ABSTRACT
Background: Covid redefined how the world functions. The electrophysiology (EP) community identified multiple needs that arose due to this paradigm and redefined workflows. The geographic paucity of experienced clinical mapping support was a crucial issue that limited the worldwide adoption of complex ablation procedures. Objective(s): To ascertain the feasibility and safety of utilizing a novel software for remote mapping and remote clinical support for all spectrums of cardiac ablation procedures and to compare the adoption of ablation technology in that geography. Method(s): Ablation procedures performed at Metromed International Cardiac Centre (MICC), India were included in this early feasibility analysis (EFA). All procedures were performed by a single EP operator. Remote Clinical support was provided by an EP physician (primary operator's sibling) in the USA. All mapping was performed by an experienced mapper from a remote location 400 miles away from the primary EP operator in India. The mapping system utilized was Ensite Precision with SJM Connect software. Result(s): 300 contiguous ablation procedures from 2020 to 2022 were included in this EFA. The proprietory SJM Connect software allows remote access to the Ensite console via a secured connection. The software requires the operator to be granted access to the Ensite console via a permission request that must be acknowledged on the Ensite Console. The software will then allow the remote operator to levels of access to the system, view-only access, or complete control of the console to provide full remote support. Communication occurs between the remote user and the console via a chat function and over a voice call. This remote connection can be terminated at any time from either the console or the remote operator. There is no PHI displayed. Results detailing case demographics and acute procedural success and safety will be presented. Results comparing the adoption of ablation technology with the previous 3 years in this geography will be presented. Conclusion(s): This EFA demonstrates the safety and efficacy of using remote clinical support and remote mapping for ablation procedures. This opens a world of possibilities including the expansion of ablation technology to all corridors of the world with experienced clinical and mapping support connecting the EP community on a worldwide platform. Additional studies and strategies are needed to further understand the implication of remote support algorithms in bridging the healthcare gaps in the field of cardiac EP. [Formula presented]Copyright © 2023
ABSTRACT
Background: Ictal-induced cardiac bradyarrhythmia and asystole is a rare phenomenon. The exact mechanism of ictal-induced cardiac bradyarrhythmia and asystole remains unclear. It was postulated that stimulation of central autonomic network during ictal episode may trigger an abrupt burst of hypervagotonia. Prolonged episode of cardiac bradyarrhythmia and asystole may result in syncope or death due to impairment of cerebral perfusion. The role of cardioneuroablation (CNA) in this condition has not been well-described in the literature. Objective(s): To describe a case of successful CNA in a patient with ictal-induced bradyarrhythmia and asystole. Method(s): n/a Results: A 47-year-old female has a 1.5-year history of intractable focal epilepsy and COVID-19 infection. She started having multiple episodes of seizures following a mild COVID-19 infection. Electroencephalogram (EEG) and brain MRI revealed right temporal onset seizures without structural lesions. Due to ongoing uncontrolled seizures with multiple semiologies despite multiple anti-epileptic drugs, she was admitted to Epilepsy Monitoring Unit for seizure classification. Her ictal EEGs (Figure 1) showed onset of ictal rhythm in the right temporal region with episodes of severe sinus bradycardia (15-30 bpm) and sinus pauses (15-16 seconds). Telemetry tracings demonstrated PP interval slowing with PR interval prolongation prior to the pauses consistent with a vagally-mediated mechanism. Cardiac electrophysiology team recommended CNA for treating the episodes of ictal-induced bradyarrhythmia and asystole. 3D anatomic maps of the right atrium (RA) and left atrium (LA) were created using CARTO system (Biosense Webster). Right superior ganglionated plexus (RSGP) was localized with fractionation mapping and intracardiac echocardiography guidance. RSGP was targeted from the RA using an irrigated radiofrequency catheter with power limit of 25 W. Post-ablations of RSGP, her heart rate increased from 60 - 99 bpm. Additional lesions were delivered from the LA site but no additional heart rate increase was not seen. An implantable loop recorder was implanted post-ablation procedure. During follow-up of 8 months, she had recurrent focal epilepsy, but no bradyarrhythmias or asystole was noted on her loop recorder. Resting heart rates at long-term follow up were between 70 - 100 bpm. Conclusion(s): This case highlights the utility of CNA in patient with ictal-induced cardiac bradyarrhythmia and asystole. CNA may be an approach to avoid permanent pacemakers in this population. [Formula presented]Copyright © 2023
ABSTRACT
Myocarditis is usually diagnosed clinically by electrocardiograms, echocardiography, and increased cardiac enzymes since troponin is also defined as a marker of cardiac injury in children and adolescents. Myocarditis and pericarditis have been found in up to 40% and 25% of patients, respectively. Pericardial effusion occurred in up to 32% of patients. Together with the myocardial dysfunction findings, these characterize the pancarditis associated with COVID-19. Myocardial involvement may also be related to the presence of arrhythmias. In COVID-19, hypoxia, neurohormonal or inflammatory stress, and metabolic disorders contribute to changes in the cardiac rhythm. Some of the current drug therapies used in this disease can also induce arrhythmia, adversely affecting cardiac electrophysiology. Patients with COVID-19 have an increased risk of developing venous thrombosis, reaching 25%, with the highest risk in those with increased Ddimer and inflammatory markers, decreased fibrinogen, and those with the severe acute respiratory syndrome. There is suspicion mainly in patients who develop refractory hypoxemia or asymmetric edema of the lower limbs. Coronary thrombosis, in addition to the one being characterized, may correspond to one of the pathophysiological mechanisms of cardiovascular complications. Because of the systemic inflammatory response and imbalance in the oxygen supply, there is also an increased risk of coronary ischemia.
ABSTRACT
Background: Following restrictions imposed by the Covid-19 pandemic, virtual care became frequently employed. The adoption and maintained utilization of virtual care in Cardiac Arrhythmia specialty compared to other parts of cardiology may be greater owing to the nature of the care being given. Objective: To assess digital health resource utilization over time in EP and non-EP providers. Methods: All patient appointments in our cardiovascular medicine clinics at our Center from March 2020 through November 2021 were analyzed. Completed appointments by EP and non-EP providers were categorized as Virtual (VV) or In-Person (IPV). Routine remote device transmissions were excluded from the analysis. The VV rate was defined as the number of VVs divided by total Visits (IPVs and VVs). Results: Over the 21-month observation period, a total of 23,052 VVs (37%) and 39,882 IPVs (63%) were completed. The monthly percentage of virtual visits ranged from 13.5% (N=454/3383) in November 2021 to 97.5% in April of 2020 (N=2123/2178). Compared to other cardiovascular subspecialties, EP had a consistently higher proportion of virtual visits that has persisted throughout the observation period (range 29%-98.4%). With regard to new visits only, in 2020 there were 395/735 (53.7%) new EP VVs vs. 1608/3523 45.6% Non-EP VVs (p<.01). This discrepancy widened in 2021 as there were 524/1353 (38.7%) of all new EP VVs vs. 1400/6181 (22.7%) of all new non-EP VVs. The same widening discrepancy was seen with return visits (RPV). RPVs in 2020 were 3155/4720 (66.8%) EP VVs vs. 9659/16516 (58.5%;p<.01). This discrepancy for RPVs also widened in 2021 as there were 2010/4662 (43.1%) of all RPV EP VVs vs. 4301/19607 (21.9%;p<.01) of all new non-EP VVs. (see attached figure). Conclusion: Cardiac electrophysiologists and arrhythmia patients have adopted and maintained virtual visits to a greater extent compared to other areas of cardiovascular medicine. This may reflect improved at home sensor use and outpatient monitors to facilitate virtual visits in EP. [Formula presented] [Formula presented]