Faculty Bibliography

BACKGROUND:Vein of Marshall (VOM) ethanol ablation is effective in preventing recurrence in patients with persistent atrial fibrillation (AF) as a de novo strategy. There is minimal data on its use in recurrent AF. OBJECTIVE:We investigated the efficacy of VOM ethanol ablation for recurrence despite initial AF ablation. METHODS:Retrospective analysis was performed of persistent AF patients who underwent repeat ablation after an initial ablation for persistent AF. All patients had pulmonary vein isolation (PVI), posterior wall isolation (PWI), and cavotricuspid isthmus (CTI) during their previous ablation(s). At redo ablation, controls underwent confirmation and completion of previous ablation steps, substrate modification, and a search for non-PV triggers. Cases had additional VOM ethanol ablation combined with mitral isthmus ablation. RESULTS:One hundred and seven patients (49 VOM, 60 control) were included. There was no difference in AF recurrence at 1-year comparing VOM patients (47%) and controls (38%), (p = 0.39). Within the VOM group, the mean AF burden decreased from 38% preablation to 10% 12-months post (p = 0.003). The proportion of recurrent persistent AF decreased from 65% preablation to 26% post (p = 0.004). There was no significant difference in reduction in AF burden or proportion of recurrent persistent AF when comparing VOM cases and controls. Six percent of VOM patients developed intraprocedural left atrial appendage (LAA) isolation. CONCLUSIONS:In patients with previous PVI, PWI, and CTI ablation, VOM ethanol ablation did not demonstrate a reduction in AF recurrence or burden when compared with a strategy of substrate modification and trigger ablation alone and increases the risk of LAA isolation.

BACKGROUND:Cardiac implantable electronic device (CIED)-related bacteremia necessitates device extraction, but if there are large lead-related vegetations, surgical extraction is recommended. The associated higher morbidity and mortality complicate the management of these patients. OBJECTIVES/OBJECTIVE:The aim of this study was to assess the outcomes of percutaneous mechanical debulking (PMD) of lead-associated vegetations using a manual vacuum aspiration device during CIED extraction. METHODS:This was a retrospective analysis of patients from 3 centers undergoing CIED extraction with lead-associated vegetations between 2023 and 2025. Patients were separated into 2 groups: those in whom PMD was used or those in whom PMD was not used (controls). Clinical outcomes and surrogates of infection severity were assessed. RESULTS:/L). Extraction in both cohorts occurred without major complications. There was a significant change in WBC count postprocedure compared with baseline: in the control arm, WBC count increased (mean 21.1%; 27.6% had a >20% increase), whereas WBC count decreased in the PMD arm (mean 8.35%; only 7.7% had a >20% increase; P = 0.046). The postextraction hospital stay was shorter with PMD (8.4 ± 7.3 days vs 15.8 ± 14.5 days; P = 0.056). One-month mortality was 0% with PMD vs 14% (n = 4) in the control group (P = 0.401). CONCLUSIONS:In this contemporary study of PMD of large lead-associated vegetations, manual vacuum aspiration was feasible and appeared associated with better outcomes, including postoperative markers of infection severity, hospital stay, and, perhaps, mortality.

BACKGROUND:In treating atrial fibrillation, pulsed-field ablation (PFA) has comparable efficacy to conventional thermal ablation, but with important safety advantages: no esophageal injury or pulmonary vein stenosis, and rare phrenic nerve injury. However, when PFA is delivered in proximity to coronary arteries using a pentaspline catheter, which generates a broad electrical field, severe vasospasm can be provoked. OBJECTIVES/OBJECTIVE:The authors sought to study the vasospastic potential of a focal PFA catheter with a narrower electrical field and develop a preventive strategy with nitroglycerin. METHODS:During atrial fibrillation ablation, a focal PFA catheter was used for cavotricuspid isthmus ablation. Angiography of the right coronary artery (some with fractional flow reserve measurement) was performed before, during, and after PFA. Beyond no nitroglycerin (n = 5), and a few testing strategies (n = 8), 2 primary nitroglycerin administration strategies were studied: 1) multiple boluses (3-2 mg every 2 min) into the right atrium (n = 10), and 2) a bolus (3 mg) into the right atrium with continuous peripheral intravenous infusion (1 mg/min; n = 10). RESULTS:Without nitroglycerin, cavotricuspid isthmus ablation provoked moderate-severe vasospasm in 4 of 5 (80%) patients (fractional flow reserve 0.71 ± 0.08). With repetitive nitroglycerin boluses, severe spasm did not occur, and mild-moderate vasospasm occurred in only 2 of 10 (20%). Using the bolus + infusion strategy, severe and mild-moderate spasm occurred in 1 and 3 of 10 patients (aggregate 40%). No patient had ST-segment changes. CONCLUSIONS:Ablation of the cavotricuspid isthmus using a focal PFA catheter routinely provokes right coronary vasospasm. Pretreatment with high doses of parenteral nitroglycerin prevents severe spasm.

Mitral valve prolapse (MVP) is a well-studied, mostly benign, phenomenon; however, arrhythmic mitral valve prolapse (AMVP) is a rare subtype that can precipitate sudden cardiac death (SCD). Herein, we present a case of a young female with sudden cardiac arrest. Extensive multimodality imaging and follow-up helped establish the diagnosis of AMVP.

IMPORTANCE:Effective treatments for patients with severe COVID-19 are needed. OBJECTIVE:To evaluate the efficacy of canakinumab, an anti-interleukin-1β antibody, in patients hospitalized with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS:This randomized, double-blind, placebo-controlled phase 3 trial was conducted at 39 hospitals in Europe and the United States. A total of 454 hospitalized patients with COVID-19 pneumonia, hypoxia (not requiring invasive mechanical ventilation [IMV]), and systemic hyperinflammation defined by increased blood concentrations of C-reactive protein or ferritin were enrolled between April 30 and August 17, 2020, with the last assessment of the primary end point on September 22, 2020. INTERVENTION:Patients were randomly assigned 1:1 to receive a single intravenous infusion of canakinumab (450 mg for body weight of 40-<60 kg, 600 mg for 60-80 kg, and 750 mg for >80 kg; n = 227) or placebo (n = 227). MAIN OUTCOMES AND MEASURES:The primary outcome was survival without IMV from day 3 to day 29. Secondary outcomes were COVID-19-related mortality, measurements of biomarkers of systemic hyperinflammation, and safety evaluations. RESULTS:Among 454 patients who were randomized (median age, 59 years; 187 women [41.2%]), 417 (91.9%) completed day 29 of the trial. Between days 3 and 29, 198 of 223 patients (88.8%) survived without requiring IMV in the canakinumab group and 191 of 223 (85.7%) in the placebo group, with a rate difference of 3.1% (95% CI, -3.1% to 9.3%) and an odds ratio of 1.39 (95% CI, 0.76 to 2.54; P = .29). COVID-19-related mortality occurred in 11 of 223 patients (4.9%) in the canakinumab group vs 16 of 222 (7.2%) in the placebo group, with a rate difference of -2.3% (95% CI, -6.7% to 2.2%) and an odds ratio of 0.67 (95% CI, 0.30 to 1.50). Serious adverse events were observed in 36 of 225 patients (16%) treated with canakinumab vs 46 of 223 (20.6%) who received placebo. CONCLUSIONS AND RELEVANCE:Among patients hospitalized with severe COVID-19, treatment with canakinumab, compared with placebo, did not significantly increase the likelihood of survival without IMV at day 29. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04362813.