Objectives The authors sought to characterize the left atrial (LA) and pulmonary vein (PV) electrophysiological and hemodynamic features in obese patients with atrial fibrillation (AF). Background ...Obesity is associated with increased risk for AF. Methods A total of 63 consecutive patients with AF who had normal left ventricular (LV) ejection fraction and who underwent catheter ablation were studied. Atrial and PV electrophysiological studies were performed at the time of ablation with hemodynamic assessment by cardiac catheterization, and LA/LV structure and function by echocardiography. Patients were compared on the basis of body mass index (BMI): <25 kg/m2 (n = 19) and BMI ≥30 kg/m2 (n = 44). Results At a 600-ms pacing cycle length, obese patients had shorter effective refractory period (ERP) in the left atrium (251 ± 25 ms vs. 233 ± 32 ms, p = 0.04), and in the proximal (207 ± 33 ms vs. 248 ± 34 ms, p < 0.001) and distal (193 ± 33 ms vs. 248 ± 44 ms, p < 0.001) PV than normal BMI patients. Obese patients had higher mean LA pressure (15 ± 5 mm Hg vs. 10 ± 5 mm Hg, p < 0.001) and LA volume index (28 ± 12 ml/m2 vs. 21 ± 14 ml/m2 , p = 0.006), and lower LA strain (5.5 ± 3.1% vs. 8.8 ± 2.8%; p < 0.001) than normal BMI patients. Conclusions Increased LA pressure and volume, and shortened ERP in the left atrium and PV are potential factors facilitating and perpetuating AF in obese patients with AF.
Novel oral anticoagulants (NOACs) are safe and effective for the prevention of stroke or systemic embolism (S/SE) in atrial fibrillation. The efficacy and safety of NOACs compared with warfarin has ...not been systematically assessed in subjects with mild or moderate renal dysfunction. We performed a meta-analysis of the randomized clinical trials that compared efficacy and safety (major bleeding) outcomes of NOACs compared to warfarin for the treatment of nonvalvular atrial fibrillation and had available data on renal function. We estimated the pooled relative risk (RR) of S/SE and major bleeding in relation to renal function (assessed by baseline estimated glomerular filtration rate divided in 3 groups: normal estimated glomerular filtration rate >80 ml/min, mildly impaired 50 to 80 ml/min, and moderate impairment <50 ml/min). We included 4 randomized clinical trials enrolling a total of 58,338 subjects. The RRs of S/SE and major bleeding were higher in subjects with renal impairment compared to normal renal function, independent of type of anticoagulant therapy. In subjects with normal renal function, no difference in the risk of S/SE was observed, whereas the risk of major bleeding was slightly lower for subjects taking NOACs (RR 0.87, 95% confidence interval CI 0.76 to 0.99). In subjects with mild or moderate renal impairment, NOACs were associated with a reduced risk of S/SE (RR 0.75, 95% CI 0.66to 0.85 and RR 0.80, 95% CI 0.68 to 0.94, respectively) and major bleeding (RR 0.87, 95% CI 0.79 to 0.95 and RR 0.80, 95% CI 0.71 to 0.91, respectively) compared to warfarin. The pooled analysis for major bleeding demonstrated significant heterogeneity. In conclusion, the use of NOACs was associated with a reduced risk of S/SE and reduced risk of major bleeding compared to warfarin in subjects with mild or moderate renal impairment suggesting a favorable risk profile of these agents in patients with renal disease.
Repaired congenital heart disease (rCHD) is strongly associated with ventricular tachycardia (VT) as an important late cause of morbidity and mortality. Ventricular reentry most commonly includes ...anatomic isthmuses created during the repair procedures.
The purpose of this study was to analyze the long-term outcomes of catheter ablation, a commonly used standalone or adjunctive therapy, in a cohort of rCHD patients.
A retrospective analysis of 21 consecutive patients with rCHD (45.0 ± 3.0 years, 71.4% male) undergoing ablation for VT was performed. The primary composite outcome was defined as in-hospital arrhythmic death, out-of-hospital sudden cardiac death, or appropriate implantable cardioverter-defibrillator therapy.
At initial electrophysiologic study, 14 patients (66.7%) had reentrant VT through an electroanatomic isthmus; the remaining 7 patients (33.3%) demonstrated focal VT. Isthmus-dependent reentry was identified as the mechanism for VT in 14 patients (66.7%), and conduction block was confirmed in 8 of these patients (57.1%). No patients with confirmed block developed VT recurrence. During long-term follow-up (33 ± 7 months), 20 of 21 patients (95.2%) had not reached the primary composite outcome. Three patients died of nonarrhythmic causes.
Catheter-based VT ablation in patients with rCHD is associated with a low rate of VT recurrence. Focal VT was not uncommon in this cohort. If a reentrant mechanism is present, confirmation of conduction block across the isthmus is vital to prevent recurrence.
It is known that statins are effective in preventing atrial fibrillation (AF) in patients undergoing cardiac surgery.
The purpose of this study was to evaluate the efficacy of statins in preventing ...AF recurrence following left atrial ablation.
One hundred twenty-five patients who had no statin indication undergoing catheter ablation due to drug-refractory paroxysmal (n = 90) or persistent (n = 35) AF were randomized in a prospective, double-blind, placebo-controlled trial to receive 80 mg atorvastatin (n = 62) or placebo (n = 63) for 3 months. The primary endpoint was freedom from symptomatic AF at 3 months. Secondary endpoints included freedom from any atrial arrhythmia recurrence irrespective of symptoms, quality of life (QoL), and reduction in C-reactive protein (CRP).
At 3 months, 95% of patients in the atorvastatin group were free of symptomatic AF compared with 93.5% in the placebo group (P = .75). Similarly, 85% of patients treated in the atorvastatin group remained free of any recurrent atrial arrhythmia vs 88% of patients in the placebo group (P = .37). Mean CRP levels decreased in the atorvastatin group (mean change -0.75 ± 3, P = .02) and increased in the placebo group (mean change 2.1 ± 19.9, P = .48). Mean QoL score improved significantly in both groups (mean change 13.14 ± 18.2 in the atorvastatin group and 11.10 ± 17.7 in the placebo group, P = .53).
In patients with no standard indication for statin therapy, treatment with atorvastatin 80 mg/day following AF ablation does not decrease the risk of AF recurrence in the first 3 months and should not be routinely administered to prevent periprocedural arrhythmias.
Sudden death may occur after radiofrequency catheter ablation of the atrioventricular node (AVN) and permanent pacemaker implantation. It is unclear whether a faster initial heart rate with gradual ...rate reduction decreases the risk of sudden death.
To evaluate the effects of initial pacing at a faster rate after AVN ablation, with a gradual rate decrease over 3 months, on the rate of sudden death in patients with atrial fibrillation.
We compared the rate of likely or possible procedure-related sudden death in 2 groups of patients who had AVN ablation and pacemaker implantation. The study cohort was treated between January 2005 and December 2009, and pacemakers were programmed to a lower rate of 90 beats/min after the procedure, with a monthly decrement of 10 beats/min until 60 beats/min was reached. The control group was treated between July 1990 and December 1998 when pacemakers were programmed to a lower rate of 60 beats/min immediately after ablation.
The study cohort included 520 patients (mean age 73.6 ± 10.3 years), and the control cohort comprised 334 patients (mean age 68.1 ± 1.1 years). Sudden death deemed likely or possibly related to ablation and pacemaker implantation occurred in 1 patient in the study cohort (0.2%) and in 7 patients (2.1%) in the control group (P = .007).
Sudden death was significantly decreased in the study cohort compared to controls. The faster lower pacing rate immediately after AVN ablation with a gradual decrease is a plausible mechanism for the improved clinical outcome.
With the increasing use, complexity, anatomical approaches, and tools related to epicardial procedures, complications previously not seen during endovascular ablation are now well recognized with ...epicardial ablation. Whether newer approaches and the regional anatomy of the pericardial space contribute to unexpected complications after epicardial access (EpiAcc) is presently unknown.
To characterize underreported, or novel, complications associated with percutaneous EpiAcc as part of an electrophysiology procedure.
We retrospectively reviewed percutaneous EpiAcc as part of an ablation procedure from January 1, 2004, to December 31, 2011.
Of 116 attempts in 107 patients, 8 atypical ablation complications (no procedural deaths) were noted; complications included delayed pericarditis (2 weeks), chronic refractory pericarditis, requirement for snaring of broken intrapericardial wire, pleural perforation, phrenic nerve injury despite protective strategies, hemoperitoneum, and abdominal-pericardial fistula.
Vigilance both during and after EpiAcc is needed to recognize these complications, some of which may be life-threatening.
On the basis of this information, the writing committee was constituted to ensure that the Chair and a majority of members have no relevant RWI.\n Miles University of Florida--Professor of Medicine ...Content Reviewer, EP Training Program Director None None None Medtronic UCSF/ZOLL Medical Boston Scientificlow * Medtroniclow * St. Jude Medicallow * None Maged Nageh Kaiser Permanente Los Angeles Medical Center--Attending Physician; Clinical Cardiac Electrophysiology Program Director Content Reviewer, EP Training Program Director None None None None None None Duy Thai Nguyen University of Colorado--Electrophysiology Training Program Director Content Reviewer, EP Training Program Director None None None None None None Kristen K. Patton University of Washington--Associate Professor of Medicine Content Reviewer, ACC EP Section Leadership Council None None None None None None Marwan Refaat American University of Beirut Medical Center--Assistant Professor of Medicine Content Reviewer, ACC EP Section Leadership Council None None None None None None Lynda Rosenfeld Yale University School of Medicine--Director, Yale University Clinical Cardiac Electrophysiology Fellowship Program Content Reviewer, EP Training Program Director None None None Medtronicdagger Boston Scientificlow * Medtroniclow * St. Jude Medicallow * None Peter Santucci Loyola University-- Electrophysiology Training Program Director; Professor of Medicine Content Reviewer, EP Training Program Director None None None None Biosense Websterlow * Biotroniklow * Boston Scientificlow * Medtroniclow * None Komandoor Srivathsan Mayo Clinic--Associate Professor, College of Medicine Content Reviewer, EP Training Program Director St. Jude Medical Biosense Webster None None None None Gregory Supple University of Pennsylvania Health System--Associate Director, Cardiac Electrophysiology Fellowship Program; Assistant Professor of Clinical Medicine Content Reviewer, EP Training Program Director Biotronik St. Jude Medical None None Boston Scientific Medtronic None None Gaurav A. Upadhyay University of Chicago--Assistant Professor of Medicine Content Reviewer, ACC EP Section Leadership Council Biosense Webster Biotronik Boston Scientific Medtronic None None None None None * This table reflects peer reviewers' relationships with industry and other entities that were reported and deemed to be relevant to this document, as well as employment, representation in the review process, and reporting categories.
With the increased number of implantable cardioverter-defibrillator (ICD) recipients and the frequent need for device upgrading, lead malfunction is a concern, but the optimal approach to managing ...nonfunctioning leads is unknown.
The purpose of this study was to determine the rate and characteristics of complications related to abandoned ICD leads.
Patients with abandoned leads were identified by retrospective review of the Mayo Clinic ICD database from August 1993 to May 2002. We reviewed the medical records to assess long-term follow-up for venous thromboembolic complications, device sensing malfunction, appropriateness of delivered shocks, defibrillation threshold (DFT) values before and after lead abandonment, and subsequent surgical procedures related to devices or leads.
We identified 78 ICD patients (81% males; mean age 63 +/- 14 years) with 101 abandoned leads (69 in the right ventricle, 31 in the right atrium or superior vena cava, 1 in the coronary sinus). During a mean follow-up of 3.1 +/- 2.0 years, neither sensing malfunction nor venous thromboembolic complications were detected. DFT values were high in 13 patients (17%), but there was no significant increase in mean DFT values before and after lead abandonment in 43 patients for whom both values were available (16.2 +/- 9.2 J before abandonment vs 14.1 +/- 5.5 J after; P = .24). Fourteen patients (18%) required further ICD-related surgery; none of these operations were attributed to abandoned leads. Five-year rates of appropriate and inappropriate shocks were 25.9% and 20.5%, respectively.
Abandoning a nonfunctioning lead appears to be safe and does not pose a clinically significant additional risk of future complications.
Device implantation is sometimes required in congenitally corrected transposition of the great arteries (ccTGA) because of morphologic right ventricular (RV) dysfunction and complete heart block. The ...anatomical course of the veins remains unknown, despite well-described coronary arterial anatomy. Knowledge of the venous anatomy may facilitate planning of percutaneous cardiac procedures in these patients.
This study sought to characterize the venous anatomy in ccTGA.
Pathologic cardiac specimens from patients with ccTGA were identified from the Mayo Clinic pathology database. Coronary sinus (CS) anatomy and distances from the CS ostium to the major cardiac veins were evaluated. Thebesian veins with ostial openings >1 mm, epicardial veins, and venous collaterals were also quantified.
There were 56 hearts with a diagnosis of ccTGA identified. The CS was unidentifiable in 5 hearts due to slicing, and assessment of the Thebesian veins was not possible in 16. Seven hearts had an abnormal CS, 2 of which had atretic ostia and the other 5 of which either had an abnormal ostial location or multiple ostia. There were 28 hearts with at least 1 Thebesian vein with an ostial opening >1 mm. All 12 hearts with unidentifiable Thebesian veins had venous collaterals from the right ventricle (RV) to the major cardiac veins. Epicardial veins extended to the proximal, middle, and distal thirds of the RV in 71%, 23%, and 6%, respectively.
In ccTGA, the ventricular venous anatomy is abnormal and follows the morphologic RV. However, large interventricular and Thebesian veins may offer options for percutaneous lead or catheter placement when approaching the systemic RV.
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