Use of a radiofrequency guidewire to simplify workflow for left atrium access: a case series.

PURPOSE: Transseptal puncture (TSP) is widely used in catheter-based cardiac procedures to gain left atrial access, but its workflow has remained largely unchanged in the last 50 years. This study evaluated the safety and efficacy of a novel, simplified technique for TSP with a radiofrequency (RF)-powered guidewire that eliminates multiple exchanges required with standard needles. METHODS: TSP was performed in 84 patients undergoing left-sided procedures (72 atrial fibrillation ablations [32 RF, 40 cryoballoon], 4 atrial tachycardia ablations, 2 ventricular arrhythmia ablations, 6 left atrial appendage closure) utilizing a stiff, exchange length RF guidewire. Under fluoroscopic and echocardiographic guidance, the RF guidewire was used to facilitate septal puncture with RF energy and provide a rail for advancing catheters to the left atrium without exchange. All procedures were performed under general anesthesia or sedation. RESULTS: TSP was achieved in all patients with no complications. The RF guidewire allowed catheters to be tracked back up to the superior vena cava without exchange in cases where another dropdown was desired to locate a preferred puncture site. The stiffness of the wire provided adequate support to advance all sheaths to the left side regardless of outer diameter. CONCLUSION: TSP was performed safely and successfully for various left heart procedures with a RF guidewire that served as an RF transseptal device and a stiff guidewire. This allowed for a more efficient and potentially safer technique without the need for re-wiring or an over the wire sheath exchange. This provides substantial savings in both time and materials.

Comparison between radiofrequency with contact force-sensing and second-generation cryoballoon for paroxysmal atrial fibrillation catheter ablation: a multicentre European evaluation.

AIMS: Whether pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using contact force (CF)-guided radiofrequency (RF) or second-generation cryoballoon (CB) present similar efficacy and safety remains uncertain. METHODS AND RESULTS: We performed a multicentre study comparing procedural safety and arrhythmia recurrence after standardized PVI catheter ablation for PAF using CF-guided RF ablation (Thermocool(®) SmartTouch™, Biosense Webster; or Tacticath™, St Jude Medical) (CF group) with second-generation CB ablation (Arctic Front Advance™, Medtronic) (CB group). Overall, 376 patients (mean age 59.8 ± 10.4 years, 280 males) were enrolled in 4 centres: 198 in CF group and 178 in CB group. Procedure was shorter for CB group than for CF group (109.6 ± 40 vs. 122.5 ± 40.7 min, P = 0.003), but fluoroscopy duration and X-ray exposure were not statistically different (P = 0.1 and P = 0.22, respectively). Overall complication rate was similar in both groups: 14 (7.1%) in the CF group vs. 13 (7.3%) in the CB group (P = 0.93). However, transient right phrenic nerve palsy occurred only in CB group (10 patients, 5.6%; P = 0.001 vs. CF group) and severe non-lethal complications (embolic event, tamponade, or oesophageal injury) occurred only in CF group (5 patients, 2.5%; P = 0.03 vs. CB group). No periprocedural death occurred in either group. Single-procedure freedom from any atrial arrhythmias at 18 months post-ablation was comparable in CF group and CB group (76 vs. 73.3%, respectively, log rank P = 0.63). CONCLUSION: Pulmonary vein isolation using CF-guided RF and second-generation CB leads to comparable single-procedure arrhythmia-free survival at up to 18 months with similar overall complication rate.

Comparison of a radiofrequency powered flexible needle with a classic rigid Brockenbrough needle for transseptal punctures in terms of safety and efficacy.

INTRODUCTION: This study aimed to evaluate the safety and efficacy of utilising an innovative radiofrequency (RF) powered flexible needle to achieve transseptal puncture (TSP). METHODS AND RESULTS: A RF powered flexible needle (Toronto catheter, Baylis Medical Company Inc.) associated with a stiffer dilator (Torflex Superstrong, Baylis Medical Company Inc.) was used in 125 consecutive patients referred for left sided ablations (mean age=55.6, male=86.5%) and compared with a standard transseptal set (BRK needle, SL0 sheath and dilator, St Jude Medical, Inc.) used in the previous 100 patients (mean age=56, male 82%). TSP was achieved in 95/100 patients in the Brockenbrough group and in all 125 patients in the Toronto group (p=0.01) despite an equivalent proportion of difficult situations (8 and 9% respectively) and patients with a prior TSP (17% vs 24%). 7/100 needle related events (failure, aborted attempt or pericardial effusion) occurred in the Brockenbrough group and none in the Toronto group (p=0.01). The Toronto needle crossed the septum at the first attempt in 123/125 (98.4%) patients and the Brockenbrough needle in 84/95 (88%) patients (p<0.001). CONCLUSION: Our data suggest that the Toronto RF powered flexible needle is safer and more efficient than a standard Brockenbrough needle and can be used not only in difficult situations but routinely to achieve TSP.

Ventricular pacing through coronary sinus in patients with tricuspid prosthesis.

We report four cases of ventricular pacing through the coronary sinus in patients with tricuspid biological valves for whom recordings of atrioventricular block indicated required pacemaker implantation. To avoid risk of tricuspid damage, endocardial pacemaker implantation is not recommended for patients with prior tricuspid valve replacement. These patients historically undergo epicardial lead implantation on the diaphragmatic surface of the ventricle, requiring a lateral thoracotomy, which remains a challenging technique. For our cases, satisfactory pacing data was collected for a 6-year follow-up. This technique enables a minimally invasive approach and effective stimulation for patients with a prosthetic tricuspid valve.

Percutaneous epicardial radiofrequency ablation of ventricular arrhythmias after failure of endocardial approach: a 9-year experience.

INTRODUCTION: Management of recurrent ventricular tachycardia (VT) remains difficult. Neither medical treatments nor conventional endocardial radiofrequency (RF) ablation are efficient to prevent some recurrences. In these cases, a percutaneous pericardial approach may be required. METHODS: Among all the patients referred to our center between 1998 and 2007 for a VT ablation, 276 endocardial and 35 epicardial procedures were performed, the latter in case of failure of the conventional approach. We report in this study the efficacy and the safety of these 35 interventions analyzed retrospectively. RESULTS: Thirty-five epicardial procedures were attempted in 32 patients. An electric storm was present in 5 of 32 (16%) patients, with other individuals presenting with a recurrent VT despite drug therapy and a previous endocardial ablation. Pericardial space was reached in 28 of 32 patients by a xyphoidian puncture. An immediate success of RF on clinical VT was obtained in 22 of 29 (76%) cases. During a mean follow-up of 384 +/- 405 days, only 9 patients (26%) experienced a recurrence of a sustained VT. One patient died from tamponade during the procedure despite surgical drainage. Other complications had no significant consequences. CONCLUSION: Percutaneous epicardial puncture is feasible and relatively safe in patients with recurrent VT in whom conventional endocardial RF ablation failed. Epicardial RF ablation offers a high success rate in these challenging patients with only few severe complications.

Comparison of beta blocker and digoxin alone and in combination for management of patients with atrial fibrillation and heart failure.

In patients with atrial fibrillation (AF) and heart failure (HF), beta blockers and digoxin reduce the ventricular rate, but controversy exists concerning how these drugs affect prognosis in this setting. This study compared the effects of beta blocker and digoxin on mortality in patients with both AF and HF. In a single-center institution, patients with AF and HF seen between January 2000 and January 2004 were identified and followed until September 2007. Of 1,269 consecutive patients with both AF and HF, 260 were treated with a beta blocker alone, 189 with beta blocker plus digoxin, 402 with digoxin alone, and 418 without beta blocker or digoxin (control group). During a follow-up of 881+/-859 days, 247 patients died. Compared with the control group, treatment with beta blocker was associated with a decreased mortality (relative risk=0.58, 95% confidence interval 0.40 to 0.85, p=0.005 for beta blocker alone and 0.59, 95% confidence interval 0.40 to 0.87, p=0.008 for beta blocker plus digoxin). By contrast, treatment with digoxin alone was not associated with a better survival (relative risk=0.97, 95% confidence interval 0.73 to 1.30, p=NS). Results remained significant after adjustment for potential confounders and similar when we considered, separately, HF with permanent or nonpermanent AF, presence or absence of coronary disease, and patients with decreased or preserved systolic function. In conclusion, in unselected patients with AF and HF, treatments with beta blocker alone or with beta blocker plus digoxin are associated with a similar decrease in the risk of death. Digoxin alone is associated with a worse survival chance, similar to that of patients without any rate control treatment.

Electrical storm reversible by isoproterenol infusion in a striking case of early repolarization.

A 40-year-old woman was referred to intensive care unit after recurrent ventricular fibrillation. She was free of cardiac medical history or medications. The resting ECG displayed an extended early repolarization in the inferior leads and all the precordial leads. Incessant ventricular fibrillations justified a treatment by intravenous amiodarone associated with general anaesthesia and mechanical ventilation without success on ventricular fibrillation. Because of a low heart rate intravenous isoproterenol infusion was initiated. Isoproterenol infusion was associated with heart rate acceleration and a decrease in J point elevation and the disappearance of ventricular fibrillation episodes. No cardiac disease was documented and the patient was implanted of a single chamber ICD. Six months later the patient was free of syncope and ventricular fibrillation on ICD memory. This case report demonstrates the usefulness and efficiency of the isoproterenol infusion to eliminate recurrent ventricular fibrillation in patients with early repolarization.

Incidence and predictive factors of atrial fibrillation after ablation of typical atrial flutter.

Although cavotricuspid isthmus radiofrequency catheter ablation is considered curative therapy for typical atrial flutter, many patients develop an atrial fibrillation after ablation. The purpose of our study was to determine the incidence and the predictive factors of post-ablation atrial fibrillation. One hundred and forty eight consecutive patients underwent cavotricuspid isthmus ablation for the treatment of typical atrial flutter between January 2004 and December 2005 in our electrophysiological department. Complete cavotricuspid isthmus block was successfully obtained in 96.6% of the patients. At the end of the electrophysiological study a sustained atrial fibrillation was inducible in 20 patients (13.5%). During an average follow-up of 21.3 +/- 8.2 months, atrial fibrillation occurred in 27% of the patients. Univariate analysis identified four parameters correlated with post-ablation atrial fibrillation among the 21 parameters tested: the young age of the patients, a prior history of atrial fibrillation, an inducible atrial fibrillation, and a paroxysmal atrial flutter. Only inducible atrial fibrillation and paroxysmal atrial flutter were independent factors linked to atrial fibrillation after ablation. In our study the incidence of atrial fibrillation after cavotricuspid isthmus radiofrequency catheter ablation is 152 per 1,000 patient-years, i.e. 25 times higher than the incidence of atrial fibrillation in the general population of the same age. Twenty five percent of the patients who had neither prior history of atrial fibrillation nor structural heart disease suffered from atrial fibrillation during a mean follow-up of 21.3 +/- 8.2 months. All these results suggest that atrial flutter and fibrillation could be manifestations of a more general electrophysiologic disease. They emphasize the need for all these patients to benefit from regular, long-term cardiological follow-up after cavotricuspid isthmus ablation because of the high incidence of atrial fibrillation. Treatment with antiarrhythmic and antithrombotic agents should also be adapted to these factors.

Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials.

OBJECTIVES: To improve the evaluation of the possible antiarrhythmic effect of statins, we performed a meta-analysis of randomized trials with statins on the end point of incidence or recurrence of atrial fibrillation (AF). BACKGROUND: The use of statins had been suggested to protect against AF in some clinical observational and experimental studies but has remained inadequately explored. METHODS: A systematic review of controlled trials with statins was performed. Eligible studies had to have been randomized controlled parallel-design human trials with use of statins that collected data on incidence or recurrence of AF. RESULTS: Six studies with 3,557 patients in sinus rhythm were included in the analysis. Three studies investigated the use of statins in patients with a history of paroxysmal AF (n = 1) or persistent AF undergoing electrical cardioversion (n = 2), and 3 investigated the use of statins in primary prevention of AF in patients undergoing cardiac surgery or after acute coronary syndrome. Incidence or recurrence of AF occurred in 386 patients. Overall, the use of statins was significantly associated with a decreased risk of AF compared with control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.18 to 0.85, p = 0.02). Benefit of statin therapy seemed more marked in secondary prevention of AF (OR 0.33, 95% CI 0.10 to 1.03, p = 0.06) than for new-onset or postoperative AF (OR 0.60, 95% CI 0.27 to 1.37, p = 0.23). CONCLUSIONS: Use of statins was significantly associated with a decreased risk of incidence or recurrence of AF in patients in sinus rhythm with a history of previous AF or undergoing cardiac surgery or after acute coronary syndrome.