Mitigating Esophageal Injury after Atrial Fibrillation Ablation Guided by Ablation Index; CLOSEr to goalJason S. Chinitz, MD1 and Eli Q. Harris, MD21.South Shore University HospitalNorthwell HealthBay Shore, NY2. Nassau University Medical CenterEast Meadow, NYFinancial support : none.Disclosures : Dr. Chinitz serves on the scientific advisory board for Biosense Webster and has received consulting fees
Abstract: After several years with sobering experiences with electrogram-based AF ablation approaches, Seitz et al present with the VX1 software a reliable tool to map and ablate spatio-temporal dispersion. The presented multicenter study in persistent AF patients was conducted in 1 expert and 7 satellite centers with a total of 17 operators, using the VX1 software to detect and subsequently ablate spatiotemporal dispersion. While the AF termination rate (88%) and the freedom from AF in 12 months FU (82%) was very encouraging, the VX1 software, using AI enhanced electrogram adjudication, achieved very similar results in all centers, regardless of the centre’s or the operator’s experience. Thus, the biggest criticism of electrogram-based ablation strategies, i.e. the lack of reproducibility in “non-expert” centers, seems to be finally addressed.
A global coronavirus (COVID-19) pandemic occurred at the start of 2020 and is already responsible for more than 74,000 deaths worldwide, just over 100 years after the influenza pandemic of 1918. At the center of the crisis is the highly infectious and deadly SARS-CoV-2, which has altered everything from individual daily lives to the global economy and our collective consciousness. Aside from the pulmonary manifestations of disease, there are likely to be several electrophysiologic (EP) sequelae of COVID-19 infection and its treatment, due to consequences of myocarditis and the use of QT-prolonging drugs. Most crucially, the surge in COVID-19 positive patients that have already overwhelmed the New York City hospital system requires conservation of hospital resources including personal protective equipment (PPE), reassignment of personnel, and reorganization of institutions, including the EP laboratory. In this proposal, we detail the specific protocol changes that our EP department has adopted during the COVID-19 pandemic, including performance of only urgent/emergent procedures, afterhours/7-day per week laboratory operation, single attending-only cases to preserve PPE, appropriate use of PPE, telemedicine and video chat follow-up appointments, and daily conferences to collectively manage the clinical and ethical dilemmas to come. We discuss also discuss how we perform EP procedures on presumed COVID positive and COVID tested positive patients in order to highlight issues that others in the EP community may soon face in their own institution as the virus continues to spread nationally and internationally.
Introduction: Standard two-dimensional (2D), phased-array intracardiac echocardiography (ICE) is routinely used to guide interventional electrophysiology (EP) procedures. A novel four-dimensional (4D) ICE catheter (VeriSight Pro®, Philips, Andover, MA) can obtain 2D and three-dimensional (3D) volumetric images and cine-videos in real time (4D). The purpose of this study was to determine the early feasibility and safety of this 4D ICE catheter during EP procedures. Methods: The 4D ICE catheter was placed from the femoral vein in ten patients into various cardiac chambers to guide EP procedures requiring transseptal catheterization, including ablation for atrial fibrillation and left atrial appendage closure. 2D- and 3D- ICE images were acquired in real time by the electrophysiologist. A dedicated imaging expert performed digital steering to optimize and post-process 4D images. Results: Eight patients underwent pulmonary vein isolation (cryoballoon in 7 patients, pulsed field ablation in 1, additional radiofrequency left atrial ablation in 1). Two patients underwent left atrial appendage closure. High quality images of cardiac structures, transseptal catheterization equipment, guide sheaths, ablation tools, and closure devices were acquired with the ICE catheter tip positioned in the right atrium, left atrium, pulmonary vein, coronary sinus, right ventricle, and pulmonary artery. There were no complications. Conclusion: This is the first-in-human experience of a novel deflectable 4D ICE catheter used to guide EP procedures. 4D ICE imaging in safe and allows for acquisition of high-quality 2D and 3D images in real-time. Further use of 4D ICE will be needed to determine its added value for each EP procedure type.
Significant changes or cancellation of MCIT could result in limiting access to breakthrough medical technologies that could improve the health and well-being of Medicare beneficiaries. For these reasons, we encourage federal agencies to work together and CMS to implement the MCIT rule without delay to ensure timely access to breakthrough technologies
Background: Cardiac Sympathetic Denervation (CSD) involves surgical removal of lower half of the stellate ganglion and the T1-T4 ganglia for reducing sympathetic discharge to the heart. CSD is a useful therapeutic option in patients with ventricular tachycardia (VT) when they are non-responsive to standard drug therapy or catheter ablation. We report here the clinical profile and long-term outcome of all our patients who underwent CSD for refractory VT or VT storm. Method: Data of all patients who underwent CSD from 2010 to 2019 was analysed. They were regularly followed up, focusing on arrhythmia recurrence. Complete response to CSD was defined as more than 75% decrease in the frequency of VT. Results: A total of 65 patients (50 male, 15 female) underwent CSD in the above-mentioned period and the duration of follow-up was 27±24 months. The underlying substrate was for VT was coronary artery disease in 30 (46.2%) patients and 35 (53.8%) patients had a variety of other causes. Complete response to CSD was attained in 47 (72.3%) patients. There was a significant decline in the incidence of number shocks after CSD (24±37 vs 2±4; p <0.01). Freedom from a combined end point of ICD shock or death at the end of two years was 51.5%. Advanced NYHA class (III and IV) was the only parameter shown to have significant association with this combined end point. Conclusion: The current retrospective analysis reemphasize the role of surgical CSD in the treatment of patients with refractory VT or VT storm.
Introduction Left bundle branch area pacing (LBBAP) aims to achieve physiological pacing by capturing the conduction system in the area of the left bundle branch. LBBAP has exclusively been performed using lumen-less pacing leads (LLL) with fixed helix design. This study explores the feasibility, safety and pacing characteristics of LBBAP using stylet-driven leads (SDL) with an extendable helix design. Methods Patients, in which LBBAP was attempted for bradycardia or heart failure pacing indications, were prospectively enrolled at the Ghent University Hospital. LBBAP was attempted with two different systems: 1/ LLL with fixed helix (SelectSecure 3830, Medtronic, Inc) delivered through a preshaped sheath (C315His Medtronic) and 2/ SDL with extendable helix (SoliaS60, Biotronik, SE & CO) delivered through a new delivery sheath (Selectra 3D, Biotronik). Results The study enrolled 50 patients (mean age 7014 years, 44% female). LBBAP with SDL was successful in 20/23 (87%) patients compared to 24/27 (89%) of patients in the LLL group (p=0.834). Screw attempts, screw implant depth, procedural and fluoroscopy times were comparable among both groups. Acute LBBAP thresholds were low and comparable between SDL and LLL (0.50.15V versus 0.40.17V, p=0.251). Pacing thresholds remained low at 32.1 months of follow up in both groups and no lead revisions were necessary. Post procedural echocardiography revealed a septal coronary artery fistula in one patient with SDL LBBAP. Conclusion LBBAP using stylet-driven pacing leads is feasible and yields comparable implant success to LBBAP with lumen-less pacing leads. LBBAP thresholds are low and comparable with both types of leads.
It is increasingly recognized that the autonomic nervous system (ANS) is a major contributor in many cardiac arrhythmias. Cardiac ANS can be divided into extrinsic and intrinsic parts according to the course of nerve fibers and localization of ganglia and neuron bodies. Although the role of extrinsic part has historically gained more attention, the intrinsic cardiac ANS may affect cardiac function independently as well as influence the effects of the extrinsic nerves. Catheter based modulation of the intrinsic cardiac ANS is emerging as a novel therapy for management of patients with brady and tachy arrhythmias resulting from hyperactive vagal activation. However, distribution of intrinsic cardiac nerve plexus in the human heart and the functional properties of intrinsic cardiac neural elements remain insufficiently understood. The present review aims to bring the clinical and anatomical elements of the ICANS together, by reviewing neuroanatomical terminologies and physiological functions, in order to guide the clinical electrophysiologist in the catheter lab, and to serve as a reference for further research.
Background Charge density mapping of atrial fibrillation (AF) reveals dynamic patterns of localised rotational activation (LRA), irregular activation (LIA) and focal firing (FF). Their spatial stability, conduction characteristics and the optimal duration of mapping required to reveal these phenomena and has not been explored. Methods Bi-atrial mapping of AF propagation was undertaken and variability of activation patterns quantified up to a duration of 30-seconds(s). The frequency of each pattern was quantified at each vertex of the chamber over 2 separate 30s recordings prior to ablation and R2 calculated to quantify spatial stability. Regions with the highest frequency were identified at increasing time durations and compared to the result over 30s using Cohen’s kappa. Properties of regions with the most stable patterns were assessed during sinus rhythm and extrastimulus pacing. Results In twenty-one patients, 62 paired LA and RA maps were obtained. LIA was highly spatially stable with R2 between maps of 0.83(0.71-0.88) compared to 0.39(0.24-0.57) and 0.64(0.54-0.73) for LRA and FF, respectively. LIA was also most temporally stable with a kappa of >0.8 reached by 12s. LRA showed greatest variability with kappa>0.8 only after 22s. Regions of LIA were of normal voltage amplitude (1.09mv) but showed increased conduction heterogeneity during extrastimulus pacing (p=0.0480). Conclusion Irregular activation patterns characterised by changing wavefront direction are temporally and spatially stable in contrast with rotational patterns that are transient with least spatial stability. Focal activation appears of intermediate stability. Regions of LIA show increased heterogeneity following extrastimulus pacing and may represent fixed anatomical substrate.
Background: Local impedance (LI) can indirectly measure catheter contact and tissue temperature during radiofrequency catheter ablation (RFCA). However, data on the effects of catheter contact angle on LI parameters are scarce. This study aimed to evaluate the influence of catheter contact angle on LI changes and lesion size with 2 different LI-sensing catheters in a porcine experimental study. Methods: Lesions were created by the INTELLANAV MiFi™ OI (MiFi) and the INTELLANAV STABLEPOINT™ (STABLEPOINT). RFCA was performed with 30 watts and a duration of 30 seconds. The CF (0, 5, 10, 20, and 30 g) and catheter contact angle (30°, 45°, and 90°) were changed in each set (n=8 each). The LI rise, LI drop, and lesion size were evaluated. Results: The LI rise increased as CF increased. There was no angular dependence with the LI rise under all CFs in the MiFi. On the other hand, the LI rise at 90° was lower than at 30° under 5 and 10 g of CF in STABLEPOINT. The LI drop increased as CF increased. Regarding the difference in catheter contact angles, the LI drop at 90° was lower than that at 30° for both catheters. The maximum lesion widths and surface widths were smaller at 90° than at 30°, whereas there were no differences in lesion depths. Conclusion: The LI drop and lesion widths at 90° were significantly smaller than those at 30°, although the lesion depths were not different among the 3 angles for the MiFi and STABLEPOINT.
Catheter based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and functional atrioventricular block. There is now increasing convergence amongst enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, pre- and post-procedure management, necessary equipment, and its potential limitations.
Recently receiving FDA approval, the Amplatzer Amulet™ LAA occluder device (Abbott Medical Inc) provides a dual seal mechanism alternative to the commercially available Watchman FLX or Watchman 2.5 device for embolic stroke prevention in patients with non-valvular atrial fibrillation (NVAF). This Step-by-Step review will cover patient selection, pre-procedure imaging assessment, device sizing, device preparation, implant target position assessment, implant technique and troubleshooting, and immediate post implant follow-up.
Introduction: Ablation Index guided ablation according to the CLOSE protocol is very effective in terms of chronic pulmonary vein isolation (PVI). However, the optimal RF power remains controversial. Here, we thought to investigate the efficiency and safety of an AI guided fixed circumferential 50W high power short duration (HPSD) PVI using the CLOSE protocol Methods and results: In a single-centre prospective “proof of concept” trial 40 patients underwent randomized PVI using AI guided RF ablation without oesophageal temperature monitoring. In 20 patient fixed 50W HPSD was used irrespective to the anatomical localization. 20 subjects were ablated with standard power settings (20W posterior and 40W roof and anterior wall). Additionally, 80 consecutive patients were treated according to the HPSD protocol to gather additional safety data. All patients underwent post-procedural oesophago-gastro-duodenoscopy to reveal oesophageal lesions (EDEL). The mean total procedural time was 80.3±22.5 minutes in HPSD compared to control 109.1±27.4 (p<0.001). The total RF-time was significantly lower in HPSD 1379±505 sec vs. control 2374±619 sec (p<0.001).There were no differences in periprocedural complications. EDEL occurred in 13% in the HPSD and 10% in control group. EDEL occurring in the 50W HSDP patients were smaller, more superficial and had a faster healing tendency. Conclusions: A fixed 50W HPSD circumferential PVI relying to the ablation index and CLOSE protocol reduces the total procedure time and the total RF time compared to standard CLOSE protocol, without increasing the complication rates. The incidence of oesophageal lesions was similar using 50W at the posterior atrial wall.
Introduction: Although the presence of left atrial low-voltage areas (LVAs) is strongly associated with the recurrence of atrial fibrillation (AF) after ablation, few methods are available to classify the prevalence of LVAs. The purpose of this study was to establish a risk score for predicting the prevalence of LVAs in patients undergoing ablation for AF. Methods: We enrolled 1004 consecutive patients who underwent initial ablation for AF (age, 68 ± 10 years old; female, 346 (34%); persistent atrial fibrillation, 513 (51%)). LVAs were deemed present when the voltage map after pulmonary vein isolation demonstrated low-voltage areas with a peak-to-peak bipolar voltage of <0.5 mV covering ≥5 cm2 of the left atrium. Results: LVAs were present in 206 (21%) patients. The SPEED score was obtained as the total number of independent predictors as identified on multivariate analysis, namely female sex (odds ratio (OR) 3.4 [95% confidence interval (CI) 2.2-5.2], p <0.01), persistent AF (OR 1.8 [95% CI 1.1-3.0], p=0.02), age ≥70 years (OR 2.3 [95% CI 1.5-3.4], p <0.01), elevated brain natriuretic peptide ≥100 pg/ml or N-terminal pro-brain natriuretic peptide ≥400 pg/ml (OR 1.7 [95% CI 1.02-2.8], p=0.04), and diabetes mellitus (OR 1.8 [95% CI 1.1-2.8], p=0.02). LVAs were more frequent in patients with a higher SPEED score, and prevalence increased with each additional SPEED score point (OR 2.4 [95% CI 2.0-2.8], p <0.01). Conclusion: The SPEED score accurately predicts the prevalence of LVAs in patients undergoing ablation for AF.
Background: Ablation for atrial fibrillation (AF) has emerged as an effective method of rhythm control. This exploratory analysis aimed to determine how various measures of recurrence would influence the definition of treatment success. Methods: Using an EHR dataset from 01/2007-06/2019 linked with Medtronic cardiac implantable electronic device (CIED) data, patients who underwent a first AF ablation procedure following CIED implantation were identified. Data were analyzed for recurrence of AF stratified by varying definitions of successful ablation. Performance of various simulated external AF monitoring strategies was assessed. Results: A total of 665 patients were analyzed including 248 with paroxysmal AF (mean age 66.2±9.3 years, 73.0% male) and 417 patients with persistent AF (mean age 67.3±9.0 years, 73.6% male). Patients with paroxysmal AF, survival free from recurrence at 1 year ranged from 28.2% to 72.1% (>6 min and >23 hours thresholds, respectively) with an overall median percentage of time in AF reduction of 99.6%. Patients with persistent AF, survival free from recurrence at 1 year ranged from 24.9% to 60.0% (>6 min and 7 consecutive days >23 hours thresholds, respectively) with an overall median percentage of time in AF reduction of 99.3%. A single 7-day monitoring strategy had a sensitivity of < 50% for detecting AF > 6 min in patients with paroxysmal and persistent AF. Conclusion: In this real-world dataset of AF patients with CIEDs undergoing catheter ablation, treatment success varied substantially with different definitions of minimally required AF duration and is significantly impacted by the method of recurrence detection.