Hospitalization for permanent pacemaker implantation in the context of isolated sinus node dysfunction is associated with increased mortality compared with an outpatient strategy.

BACKGROUND: Permanent pacemaker (PPM) implantation is a well-established treatment for symptomatic sinus node dysfunction (SND). The optimal timing of this intervention is unclear, with atrioventricular blocks often prioritized in resource stressed waiting lists due to mortality concerns. METHODS: Mortality data was compared between patients receiving elective outpatient (OP) PPM implantation, and those presenting to hospital for urgent inpatient (IP) management for symptomatic SND. Survival analysis was conducted using Kaplan-Meier plots and compared using the log-rank test. Univariable and multivariable Cox regression, as well as propensity score matching analyses were performed to assess the prognostic effect on 30-day and 1-year all-cause mortality of inpatient implant. RESULTS: Of the 1269 patients identified with isolated SND, 740 (58%) had PPMs implanted on an OP and 529 (42%) on an IP basis. Mortality was significantly worse in patients where management was driven by hospital admission on an urgent basis (Log-Rank χ2 = 21.6, p < 0.001) and remained an independent predictor of 1-year all-cause mortality (HR 3.40, 95% CI 1.97-5.86, p < 0.001) on multivariable analysis. CONCLUSIONS: SND is predominantly a disease associated with ageing and comorbid populations, where avoidance of deconditioning, hospitalization acquired infections, and polypharmacy is advantageous. Admission avoidance is therefore the preferable strategy.

Atrial fibrillation cryoablation is an effective day case treatment: the UK PolarX vs. Arctic Front Advance experience.

AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). There are limited data on the PolarX Cryoballoon. The study aimed to establish the safety, efficacy, and feasibility of same day discharge for Cryoballoon PVI. METHODS AND RESULTS: Multi-centre study across 12 centres. Procedural metrics, safety profile, and procedural efficacy of the PolarX Cryoballoon with the Arctic Front Advance (AFA) Cryoballoon were compared in a cohort large enough to provide definitive comparative data. A total of 1688 patients underwent PVI with cryoablation (50% PolarX and 50% AFA). Successful PVI was achieved with 1677 (99.3%) patients with 97.2% (n = 1641) performed as day case procedures with a complication rate of <1%. Safety, procedural metrics, and efficacy of the PolarX Cryoballoon were comparable with the AFA cohort. The PolarX Cryoballoon demonstrated a nadir temperature of -54.6 ± 7.6°C, temperature at 30 s of -38.6 ± 7.2°C, time to -40°C of 34.1 ± 13.7 s, and time to isolation of 49.8 ± 33.2 s. Independent predictors for achieving PVI included time to reach -40°C [odds ratio (OR) 1.34; P < 0.001] and nadir temperature (OR 1.24; P < 0.001) with an optimal cut-off of ≤34 s [area under the curve (AUC) 0.73; P < 0.001] and nadir temperature of ≤-54.0°C (AUC 0.71; P < 0.001), respectively. CONCLUSIONS: This large-scale UK multi-centre study has shown that Cryoballoon PVI is a safe, effective day case procedure. PVI using the PolarX Cryoballoon was similarly safe and effective as the AFA Cryoballoon. The cryoablation metrics achieved with the PolarX Cryoballoon were different to that reported with the AFA Cryoballoon. Modified cryoablation targets are required when utilizing the PolarX Cryoballoon.

Ripple mapping: Initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping.

BACKGROUND: Ripple mapping (RM) displays electrograms as moving bars over a three-dimensional surface displaying bipolar voltage, and has shown in a single-center series to be effective for atrial tachycardia (AT) mapping without annotation of local activation time or window-of-interest assignment. We tested the reproducibility of these findings in operators naïve to RM, using it for the first time in postablation AT. METHODS: Maps were collected with multielectrode catheters and CARTO ConfiDENSE. A diagnosis of the tachycardia mechanism was made using RM and an assessment of operator confidence was made according to a three-grade scale (1 highest-3 lowest). RESULTS: The first 20 patients (64 ± 9 years, median two previous ablations) undergoing RM-guided AT ablation across five sites were studied. High-density maps (2,935 ± 1,328 points) in AT (CL = 296 ± 95 milliseconds) were collected. Macroreentrant ATs bordered by scar or anatomical obstacles were identified in n = 12 (60%), small reentrant ATs around scar in n = 3 (15%), and focal ATs from scar in n = 5 (25%). Diagnostic confidence with RM was grade 1 in n = 13 (65%), where operators felt confident to proceed to ablation without entrainment. Ablation offered the correct diagnosis n = 18 (90%). Retrospective review of the accompanying LAT maps demonstrated potential sources for error related to the window of interest selection, interpolation, and differentiating regions of scar during tachycardia on the voltage map. CONCLUSION: RM was easy to adopt by operators using it for the first time, and identified the correct target for ablation with high diagnostic confidence in most cases of complex AT.

The psychosocial outcomes of anoxic brain injury following cardiac arrest.

AIM OF THE STUDY: This exploratory study aimed to investigate the psychosocial outcomes for cardiac arrest survivors and explore if there is a greater impact on psychosocial outcome for individuals experiencing anoxic brain injury as a result of the cardiac arrest. METHODS: Self-report measures were used to compare the quality of life, social functioning and symptoms of anxiety, depression and post-traumatic stress of individuals with and without anoxic brain injury. Secondary measures of subjective memory and executive difficulties were also used. Fifty-six participants (27 with anoxia, 29 without anoxia) took part in the study between six months and four years after experiencing cardiac arrest. RESULTS: A MANOVA identified a significant difference between the two groups, with the anoxia group reporting more psychosocial difficulties. They reported more social functioning difficulties and more anxiety, depression and post-traumatic stress symptoms. There was, however, no significant difference in self-reported quality of life between the two groups. CONCLUSION: As the first known study to compare psychosocial outcomes for cardiac arrest survivors experiencing anoxic brain injury with those without anoxia, the current results suggest that cardiac arrest survivors with subsequent acquired brain injury experience more psychosocial difficulties. This could be due to a combination of neuropsychological, social and psychological factors.

Atrial Fibrillation In Heart Failure: New Directions In Diagnosis, Risk Assessment And Risk Reduction.

Heart failure and atrial fibrillation are common conditions which frequently co-exist. In patients with established systolic and diastolic dysfunction, atrial fibrillation increases the risk of stroke, mortality and reduces quality of life. Recent advances in implantable device technology have improved the detection of atrial fibrillation and reduced the time to intervention. Rate control remains the mainstay of treatment to improve symptoms in patients with heart failure. Currently evidence does not suggest that the routing use of a rhythm control strategy is beneficial, other than improving symptoms in patients resistant to or intolerant of rate control medications. Atrial fibrillation ablation in heart failure is safe and may be effective in maintaining sinus rhythm. Patients with AF and heart failure have more severe strokes and require longer hospital admissions. Warfarin has traditionally been the drug of choice to reduce the risk of stroke in patients with AF and heart failure, although it use is no longer recommended in patients with heart failure and sinus rhythm. Newer oral anticoagulants offer improved stroke prevention in patients with heart failure albeit at a higher drug cost. Alternative methods of stroke reduction such as left atrial appendage occlusion are emerging, although evidence for their benefit in patients with heart failure has not yet been published.