preoperative right bundle branch block were found to be independently associated with inhospital PPM implantation or new-onset postoperative conduction disorder. At follow-up, 3 more patients (3%) underwent PPM implantation. The cumulative incidences of PPM dependency and ventricular pacing more than 25% of the time were 18% ± 11% and 21% ± 10%, respectively, at 18 months. Conclusions In the present study, the postoperative PPM implantation rate (23%) after sutureless AVR with the Perceval S prosthesis was high. Surgical strategies aimed at mitigating this risk should be further investigated.
Atrial arrhythmias are the most common complication encountered in the growing and aging population with congenital heart disease.
This study sought to assess the types and patterns of atrial ...arrhythmias, associated factors, and age-related trends.
A multicenter cohort study enrolled 482 patients with congenital heart disease and atrial arrhythmias, age 32.0 ± 18.0 years, 45.2% female, from 12 North American centers. Qualifying arrhythmias were classified by a blinded adjudicating committee.
The most common presenting arrhythmia was intra-atrial re-entrant tachycardia (IART) (61.6%), followed by atrial fibrillation (28.8%), and focal atrial tachycardia (9.5%). The proportion of arrhythmias due to IART increased with congenital heart disease complexity from 47.2% to 62.1% to 67.0% in patients with simple, moderate, and complex defects, respectively (p = 0.0013). Atrial fibrillation increased with age to surpass IART as the most common arrhythmia in those ≥50 years of age (51.2% vs. 44.2%; p < 0.0001). Older age (odds ratio OR: 1.024 per year; 95% confidence interval CI: 1.010 to 1.039; p = 0.001) and hypertension (OR: 2.00; 95% CI: 1.08 to 3.71; p = 0.029) were independently associated with atrial fibrillation. During a mean follow-up of 11.3 ± 9.4 years, the predominant arrhythmia pattern was paroxysmal in 62.3%, persistent in 28.2%, and permanent in 9.5%. Permanent atrial arrhythmias increased with age from 3.1% to 22.6% in patients <20 years to ≥50 years, respectively (p < 0.0001).
IART is the most common presenting atrial arrhythmia in patients with congenital heart disease, with a predominantly paroxysmal pattern. However, atrial fibrillation increases in prevalence and atrial arrhythmias progressively become permanent as the population ages.
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Summary Background Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by ...unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. Methods We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov , number NCT01058980. Findings Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9–38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31–0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry. Interpretation Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice. Funding Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation).
Genetic testing is recommended in specific inherited heart diseases but its role remains unclear and it is not currently recommended in unexplained cardiac arrest (UCA). We sought to assess the yield ...and clinical utility of genetic testing in UCA using whole-exome sequencing (WES).
Survivors of UCA requiring external defibrillation were included from the Cardiac Arrest Survivor with Preserved Ejection fraction Registry. Whole-exome sequencing was performed, followed by assessment of rare variants in previously reported cardiovascular disease genes. A total of 228 UCA survivors (mean age at arrest 39 ± 13 years) were included. The majority were males (66%) and of European ancestry (81%). Following advanced clinical testing at baseline, the likely aetiology of cardiac arrest was determined in 21/228 (9%) cases. Whole-exome sequencing identified a pathogenic or likely pathogenic (P/LP) variant in 23/228 (10%) of UCA survivors overall, increasing the proportion of 'explained' cases from 9% only following phenotyping to 18% when combining phenotyping with WES. Notably, 13 (57%) of the 23 P/LP variants identified were located in genes associated with cardiomyopathy, in the absence of a diagnosis of cardiomyopathy at the time of arrest.
Genetic testing identifies a disease-causing variant in 10% of apparent UCA survivors. The majority of disease-causing variants was located in cardiomyopathy-associated genes, highlighting the arrhythmogenic potential of such variants in the absence of an overt cardiomyopathy diagnosis. The present study supports the use of genetic testing including assessment of arrhythmia and cardiomyopathy genes in survivors of UCA.
Electrophysiological predictors of atrioventricular (AV) block after transcatheter aortic valve replacement (TAVR) are unknown.
We sought to assess the value of electrophysiology study before and ...after TAVR.
Seventy-five consecutive pacemaker-free patients undergoing TAVR at the Montreal Heart Institute were prospectively studied.
Eleven patients (14.7%) developed AV block during the index hospitalization and 3 (4.0%) after hospital discharge over a median follow-up of 1.4 years (interquartile range 0.6-2.1 years). AV block developed in 5 of 6 patients with preprocedural right bundle branch block (83.3%), 8 of 30 patients with new-onset left bundle branch block (LBBB; 26.7%), and 1 of 7 patients with preexisting LBBB (14.3%). In multivariate analysis that considered all patients, the delta-HV interval (HV interval after TAVR minus HV interval before TAVR) was the only factor independently associated with AV block. In the subgroup of patients with new-onset LBBB, the postprocedural HV interval was strongly associated with AV block. By receiver operating characteristic analysis, a delta-HV interval of ≥13 ms predicted AV block with 100.0% sensitivity and 84.4% specificity and an HV interval of ≥65 ms predicted AV block with 83.3% sensitivity and 81.6% specificity. In multivariate analysis, the HV interval after TAVR (hazard ratio 1.073 per ms; 95% confidence interval 1.029-1.119; P = .001) was also independently associated with all-cause mortality.
A prolonged delta-HV interval (≥13 ms) is strongly associated with AV block after TAVR. In patients with new-onset LBBB after TAVR, a postprocedural HV interval of ≥65 ms is likewise predictive of AV block.
Abstract Background There is a paucity of data to guide decisions regarding thromboprophylaxis for atrial arrhythmias in congenital heart disease. Methods A retrospective multicenter cohort study ...enrolled patients with documented sustained atrial arrhythmias and congenital heart disease from 12 North American centers to quantify thromboembolic and bleeding rates associated with antiplatelet and anticoagulation therapy, and explore associated factors. A blinded committee adjudicated all qualifying arrhythmias and outcomes. Results A total of 482 patients, 45.2% female, age 32.0 ± 18.0 years, were followed for 11.3 ± 9.4 years since the qualifying arrhythmia. Antiplatelet therapy was administered to 37.8%, anticoagulation to 54.4%, and neither to 7.9%. Congenital heart disease complexity was simple, moderate, and severe in 18.5%, 34.4%, and 47.1%, respectively. Freedom from thromboembolic events was 84.7 ± 2.7% at 15 years, with no difference between anticoagulation versus antiplatelet therapy (P = 0.97). Congenital heart disease complexity was independently associated with thromboembolic events, with rates of 0.00%, 0.93%, and 1.95%/year in those with simple, moderate, and severe forms (P < 0.001). CHADS2 and CHA2 DS2 -VASc scores were not predictive of thromboembolic risk. Annualized bleeding rates with antiplatelet and anticoagulation therapy were 0.66% and 1.82% (P = 0.039). In multivariable analyses, anticoagulation hazard ratio (HR) 4.76, 95% CI (1.05–21.58), P = 0.043 and HAS-BLED score HR 3.15, 95% CI (1.02, 9.78), P = 0.047 were independently associated with major bleeds. Conclusion Current management of atrial arrhythmias in congenital heart disease is associated with a modest rate of thromboembolic events, which is predicted by disease complexity but not CHADS2 /CHA2 DS2 -VASc scores. HAS-BLED score is applicable to the congenital population in predicting major bleeds.
The use of blanking periods, the immediate period postablation during which transient tachyarrhythmia episodes are not considered recurrences, has been predicated on the assumption that not all early ...recurrences of atrial tachyarrhythmias (ERAT) will lead to later recurrences and, as such, does not necessarily represent treatment failure. While ERAT can be expected to occur in approximately 38% of patients within the first 3 months of atrial fibrillation (AF) ablation, only half of these patients will manifest later recurrences. Clinical features related to the patient's history of AF, the index ablation procedure, and particularities of the ERAT can help identify patients at higher risk of later recurrence in whom aggressive attempts to control rhythm, including early cardioversion and reintervention, may be justified. (PACE 2012; 35:106–116)
Abstract Arrhythmic or Electrical Storm (AES) is a clinical condition characterized by three or more sustained ventricular arrhythmia episodes leading to appropriate device therapy in a 24-hour ...period, and is associated with a very high mortality. The clinical presentation is dramatic and the management remains challenging. Whereas pharmacological treatment and sedation are still part of the initial treatment, newer approaches that include ablation (endocardial, epicardial, or alternative procedures), sympathetic blockade (pharmacologic or by interventional sympathetic denervation), and mechanical hemodynamic support are increasingly used in this setting. In this article we will review the current technologies clinically at our disposal to treat AES.
Introduction
In patients with ischemic heart disease and ventricular tachycardia (VT) refractory to high dose amiodarone, the two most common therapeutic options are adjunctive mexiletine therapy or ...catheter ablation. There are little existing data on the efficacy of these strategies. We examined the relative efficacy of adjunctive mexiletine and catheter ablation among patients enrolled in the VANISH trial.
Methods
All subjects enrolled in the VANISH trial who had VT refractory to high dose (≥ 300 mg daily) amiodarone at baseline were included. Per protocol, subjects randomized to escalated drug therapy received adjunctive mexiletine.
Results
Nineteen of the 259 patients were receiving high‐dose amiodarone at baseline and 11 were randomized to escalated therapy with mexiletine and 8 to ablation. The adjunctive mexiletine group had a higher rate of the primary composite outcome (death, VT storm, or appropriate shock) in comparison to catheter ablation (HR 6.87 2.08–22.8). Over 90% of the patients in the adjunctive mexiletine/group experienced a primary endpoint during a median 9.2 months’ follow‐up. There was no difference in the rate of adverse events between the two groups.
Conclusions
Mexiletine has limited efficacy in the treatment of recurrent VT despite high‐dose amiodarone therapy, in patients with ischemic heart disease. Catheter ablation is a superior strategy in this population.
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