Novel approach to intracardiac defibrillator placement in patients with atriopulmonary Fontan: Ventricular defibrillation with an atrial positioned ICD lead.

INTRODUCTION: The Fontan procedure, used to palliate univentricular physiology, eliminates direct venous access to the ventricle and complicates implantable cardioverter-defibrillator (ICD) placement. METHODS AND RESULTS: We describe two patients with Fontan palliation who underwent a novel transvenous approach to ICD placement. The approach uses a transvenous bipolar lead placed in a coronary sinus branch for ventricular sensing, and a defibrillation lead placed in the right atrium for atrial sensing and ventricular defibrillation. CONCLUSION: Transvenous ICD implantation is possible in some patients with an atriopulmonary Fontan. This approach avoids a redo sternotomy for epicardial leads and excludes the need for lead placement in the systemic circulation.

High-density mapping and ablation of concealed low-voltage activity within pulmonary vein antra results in improved freedom from atrial fibrillation compared to pulmonary vein isolation alone.

BACKGROUND: Despite advancements, the goal of durable pulmonary vein isolation (PVI) in all patients undergoing ablation for atrial fibrillation (AF) remains elusive. New high-density mapping (HDM) allows detection of concealed low-voltage signals (CLVSs) that persist after PVI and may represent vulnerabilities in the lesion set. OBJECTIVE: The purpose of this study was to determine the incidence of CLVSs after PVI and the effect of CLVS ablation on outcomes. METHODS: We conducted a case control study comparing 150 patients undergoing HDM-guided PVI and subsequent CLVS mapping and ablation (39 redo, 111 de novo) against 452 historical controls undergoing traditional PVI alone. PVI was similarly performed and confirmed in both groups. RESULTS: Baseline characteristics were similar, except left atrial size was larger in the HDM-guided group. Acute PVI was achieved in nearly all patients in both groups. In the HDM group, 31 of 150 patients exhibited CLVS after luminal PVI, and all were subsequently eliminated. During mean follow-up of 320 days, after controlling for baseline characteristics, the HDM-guided group exhibited a hazard ratio of 0.19 in freedom from AF (P <.001). De novo patients exhibited a hazard ratio of 0.44 relative to redo patients in the HDM-guided group. Both subgroups exhibited significantly lower event rates compared to controls in log-rank analysis (P <.001). CONCLUSION: CLVSs are commonly identified with HDM after PVI, likely representing vulnerabilities in antral lesion sets. Ablation of these targets seems to significantly improve freedom from AF compared to PVI alone.

Aspirin use is associated with an improved long-term survival in an unselected population presenting with unstable angina.

BACKGROUND: Few published data are available on the benefits of aspirin use in patients with unstable angina (UA). HYPOTHESIS: Aspirin use carries a mortality benefit in a population-based cohort of patients presenting with UA. METHODS: All residents of Olmsted County, Minnesota presenting to local emergency departments with acute chest pain from January 1985 through December 1992 having symptoms consistent with UA were identified through medical records. A total of 1628 patients were identified with UA and were stratified by aspirin use in-hospital and at discharge. Cardiovascular mortality and nonfatal myocardial infarction and stroke were assessed over a median of 7.5 years follow-up and all-cause mortality data over a median of 16.7 years. The mean age of patients with UA was 65 years, and 60% were men. RESULTS: After a median of 7.5 years follow-up, all-cause and cardiovascular-mortality rates were lower among patients prescribed versus not prescribed aspirin on discharge. There were 949 postdischarge deaths over the median follow-up of 16.7 years. After multivariable adjustment, aspirin use at discharge was associated with a lower long-term mortality (hazard ratio 0.78; 95% confidence interval, 0.65-0.93). CONCLUSIONS: Aspirin use at hospital discharge following UA is associated with a reduction in long-term mortality. This long-term study extends prior trial results from select populations to a population-based cohort.

C-reactive protein predicts long-term mortality independently of low-density lipoprotein cholesterol in patients undergoing percutaneous coronary intervention.

BACKGROUND: Few data are available on the association of high-sensitivity C-reactive protein (hs-CRP) and mortality independent of low-density lipoprotein (LDL) cholesterol in patients undergoing percutaneous coronary intervention (PCI). METHODS: Consecutive patients (N = 8,834) undergoing PCI between October 28, 2002, and December 31, 2006, were followed through June 30, 2007 (average and maximum follow-up of 1.9 and 4.6 years, respectively). High-sensitivity CRP levels were classified into 4 groups: <1.0, 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L. RESULTS: All-cause mortality rates were 14.4, 17.5, 25.7, and 56.4 per 1,000 person-years in patients with hs-CRP levels of <1.0, 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L, respectively. Compared with patients with hs-CRP <1.0 mg/L, the hazard ratios of mortality after multivariable adjustment, including LDL cholesterol, associated with hs-CRP levels of 1.0 to 2.9, 3.0 to 9.9, and > or =10 mg/L were 1.27 (95% CI 0.91-1.75), 1.70 (95% CI 1.26-2.29), and 2.99 (95% CI 2.24-3.99), respectively (P trend < .001). After multivariable adjustment, trends of higher all-cause mortality at higher hs-CRP were present for patients with LDL cholesterol <70, 70 to 99, and > or =100 mg/dL (each P < .001). A test for interaction between LDL cholesterol and hs-CRP on all-cause mortality was not significant (P = .30). CONCLUSIONS: High-sensitivity CRP levels provide significant incremental prognostic information for all-cause mortality in long-term follow-up independent of LDL cholesterol.