Integrated dilator-needle transseptal crossing device in atrial fibrillation cryoballoon ablation procedures.

INTRODUCTION: In cryoballoon ablation (CBA) procedures, transseptal access (TSA) is generally achieved using a standard sheath and needle system that is exchanged for the cryoballoon delivery sheath and dilator over a long wire. Sheath exchange has been related with air embolic events. Recently, an integrated dilator-needle system assembled to the cryoballoon sheath was introduced. We aimed to evaluate the efficacy and safety of an integrated TSA tool compared with the traditional approach in atrial fibrillation CBA procedures. METHODS: Patients scheduled for CBA procedures were randomized 1:1 to traditional TSA (t-TSA) or integrated TSA (i-TSA). TSA time was defined as time from superior vena cava to LA insertion of the cryoballoon delivery sheath, after sheath exchange (t-TSA) or directly (i-TSA). RESULTS: Ninety-seven patients (76 males, mean age 59 ± 10 years) were randomized, 48 patients underwent t-TSA, and 49 i-TSA. Mean TSA time was 5 min 59 s ± 5 min 36 s in the t-TSA group and 2 min 59 s ± 2 min 14 s in the i-TSA group (p < .001). Total fluoroscopy time, skin-to-skin procedure time, and LA dwell time were respectively 15 ± 6, 69 ± 16, and 44 ± 12 min in the t-TSA group and 13 ± 6, 65 ± 15, and 43 ± 11 min in the i-TSA group (p = ns). No clinically significant acute complications related to TSA were noted in both cohorts. CONCLUSION: This is the first randomized study comparing both TSA approaches. TSA in CBA procedures using this integrated tool enables a safe and efficient workflow, reducing TSA time and avoiding sheath exchange.

Solving difficulties in transseptal sheath crossing: The shoehorn technique.

The shoehorn technique is a simple and safe maneuver that can help to solve difficulties in challenging transseptal sheath crossing for atrial fibrillation cryoablation procedures.

Left bundle branch pacing in alternating bundle branch block.

We present a case of symptomatic intermittent AV block showing during monitorization alternating bundle branch block. Presuming a high need of pacing, conduction system pacing was considered a more physiological alternative in this patient. Left bundle branch pacing restored a stable atrioventricular synchrony with a paced QRS complex similar to the native one and might be a good alternative in these cases.

Incessant accelerated idioventricular rhythm mimicking preexcitation.

ECG of patients with Wolf Parkinson White (WPW) syndrome may simulate other entities such as myocardial infarction, ventricular premature complexes, ventricular bigeminy, accelerated idioventricular rhythm, intermittent bundle branch block or electrical alternans. On the other hand, the opposite can also occur where these other conditions may simulate WPW. We present the case of a young patient referred for WPW ablation showing an incessant accelerated idioventricular rhythm mimicking preexcitation.

A novel simple, fast, and safe approach for effective superior vena cava isolation using the third-generation cryoballoon.

BACKGROUND: Superior vena cava (SVC) isolation with radiofrequency energy remains a challenge due to potential side effects, especially phrenic nerve (PN) or sinus node injury. The purpose of this study was to evaluate the feasibility of a novel SVC isolation technique using the third-generation cryoballoon (CB3). METHODS: Patients undergoing atrial fibrillation (AF) ablation were prospectively included. The procedure was performed with the CB3, beginning with the pulmonary veins and ending with SVC isolation. During applications in the SVC, continuous PN capture and sinus rate were monitored. Once reached SVC isolation during the application, 60 s more was applied, with no bonus application. If after 90 s the SVC was not isolated, application was stopped. A maximum number of four applications were permitted. RESULTS: Thirty patients (62 ± 9 years; 74% male, 78% paroxysmal AF) were included. No SVC activity was observed in two patients. Success rate for SVC isolation was 89%. Mean number of applications per patient was 2.3 ± 1. Mean time to SVC isolation was 37 ± 20  s. Mean duration of application was 92 ± 15 s. Mean total time of procedure for SVC isolation was 218 ± 43 s. We recorded only two complications: one transient PN palsy and one short and transient sinus arrest. After a mean follow-up of 5 ± 2 months, 89% are free from arrhythmia recurrence. CONCLUSIONS: We present a promising simple SVC-isolation technique using CB3, featuring a high success rate and very low incidence of complications.

Ictal asystole: A condition between neurology and cardiology.

Ictal asystole can appear in patients with focal epilepsy, even in early phases. We present our experience of 7 cases, remarking the electrocardiographic characteristics, the role of apnea, treatment and long-term evolution. Awareness of this entity and collaboration between neurologists and cardiologists are essential for a correct diagnosis and management.

An "inappropriately appropriate" shock in a subcutaneous implantable cardioverter-defibrillator: The importance of the SMART pass algorithm.

We report on a case of a 78-years-old patient with a subcutaneous implantable cardioverter defibrillator (S-ICD) and an episode of a sustained ventricular tachycardia (VT) at a rate slower than the programmed shock zone. Because of T-wave oversensing the device interpreted it as fast VT that triggered the delivery of an "inappropriately appropriate shock" that terminated it. The patient had again more VT episodes but after programming the SMART pass algorithm (previously programmed "OFF") the device showed no longer frequent T-wave oversensing and no additional inappropriate shocks occurred.