Feasibility, Efficacy, and Safety of Fluoroless Ablation of VT in Patients With Structural Heart Disease.

BACKGROUND: Catheter ablation of ventricular tachycardia (VT) typically requires radiation exposure with its potential adverse health effects. A completely fluoroless ablation approach is achievable using a combination of electroanatomical mapping and intracardiac echocardiography. Nonetheless, data in patients undergoing VT ablation are limited. OBJECTIVES: This study aimed to determine the feasibility, efficacy, and safety of VT ablation in patients with structural heart disease using a zero-fluoroscopy approach. METHODS: This multicenter study included consecutive patients with ischemic and nonischemic cardiomyopathy undergoing fluoroless VT ablation. Patients requiring epicardial access or coronary angiography were excluded. RESULTS: Between 2017 and 2023 a total of 198 patients (aged 66.4 ± 13.4 years, 76% male, 48% ischemic) were included. Most patients (95.4%) underwent left ventricular (LV) mapping and/or ablation, which was conducted via transseptal route in 54.5% (n = 103), via retrograde aortic route in 43.4% (n = 82), and using a combined approach in 2.1% (n = 4). Two-thirds of patients had a cardiac device, including a biventricular device in 15%; 2 patients had a LV assist device, and 1 patient had a mechanical aortic valve prosthesis. The mean total procedural time was 211 ± 70 minutes, and the total radiofrequency time was 30 ± 22 minutes. During a follow-up period of 22 ± 18 months, the freedom from VT recurrence was 80%, and 7.6% of patients underwent a repeated ablation. Procedural-related complications occurred in 6 patients (3.0%). CONCLUSIONS: Fluoroless ablation of VT in structural heart disease is feasible, effective, and safe when epicardial mapping/ablation is not required.

Improved all-cause mortality with left bundle branch area pacing compared to biventricular pacing in cardiac resynchronization therapy: a meta-analysis.

BACKGROUND: Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT. METHODS: Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF. RESULTS: Thirteen studies (12 observational and 1 RCT, n = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57-0.86, p < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5-0.71, p < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference- 23.2 min, 95% CI - 42.9 to - 3.6, p = 0.02) and fluoroscopy time (- 8.6 min, 95% CI - 12.5 to - 4.7, p < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:- 25.3 ms, 95% CI - 30.9 to - 19.8, p < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4-5.8, p < 0.001) compared to BIVP in the studies that reported these outcomes. CONCLUSION: In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings.

Sustained Apnea for Epicardial Access With Right Ventriculography: The SAFER Epicardial Approach.

BACKGROUND: Epicardial access (EA) has emerged as an increasingly important approach for the treatment of ventricular arrhythmias and to perform other interventional cardiology procedures. EA is frequently underutilized because the current approach is challenging and carries a high risk of life-threatening complications. OBJECTIVE: The purpose of this study was to determine the efficacy and safety of the SAFER (Sustained Apnea for Epicardial Access With Right Ventriculography) epicardial approach. METHODS: Consecutive patients who underwent EA with the SAFER technique were included in this multicenter study. The primary efficacy outcome was the successful achievement of EA. The primary safety outcomes included right ventricular (RV) perforation, major hemorrhagic pericardial effusion (HPE), and bleeding requiring surgical intervention. Secondary outcomes included procedural characteristics and any complications. Our results were compared with those from previous studies describing other EA techniques to assess differences in outcomes. RESULTS: A total of 105 patients undergoing EA with the SAFER approach from June 2021 to February 2023 were included. EA was used for ventricular tachycardia ablation in 98 patients (93.4%), left atrial appendage closure in 6 patients (5.7%), and phrenic nerve displacement in 1 patient (0.9%). EA was successful in all subjects (100%). The median time to EA was 7 minutes (IQR: 5-14 minutes). No cases of RV perforation, HPE, or need of surgical intervention were observed in this cohort. Comparing our results with previous studies about EA, the SAFER epicardial approach resulted in a significant reduction in major pericardial bleeding. CONCLUSIONS: The SAFER epicardial approach is a simple, efficient, effective, and low-cost technique easily reproducible across multiple centers. It is associated with lower complication rates than previously reported techniques for EA.

Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points.

Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.

Fluoroless Catheter Ablation of Left Ventricular Summit Arrhythmias: A Step-by-Step Approach.

Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: A cost-effectiveness analysis.

BACKGROUND: General anesthesia (GA) is the standard anesthetic approach for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Nonetheless, GA is expensive and can be associated with adverse events. Tumescent local anesthesia (TLA) has been shown to reduce in-room and procedural times and to decrease post-procedural pain, all of which could result in a reduction in procedure-related costs. OBJECTIVE: The purpose of this study is to compare the cost-effectiveness of GA and TLA in patients undergoing S-ICD implantation. METHODS: The present study is a prospective, nonrandomized, controlled study of patients who underwent S-ICD implantation between 2019 and 2022. Patients were allocated to either the TLA or the GA group. We performed a cost analysis for each intervention. As an effectiveness measure, the 0-10 point Numeric Pain Rating Scale at 1, 12, and 24 hours post-implantation was analyzed and compared between the groups. A score of 0 was considered no pain; 1-5, mild pain; 6-7, moderate pain; and 8-10, severe pain. Cost-effectiveness was calculated using incremental cost-effectiveness ratios. RESULTS: Seventy patients underwent successful S-ICD implantation. The total cost of the electrophysiology laboratory was higher in the GA group than in the TLA group (median ± interquartile range US$55,824 ± US$29,411 vs US$37,222 ± US$24,293; P < .001), with a net saving of $20,821 when compared with GA for each S-ICD implantation. There was a significant decrease in post-procedural pain scores in the TLA group when compared with the GA group (repeated measures analysis of variance, P = .009; median ± interquartile range 0 ± 3 vs 0 ± 5 at 1 hour, P = .058; 3 ± 4 vs 6 ± 8 at 12 hours, P = .030; 0 ± 4 vs 2 ± 6 at 24 hours, P = .040). CONCLUSION: TLA is a more cost-effective alternative to GA for S-ICD implantation, with both direct and indirect cost reductions. Importantly, these reduced costs are associated with reduced postprocedural pain.

Anatomical considerations and clinical interpretation of the 12-lead ECG in the prone position: a prospective multicentre study.

AIMS: The aim of this study is to provide guidance for the clinical interpretation of electrocardiograms (ECGs) in prone position and to establish the electroanatomic explanations for the possible differences to supine position ECGs that may be observed. Additionally, to determine if prone back ECG can be used as an alternative to standard ECG in patients who may benefit from prone position. METHODS AND RESULTS: The ECG in supine (standard ECG), prone back (precordial leads placed on the patient's back), and prone anterior position (precordial leads placed in the standard position with the subjects in prone position) were prospectively examined on 85 subjects. Comparisons of ECG parameters between these positions were performed. Computed tomography (CT) scans were performed in both positions to determine possible electroanatomic aetiologies for prone-associated ECG changes. There were significant differences in QRS amplitude in Leads V1-V5 between supine and prone positions. Q waves were more frequently observed in prone back position vs. supine position (V1: 74.1 vs. 10.6%, P < 0.0001; V2: 23.5 vs. 0%, P < 0.0001, respectively). Flat and inverted T waves were more common in prone back leads (V1: 98 vs. 66%, P < 0.0001; V2: 96 vs. 8%, P < 0.0001; V3: 45 vs. 7%, P < 0.0001). The 3D-CT reconstructions measurements corroborated the significant inverse correlation between QRS amplitude and the distance from the centre of the heart to the estimated lead positions. CONCLUSION: In prone back position ECG, low QRS amplitude should not be misinterpreted as low voltage conditions, neither should Q waves and abnormal T waves are considered anteroseptal myocardial infarction. These changes can be explained by an increased impedance (due to interposing lung tissue) and by the increased distance between the electrodes to the centre of the heart.

Improved survival in patients with atrial fibrillation and heart failure undergoing catheter ablation compared to medical treatment: A systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. METHODS AND RESULTS: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51-0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of all-atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40-0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6-8.8, p < .00001). CONCLUSION: CA for AF in patients with HF decreases all-cause mortality, improves all-atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated.

Electrocardiographic Features of Patients with COVID-19: An Updated Review.

Numerous systemic manifestations, including cardiac involvement in the form of myocardial infarction, myocarditis, and electrocardiographic changes, have been associated with COVID-19..In this review, the authors describe the electrocardiographic features that have been reported to date in patients affected by this disease and their possible underlying mechanisms.

Off-label direct oral anticoagulants dosing in atrial fibrillation and venous thromboembolism is associated with higher mortality.

BACKGROUND: Direct oral anticoagulants (DOAC) off-label use data is lacking. Our study aimed to assess the clinical outcomes in a racially mixed population treated for atrial fibrillation (AF) and venous thromboembolism (VTE). METHODS: We retrospectively evaluated six months of DOAC prescriptions for AF or VTE treatment. Prescriptions were classified as off-label or appropriate following FDA labeling. The off-label group was sub-classified as under or overdosing. RESULTS: Of the 1,087 DOAC prescriptions, 67% were for AF. African Americans and Caucasians were equally represented. There were 171 (16%) inappropriate prescriptions, with 106 (62%), being underdosed. The off-label group had a higher 30-day readmissions risk (OR = 1.69, 95% CI:1.11-2.54, p = 0.012) and 1-year all-cause mortality (OR = 1.90, 95% CI:1.02-3.37, p = 0.032). There was no difference in major bleeding (OR = 1.27, 95% CI:0.63-2.37, p = 0.480) or new thromboembolism (OR = 1.27, 95% CI:0.73-2.13, p = 0.369) between the groups. Underdosing carried a higher risk of new thromboembolism (OR = 3.15, 95% CI:1.09-9.15, p = 0.024). CONCLUSIONS: One in every six patients received off-label DOACs dosing. Off-label use had increased 30-day readmissions and 1-year all-cause mortality. Underdosing was associated with a higher risk of new thromboembolism.

Current practice in transvenous lead extraction in Latin America: Latin American Heart Rhythm Association survey.

BACKGROUND: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead-related complications. Currently, objective data on TLE in Latin America is lacking. OBJECTIVE: To describe the current practice standards in Latin American centers performing TLE. METHODS: An online survey was sent through the mailing list of the Latin American Heart Rhythm Society. Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for 1 month, after which no more answers were accepted. RESULTS: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27.1% from Brazil), with most respondents (82%) being electrophysiologists. Twenty-nine institutions (66%) performed <10 lead extractions/year, with 7 (16%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (66%) and only 13% reported the use of laser sheaths. Management of infected leads was performed according to current guidelines. CONCLUSION: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.

Epicardial access complications during electrophysiology procedures.

INTRODUCTION: Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically. DISCUSSION: Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation. CONCLUSION: The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications.

Focal impulse and rotor modulation guided ablation versus pulmonary vein isolation for atrial fibrillation: A meta-analysis of head-to-head comparative studies.

INTRODUCTION: Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)-guided ablation is currently used as an adjunct to PVI, evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM-guided ablation with or without PVI is associated with a decrease in all-atrial arrhythmia recurrence as compared to PVI alone. METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for head-to-head study designs comparing outcomes of patients who underwent FIRM-guided ablation with or without PVI to those who underwent PVI alone. The primary efficacy endpoint was all-atrial arrhythmia recurrence. The secondary endpoints were complications rates and procedural characteristics. RESULTS: Overall, six studies comprising 674 patients undergoing either FIRM-guided ablation ± PVI versus PVI were included (mean age 63.4 ± 9.2, male 74%, 9% paroxysmal AF, 91% nonparoxysmal AF). After a mean follow-up of 18.8 months, FIRM-guided ablation with or without PVI was not associated with improvement in all-atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs. 45.9%, risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.77-1.47; p = .70). No statistically significant difference was noted in complication rates between the two groups (RR: 1.66; 95% CI: 0.08-34.54; p = .74). CONCLUSION: In this meta-analysis of head-to-head comparison studies, FIRM-guided ablation with or without PVI did not provide any benefit in improving all-atrial arrhythmia recurrence at follow-up when compared to PVI alone.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation.

BACKGROUND: Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs. OBJECTIVE: The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation. METHODS: We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study. RESULTS: Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002). CONCLUSION: TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.