Impact of fracture-prone implantable cardioverter defibrillator leads on long-term patient mortality.

Background: The long-term relationship between fracture-prone implantable cardioverter-defibrillator (ICD) leads and poor prognosis remains unclear in Japanese patients. Methods: We conducted a retrospective review of the records of 445 patients who underwent implantation of advisory/Linox leads (Sprint Fidelis, 118; Riata, nine; Isoline, 10; Linox S/SD, 45) and non-advisory leads (Endotak Reliance, 33; Durata, 199; Sprint non-Fidelis, 31) between January 2005 and June 2012 at our hospital. The primary outcomes were all-cause mortality and ICD lead failure. The secondary outcomes were cardiovascular mortality, heart failure (HF) hospitalization, and the composite outcome of cardiovascular mortality and HF hospitalization. Results: During the follow-up period (median, 8.6 [4.1-12.0] years), there were 152 deaths: 61 (34%) in patients with advisory/Linox leads and 91 (35%) in those with non-advisory leads. There were 32 ICD lead failures: 27 (15%) in patients with advisory/Linox leads and five (2%) in those with non-advisory leads. Multivariate analysis for ICD lead failure demonstrated that the advisory/Linox leads had a 6.65-fold significantly greater risk of ICD lead failure than non-advisory leads. Congenital heart disease (hazard ratio 2.51; 95% confidence interval 1.08-5.83; p = .03) could also independently predict ICD lead failure. Multivariate analysis for all-cause mortality demonstrated no significant association between advisory/Linox leads and all-cause mortality. Conclusions: Patients who have implanted fracture-prone ICD leads should be carefully followed up for ICD lead failure. However, these patients have a long-term survival rate comparable with that of patients with non-advisory ICD leads in Japanese patients.

Prognostic significance of cardiorenal dysfunction within 1 year after atrial fibrillation ablation in patients with systolic dysfunction.

Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.

Prognostic significance of diastolic dysfunction in patients with systolic dysfunction undergoing atrial fibrillation ablation.

Background: The relationship between pre-ablation left ventricular diastolic dysfunction (LVDD) and prognosis in patients with left ventricular systolic dysfunction (LVSD) undergoing atrial fibrillation (AF) ablation remains unclear. Methods: The prognosis of 173 patients with impaired left ventricular ejection fraction (<50%) who underwent AF ablation was examined. The primary outcome was a composite of all-cause mortality, heart failure (HF) hospitalization, and worsening HF symptoms requiring unplanned outpatient intensification of decongestive therapy. Results: During the follow-up period (median, 3.5 years), the primary outcome after AF ablation occurred in 28 patients (16%). The receiver operating characteristic curve analysis showed that early septal diastolic mitral annular velocity (e') had a larger area under the curve (0.70) than other LVDD parameters, and optimal cut-off values of LVDD, represented by e', septal E (early diastolic left ventricular filling velocity)/e', and peak tricuspid valve regurgitation velocity (TRV), were 5.0 cm/s, 13.2, and 2.5 m/s, respectively. Multivariate analysis revealed that e' ≤5.0 cm/s (standard hazard ratio [HR], 3.87; 95% confidence interval [CI], 1.73-8.69; p = 0.001), septal E/e' ≥13.2 (HR, 3.62; 95% CI, 1.60-8.21; p = 0.002), and peak TRV ≥ 2.5 m/s (HR, 2.42; 95% CI, 1.13-5.16; p = 0.02) independently predicted the outcome. Patients with New York Heart Association functional status ≥ III had a 3.3-4.5-fold higher risk of the outcome. Conclusions: LVDD or severe HF symptoms predict poor outcomes in patients with LVSD undergoing AF ablation. Therefore, patients with LVDD or severe HF symptoms should receive more intensive treatment even after AF ablation.

Semi-urgent pulmonary vein isolation using cryoballoon for haemodynamically unstable atrial fibrillation storm in a patient with low cardiac output syndrome: a case report.

BACKGROUND: Atrial fibrillation and heart failure are common coexisting conditions requiring hospitalisation for heart failure and death. Pulmonary vein isolation is a well-established option for symptomatic atrial fibrillation and for atrial fibrillation concomitant with heart failure with reduced left ventricular ejection fraction. Recently, pulmonary vein isolation using cryoballoon showed non-inferiority to radiofrequency ablation with respect to the treatment of patients with drug-refractory paroxysmal atrial fibrillation. However, the effectiveness of acute-phase rhythm control by semi-urgent pulmonary vein isolation using cryoballoon in patients with haemodynamically unstable atrial fibrillation storm accompanied with low cardiac output syndrome is unclear. Herein, we present a case in which semi-urgent pulmonary vein isolation using cryoballoon was effective for acute-phase rhythm control against drug-resistant and haemodynamically unstable repetitive atrial fibrillation tachycardia accompanied with low cardiac output syndrome. CASE PRESENTATION: A 57-year-old man was hospitalised for New York Heart Association functional class 4 heart failure with atrial fibrillation tachycardia and reduced left ventricular ejection fraction of 20% accompanied with low cardiac output syndrome-induced liver damage. The haemodynamics collapsed during atrial fibrillation tachycardia, which had become resistant to intravenous amiodarone and repeated electrical cardioversions. In addition to atrial fibrillation, atrial tachycardia and common-type atrial flutter appeared on day 3. Multiple organ failure progressed gradually due to haemodynamically unstable atrial fibrillation tachycardia storm accompanied with low cardiac output syndrome. On day 4, to focus on treatment of heart failure and multiple organ failure, semi-urgent rescue pulmonary vein isolation using cryoballoon to atrial fibrillation and cavotricuspid isthmus ablation to common-type atrial flutter were performed for acute-phase rhythm control. Soon after the ablation procedure, atrial fibrillation and common-type atrial flutter were lessened, and sinus rhythm was restored. A stable haemodynamics was successfully achieved with the improvement of hepatorenal function. The patient was discharged on day 77 without complications. CONCLUSIONS: This case demonstrates that acute-phase rhythm control by semi-urgent pulmonary vein isolation using cryoballoon could be a treatment option in patients with haemodynamically unstable atrial fibrillation tachycardia storm accompanied with low cardiac output syndrome, which is refractory to cardioversion and drug therapy.