Prospective peer review of regional percutaneous interventional procedures: a tool for quality control and revalidation.

AIMS: Current quality measures of percutaneous coronary intervention (PCI) procedures are based on the incidence of major adverse cardiac events (MACE). This crude marker ignores the many clinical nuances that make for sound decision making in PCI. We have established a prospective peer review audit tool to determine the quality of PCI within our cardiac network, which consists of five PCI hospitals serving a population of 1.4 million people in Sussex, UK. METHODS AND RESULTS: Analysis of 10% of all PCI cases selected at random each month by a non-clinical audit manager is made by a rotating panel of two PCI operators and one cardiac surgeon. Each PCI case is assessed for anatomical suitability, lesion severity, strategic appropriateness and final outcome. Panel findings were reported back to the operator and the audit manager. A total of 326 cases were assessed by the review committee. Results were disseminated to individual operators. Coronary anatomy and lesion severity were considered appropriate for PCI in 94.2% and 96.0% of cases, respectively. Appropriateness of strategy was confirmed in 86.2% and the outcome considered satisfactory in 90.8%. A total of 242 subsequent cases were analysed to assess practice trends. This analysis demonstrated a statistically significant improvement in clinical decision making with respect to appropriateness of strategy (from 86.2% to 92.6%; p=0.004). CONCLUSIONS: Prospective peer review of percutaneous coronary intervention cases by a rotating regional committee is valuable in ensuring procedural quality.

The efficacy of intraoperative atrial radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery-the Surgical Atrial Fibrillation Suppression (SAFS) Study.

INTRODUCTION: Studies assessing radiofrequency ablation (RFA) for atrial fibrillation (AF) performed at the time of concomitant cardiac surgery have reported high success rates. The efficacy of this treatment has primarily been determined by a single electrocardiogram (ECG) or 24-h Holter monitor at follow-up. We sought to assess the true efficacy of this procedure using prolonged cardiac rhythm monitoring. METHODS: One hundred patients with paroxysmal (n = 47) and persistent AF (n = 53) requiring cardiac surgery were enrolled. Patients were clinically reviewed 6 weeks post-operatively and were monitored with 7-day Holter with full disclosure, 6 months post-surgery. A cohort of 50 patients also underwent 7 day Holter monitoring preoperatively. AF recurrence was defined as >30 s of AF. RESULTS: At 6 months, 75% of patients were in sinus rhythm according to a single ECG. However, only 62% of patients were free from AF on 7-day Holter; all AF episodes in these patients were asymptomatic. The procedure resulted in a significant decrease in AF burden from 56.2% at baseline to 27.5% at 6 months follow-up, (p < 0.001). Predictors of AF recurrence were (1) pre-operative AF duration; (2) persistent compared with paroxysmal AF; (3) increasing left atrial diameter and (4) requirement for mitral valve surgery. CONCLUSIONS: Surgical RFA for the treatment of AF, during concomitant cardiac surgery, is a successful procedure and significantly reduces AF burden. However, 13% of patients have asymptomatic AF episodes only identified with continuous monitoring. This has important implications for post-operative anti-arrhythmic and anticoagulant management and for the definition of surgical AF ablation success.

The relationship between right ventricular pacing and atrial fibrillation burden and disease progression in patients with paroxysmal atrial fibrillation: the long-MinVPACE study.

AIMS: In patients requiring permanent pacemaker implantation for sinus node disease (SND) or atrioventricular (AV) block, right ventricular (RV) pacing has been demonstrated to increase the risk of developing atrial fibrillation (AF). The effects of RV pacing in patients with paroxysmal AF are less well defined. Short- and medium-term studies have suggested no significant correlation between RV pacing and atrial fibrillation burden (AFB) measurement; we sought to assess for an effect in the long-term. METHODS AND RESULTS: Sixty-six patients were randomized to receive either conventional dual chamber pacing (DDDR, n = 33), or dual chamber minimal ventricular pacing (MinVP, n = 33), for a period of at least 1 year. Patients were reviewed every 6 months and all pacemaker data were downloaded. The primary outcome measures were device-derived AFB and progression to persistent AF. The mean duration of study follow-up was 1.4 ± 0.6 years. Mean ventricular pacing was less in the MinVP cohort compared with the DDDR cohort (5.8 vs. 74.0%, P < 0.001). At follow-up, the device-derived AFB was significantly lower in the MinVP cohort when compared with the DDDR cohort (12.8 ± 15.3% vs. DDDR 47.6 ± 42.2%, P < 0.001). Kaplan-Meier estimates of time to onset of persistent AF showed significant reductions in the rates of persistent AF for MinVP pacing (9%) when compared with conventional DDDR pacing (42%), P = 0.004. CONCLUSION: Right ventricular pacing induces increased AFB in patients with paroxysmal AF in the long term. Dual chamber MinVP algorithms result in reduced AFB and reduced disease progression from paroxysmal to persistent AF in the long term.

The usefulness of minimal ventricular pacing and preventive AF algorithms in the treatment of PAF: the 'MinVPace' study.

INTRODUCTION: The beneficial effects of atrial pacing on the incidence, duration and symptomatology of paroxysmal atrial fibrillation (PAF) may be negated by increased ventricular pacing. This prospective randomised study evaluates the effect of pacing algorithms that minimise ventricular pacing (MinVP) with and without anti-AF algorithms, on AF burden (AFB) in patients with symptomatic PAF. METHODS: Patients implanted with pacemakers with MinVP capability with AFB 1-70% were enrolled. Three different DDDRP devices were assessed. Following a 1-month induction phase, patients were randomised to MinVP with and without preventive AF algorithms or dual chamber rate adaptive pacemaker (DDDR) (AV delay (AVD) 150 ms) for 2 months per study phase. The primary outcome measure was AFB. RESULTS: One hundred and ten patients were enrolled; of these, 66 (mean age 74.3 + or - 7.9, 56% males) had an AFB of 1-70% during the induction phase and completed all study phases. There was no significant difference in AFB between the control phase DDDR, 13.8% (95% CI 8.7 to 18.8), and MinVP, 14.4% (95% CI 9.4 to 19.4), or MinVP with AF algorithms enabled, 14.7% (95% CI 9.7 to 19.7), (p = 0.65 and p = 0.49, respectively). Median ventricular pacing was significantly higher during the control phase, 86.0% (IQR 72.8, 97.3), than in MinVP 2.0% (IQR 0.0, 14.1) and MinVP + algorithms 3.0% (IQR 0.4, 15.6), p = < 0.001. CONCLUSION: MinVP algorithms are effective in reducing ventricular pacing. However, there is no significant reduction in AFB with minimal ventricular pacing algorithms in the short term. No additional benefit or adverse outcome was found with preventative anti-AF algorithms in combination with MinVP algorithms.