Same-day discharge following catheter ablation and venous closure with VASCADE MVP: A postmarket registry.

INTRODUCTION: Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF). METHODS: The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure. RESULTS: Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight. CONCLUSION: In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.

Confirmation of Pulmonary Vein Isolation with High-Density Mapping: Comparison to Traditional Workflows.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Yet tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. It has been suggested the use of a high-density mapping catheter, which enables simultaneous recording of adjacent bipolar EGMs in two directions, may provide improved sensitivity for gap identification. Anonymized, acute procedural data was prospectively collected in AF ablation cases utilizing various workflows for confirmation of PVI. Post-hoc analysis was performed to evaluate the incidence of gaps detected by different diagnostic catheter technologies, including a high-density mapping catheter and circular mapping catheters (CMCs), and common techniques such as pacing the ablation lines. A total of 139 cases were included across three subgroup analyses: 99 cases were included in an indirect comparison of three mapping catheter technologies, revealing gaps in 36.7%, 38.9%, and 81.8% of cases utilizing a 10-pole CMC, 20-pole CMC, and a high-density mapping catheter, respectively; a direct comparison of diagnostic catheter technologies in 18 cryoballoon ablation cases revealed residual gaps in 22.2% of patients identified by high-density mapping which were missed previously with the use of a 3.3F CMC; in 22 cases utilizing a technique of pacing the ablation lines, high-density mapping identified residual gaps in 68.2% of patients. This proof of concept analysis demonstrated that the use of a high-density catheter which records orthogonal bipoles simultaneously, appears to improve acute detection of gaps in PVI lines relative to other commonly utilized techniques and technologies. The long-term impact of ablating these concealed gaps remains unclear. Further study, including direct comparison of diagnostic catheter technologies in a randomized setting with long-term followup, is warranted.

Effectiveness of implantation of a subcutaneous implantable cardioverter-defibrillator in a patient with complete heart block and a pacemaker.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) represents an important alternative to traditional ICD therapy. The major limitation of this technology is the inability to provide pacing. Here, we present a case of a patient with complete heart block and a pacemaker who underwent placement of an S-ICD. Special considerations had to be taken with regards to evaluation and implantation of the S-ICD because of the pacemaker. In conclusion, implantation of an S-ICD can be done in patients with pacemaker effectively with appropriate electrocardiographic screening, device testing, and programming.

Innate preference or opportunism: mosquitoes feeding on birds of prey at the Southeastern Raptor Center.

The amplification of mosquito-borne pathogens is driven by patterns of host use by vectors. While each mosquito species is innately adapted to feed upon a particular group of hosts, this "preference" is difficult to assess in field-based studies, because factors such as host defenses and spatial and temporal overlap of mosquitoes and hosts affect which host animals actually get bitten. Here we examined patterns of host use by mosquitoes feeding on caged raptors at a rehabilitation and education center for birds of prey in Alabama, U.S.A. PCR-based techniques were used to determine the host species fed upon. Of 19 raptor species at the facility, seven were found to be fed upon by mosquitoes. Feeding indices and linear regression indicated that no species or family of raptor were significantly preferred over another (R(2)=0.46). Relative abundance adjusted for bird size explained a statistically significant amount of the variation in relative host use (R(2)=0.71), suggesting that bird size is an important component of host selection by mosquitoes. These findings support the hypothesis that traits of host animals drive patterns of host use by mosquitoes in nature, an interaction that leads to amplification of mosquito-borne viruses.

Who Needs Pharmacologic Therapy?

Treatment of atrial fibrillation has evolved significantly in the last ten years, with ablation becoming a far more common form of treatment for this most common type of arrhythmias. However, while ablation has become more common, certain populations derive continued benefit from the use of pharmacologic therapy for treatment. We review the use of pharmacologic therapy and novel considerations for treatment of atrial fibrillation.

Reliability using the universal classification of acute myocardial infarction compared to ST-segment classification.

OBJECTIVES: To study the inter-physician reliability using the universal classification (UC) of acute myocardial infarction (AMI) compared to the ST-segment classification (STC). The UC is based on clinical, electrocardiographic (ECG), and pathophysiologic characteristics compared to the STC, which is mainly ECG based. METHODS: In this registry of consecutive patients with AMI presenting to a tertiary hospital, we studied the inter-physician reliability [weighted kappa (wK)] using the UC and the STC. Two physician investigators independently classified each patient with AMI according to the UC and STC, and a third senior physician investigator resolved any disagreement. RESULTS: The study included Type 1=226 (89.7%), Type 2=16 (6.3%), Type 3=3 (1.2%), Type 4a=1 (0.4%), Type 4b=4 (1.6%), Type 5=2 (0.8%), ST-segment-elevation AMI (STEMI)=140 (55.6%), and non-ST-segment-elevation AMI (NSTEMI)=112 (44.4%). Inter-physician reliability using the UC was very good (wK=0.84, 95% CI 0.68-0.99) and using the STC was good (wK=0.78, 95% CI 0.70-0.86). Of patients with Type 1 AMI, 57.1% were STEMI and 42.9% were NSTEMI. In contrast, of patients with Type 2 AMI, 18.8% were STEMI and 81.2% were NSTEMI. CONCLUSION: The UC is a reliable method to classify patients with AMI and performs better than the STC in this study. Validation of the two classifications should be performed in large prospective studies.

The universal classification is an independent predictor of long-term outcomes in acute myocardial infarction.

BACKGROUND: The long-term outcomes of patients with acute myocardial infarction (AMI) according to the universal classification (UC) are unknown. We investigated whether the outcome of these patients is better predicted by the UC than the ST-segment classification (STC). METHODS: We conducted a retrospective study of 348 consecutive patients with AMI with mean follow-up of 30.6 months. The primary outcome was major adverse cardiovascular events (MACE) [composite of all causes of death and AMI]. RESULTS: The study included ST-segment elevation (STEMI) = 168 (48%), non-ST-segment elevation (NSTEMI) = 180 (52%), Type 1 = 278 (80%), Type 2 = 55 (15.8%), Type 3 = 5 (1.4%), Type 4a = 2 (0.6%), Type 4b = 5 (1.4%), and Type 5 = 3 (0.9%). During follow-up, 102 (29.3%) patients had MACE, 80 (23%) patients died, and 31 (8.9%) had an AMI. The adjusted risk of MACE was similar for NSTEMI and STEMI (HR 1.26, 95% CI 0.77-2.03, P = .35) but was significantly lower for patients with Type 2 AMI as compared to Type 1 (HR 0.44, 95% CI 0.21-0.90, P= .02). The UC, peak troponin levels, discharge glomerular filtration rate <60 ml/min per 1.73 m(2), and thrombolysis in myocardial infarction risk score were independent predictors of MACE (all, P<.05). CONCLUSIONS: The UC is an independent predictor of long-term outcomes in AMI patients compared to the STC. Type 2 AMI has less than half the risk of MACE as Type 1 AMI. Future studies should report outcomes of AMI patients according to the UC types.

Quartiles of peak troponin are associated with long-term risk of death in type 1 and STEMI, but not in type 2 or NSTEMI patients.

BACKGROUND: The prognostic value of peak cardiac troponin (cTn) in different types of acute myocardial infarction (AMI) under the universal clinical classification is unknown. HYPOTHESIS: We tested the hypothesis that the prognostic value of cTn varies with its peak level and type of AMI. METHODS: We studied 345 consecutive patients with AMI with mean follow-up of 30.6 months according to quartiles of peak cTn level (QPTL) and the type of AMI. The study outcomes were the major adverse cardiovascular events (MACE; composite of all causes of mortality and recurrent AMI) and the individual components of MACE. RESULTS: The study included patients with AMI Type 1 (n = 276), type 2 (n = 54), ST-segment elevation myocardial infarction (STEMI; n = 159), and non-ST-segment elevation myocardial infarction (NSTEMI; n = 186). Overall, peak cTn level was an independent predictor of MACE (hazard ratio [HR]: 1.001, 95% confidence interval [CI]: 1.000-1.003, P = 0.01) and death (HR: 1.002, 95% CI: 1.001-1.004, P = 0.003), but not of recurrent AMI. The highest risk of MACE and death was in the highest QPTL (61.6%, P = .016 and 66.3%, P = 0.021, respectively) while the highest risk of recurrent AMI was in the lowest QPTL (83.7%, P = 0.04). Quartiles of peak cTn level were significantly associated with increased risk of MACE and death in patients with Type 1 (all P = 0.01) and STEMI (P = 0.01 and P = 0.02, respectively), but no association existed in type 2 or NSTEMI patients. CONCLUSIONS: Overall, peak cTn predicts the risk of MACE and death but not the risk of AMI. While in Type 1 and STEMI patients, QPTL are associated with risk of MACE and death, no association exists in type 2 or NSTEMI patients.