Faculty Bibliography

INTRODUCTION/BACKGROUND:Acute hemopericardium during cardiac electrophysiology (EP) procedures may result in significant blood loss and is the most common cause of procedure related death. Matched allogeneic blood is often not immediately available. The feasibility and safety of direct autotransfusion in cardiac electrophysiology patients requiring emergency pericardiocentesis is unknown. METHODS:We retrospectively analyzed records of patients undergoing EP procedures at a single, tertiary care medical center who had procedure-related acute hemopericardium requiring emergency pericardiocentesis during a three-year period. Procedure details, transfusion volumes, and clinical outcomes of patients who received direct autotransfusion of aspirated pericardial blood via a femoral venous sheath were compared to those of patients who did not receive direct autotransfusion. RESULTS:During the study period, 10 patients received direct autotransfusion (group 1) and outcomes were compared with those of 14 control patients who did not receive direct autotransfusion (group 2). Volume of aspirated pericardial blood was similar in groups 1 and 2 (1.6±0.7 L vs. 1.3±1.0 L, respectively; p=0.52). Amongst patients with aspirated volumes < 1L, group 1 patients (n=4) were less likely than group 2 patients (n=8) to require allotransfusion (0% vs. 75%, p=0.02). Amongst patients with aspirated volume ≥ 1L, group 1 patients (n=6) required fewer units of red cell allotransfusion than group 2 patients (n=6) (1.5±0.8u vs. 4.3±2.0u, p=0.01). No procedural complications related to direct autotransfusion occurred. CONCLUSIONS:Direct autotransfusion following emergency pericardiocentesis during electrophysiology procedures requiring systemic anticoagulation is feasible and safe. Utilization of direct autotransfusion may eliminate or reduce the need for allotransfusion. This article is protected by copyright. All rights reserved.

INTRODUCTION/BACKGROUND:Implantable cardioverter defibrillators (ICDs) are proven to prevent sudden death in patients at elevated risk for sustained ventricular tachycardia or fibrillation. Complications related to ICD failure can stem from lead dysfunction, manufacturing defects, patient characteristics or implantation technique. We conducted a review of all ICD leads implanted at our center from 2011-2017 to determine risk factors for premature lead failure. METHODS:We conducted a retrospective review of patients of all ICD leads implanted from December 2011 to June 2017 at our institution. A total of 660 patients (Biotronik Linox S/SD, n = 281; Sprint Quatro, n = 207; Durata, n = 121; Endotak, n = 51) underwent ICD implantations. Patient and lead characteristics, procedural outcomes and complications were recorded. Lead failure was defined per Heart Rhythm Society lead-management consensus as a lack of procedural or clinical success, thus requiring an extraction of the lead. Patient and lead outcomes were recorded and variables associated with lead failure were assessed by the Kaplan-Meier method. RESULTS:Overall failure rate was similar for all leads: Linox S/SD - 0.29%/year; Sprint Quattro - 0.21%/year, Durata - 0.39%/year and Endotak Reliance - 0.0% (p=0.769). No difference was found in overall survival when comparing all ICD manufacturers during the study period. Subgroup analysis revealed the risk of premature lead failure was particularly pronounced in multi-lead ICD systems implanted via cephalic access (p<0.001). The estimated failure rate of Linox leads implanted via cephalic access in multi-lead systems was 19%/year. The estimated failure rate of non-Linox leads implanted via cephalic access in multi-lead systems was 11%/year. Neither age, nor gender were risk factors for lead failure in the Linox, or non-Linox cohorts. CONCLUSION/CONCLUSIONS:All analyzed ICD leads were found to have a similar overall risk of premature failure. ICD lead implantation via cephalic access in multilead ICD systems may be a previously unidentified risk factor for premature ICD lead failure, although these findings require further validation. This article is protected by copyright. All rights reserved.

BACKGROUND:Increased peak luminal esophageal temperature (LET) is associated with increased risk of esophageal injury following left atrial posterior wall (LAPW) ablation. The magnitude, distribution, and risk factors of LET increase with high power short duration (HPSD) LAPW ablation are not well understood. OBJECTIVE:We aimed to describe the spatial and temporal characteristics of LET changes associated with HPSD LAPW RFA. METHODS:LET was sampled at 20Hz using a 12-point esophageal temperature monitor (CIRCA S-CATH, Circa Scientific, Inc.) in 16 patients undergoing LAPW ablation. Esophageal temperature sensor position and lesion locations were recorded using an electroanatomic mapping system with fluoroscopic integration (CARTO 3, CARTOUNIVU, Biosense Webster, Inc). Point-by-point LAPW ablation was performed at 50W for 6s. The first 20 LAPW lesions were individually analyzed in each patient. RESULTS:LET increase ≥4°C (8 lesions: Max LET 5.8°C), 2-4°C (34 lesions), and 1-2°C (58 lesions) occurred at 9±2 mm, 8±2 mm, and 13±2mm from sensors, respectively. Lesions placed >20mm from a temperature sensor did not result in an LET increase ≥2°C. Temperature resolution to within 1°C of baseline occurred at ∼60s after cessation of RF. Consecutive lesions resulting in additive heating of at least 1°C occurred in 17 lesion pairs with an inter-lesion distance of 9±4mm and inter-lesion time of 21±4s. CONCLUSION/CONCLUSIONS:HPSD LAPW ablation can result in severe esophageal temperature increases. Significant LET increase will be undetected when lesions are >20mm away from a temperature sensor. Additive LET increase was observed with consecutive lesions placed less than 20mm apart within 60s.

BACKGROUND:Optimal ablation technique, including catheter-tissue contact during atrial fibrillation (AF) radiofrequency (RF) ablation, is associated with improved procedural outcomes. We used a custom developed software to analyze high-frequency catheter position data to study the interaction between catheter excursion during lesion placement, lesion-set sequentiality, and arrhythmia recurrence. METHODS:A total of 100 consecutive patients undergoing first-time RF ablation for paroxysmal AF were analyzed. Spatial positioning of the ablation catheter sampled at 60 Hz during RF application was extracted from the CARTO3 system (Biosense Webster Inc, USA) and analyzed using custom-developed MATLAB software to determine precise catheter spatial 3D excursion during RF ablation. The primary end point was freedom from atrial arrhythmia lasting longer than 30 seconds after a single ablation procedure. RESULTS:At 1 year, 86% of patients were free from recurrent arrhythmia. There was no significant difference in clinical, echocardiographic, or ablation characteristics between patients with and without recurrent arrhythmia. Analyzing 15,356,998 position data points revealed that lesion-set sequentiality and mean lesion catheter excursion were predictors of arrhythmia recurrence. Analyzing arrhythmia recurrence by mean single-lesion catheter excursion (excursion >2.81 mm) and by sequentiality (using 46% of lesions with interlesion distance >6 mm as cutoff) revealed significantly increased arrhythmia recurrence in the higher excursion group (23% vs 6%, P = .03) and in the less sequential group (24% vs 4%, P = .02). CONCLUSIONS:Ablation lesion sequentiality measured by catheter interlesion distance and catheter stability measured by catheter excursion during lesion placement are potentially modifiable factors affecting arrhythmia recurrence after RF ablation for AF.

INTRODUCTION/BACKGROUND:A common complication of TAVR is development of conduction defects requiring pacemaker (PPM) implantation. These defects are not universally permanent. OBJECTIVE:To determine the incidence and predictors of persistent device dependency in patients with PPM implantation following TAVR with a self-expanding prosthesis. METHODS:Records of patients who underwent post-TAVR PPM implantation were reviewed. Patients with persistent complete AV block (AVBIII) one month post-TAVR were compared to those regaining conduction. RESULTS:Between September 2014 and March 2017, 485 patients underwent TAVR with a self-expanding prosthesis; 77 (15.9%) underwent PPM implantation for AVBIII. Device interrogation at one month was available for 61 patients (79%): 22 (36.1%) had resolution of AVBIII while 39 (63.9%) remained pacemaker-dependent. Pre-TAVR RBBB was more frequent in device-dependent patients (19 of 38, 50% vs 4 of 22, 18%; RR 2.75; p = 0.01). Device-dependence was associated with AVBIII as the first post-procedural rhythm (37 of 39, 95% vs 12 of 22, 55%; RR 1.74; p<0.0001), earlier implantation (median 1d, IQR: 0-1.5d vs 2d, IQR: 1.0-4.0d, p = 0.0004), and a shorter duration of hospitalization (median 3d, IQR: 2-3.5d vs 4d, IQR: 2-5.75d, p = 0.03). Pacemaker dependence was also associated with a higher prosthesis-to-LVOT diameter (1.45±0.11 vs 1.39±0.07; p = 0.02) and the lack of prior aortic valvuloplasty (5 of 39, 13% vs 8 of 22, 36%; RR 0.35; p = 0.03). CONCLUSIONS:In patients receiving a PPM following self-expanding TAVR, a long-term pacing requirement can be predicted from the timing of AV block, existing conduction-system disease, larger prosthesis-to-LVOT diameter, and the lack of aortic valvuloplasty. This article is protected by copyright. All rights reserved.

Recent improvements in 3D TEE post processing rendering techniques referred to as TrueVue (Philips Medical Systems, Andover, MA, USA). It allows for novel photorealistic imaging of cardiac structures including left atrial appendage (LAA) and its closure devices. Here we present TrueVue images of the LAA prior to and after LAA exclusion/occlusion using various percutaneous and surgical techniques. TrueVue may improve delineation of LAA anatomy prior to occlusion as well as visualization of occluder device position within the LAA.

PURPOSE OF REVIEW/OBJECTIVE:Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. For patients with atrial fibrillation who are unable to tolerate systemic anticoagulation, left atrial appendage (LAA) occlusion has been shown to mitigate stroke risk. In this article, we describe the vital role of the echocardiographer in intraprocedural guidance of percutaneous LAA occlusion procedures as well as in the pre- and post-procedure assessment of these patients. RECENT FINDINGS/RESULTS:A few percutaneously delivered devices for LAA exclusion from the systemic circulation are available in contemporary practice. These devices employ an either exclusive endocardial LAA occlusion approach, such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both an endocardial and pericardial (epicardial) approach such as the Lariat procedure (SentreHEART, Palo Alto, CA). Two- and three-dimension transesophageal echocardiography is critical for patient selection, procedure planning, procedural guidance, and ensuring satisfactory immediate as well as long-term LAA occlusion/exclusion efficacy. This review will provide an overview of the role of the echocardiographer in all aspects of LAA occlusion/exclusion procedures for the most commonly used commercially available devices in current practice.

Background: Left atrial posterior wall (LAPW) isolation is associated with favorable outcomes for catheter ablation of persistent atrial fibrillation (AF) in several studies. Reported techniques for LAPW isolation include ablation at the periphery without ablation within the LAPW, and high density ablation of all sites of electrical activity within the LAPW. The proportion of LA isolated by the lesion set in various reports also varies greatly. The optimal technique to achieve LAPW isolation is not clear.
Objective(s): To assess impact of ablation lesion density within the LAPW and dimensions of LAPW isolation region on arrhythmia recurrence in catheter ablation of persistent AF.
Method(s): LAPW lesion density, and LAPW isolation surface area relative to total LA surface area were calculated using electroanatomic maps of 110 consecutive patients undergoing LAPW isolation for persistent AF (CARTO 3, Biosense Webster, Inc.) LAPW isolation lesion sets were created at the discretion of 5 experienced operators after LA voltage mapping. LAPW and PV entrance block and exit block were confirmed. Arrhythmia recurrence at one year was assessed by the Kaplan-Meier method.
Result(s): LAPW lesion density ranged from 0% - 99%. Proportion of LA surface area isolated ranged from 35% - 75%. There was no significant difference in arrhythmia-free survival by quartile of LAPW ablation density (81% vs. 68% vs. 85% vs. 78%, p=0.8), or by quartile of LA surface area proportion isolated (85% vs. 75% vs. 79% vs. 74%, p=0.3). Voltage map guided LAPW isolation resulted in no significant difference in incidence of recurrent arrhythmia by quartile of total LA surface area (81% vs. 78% vs. 78% vs. 74%, p=0.5).
Conclusion(s): Neither the density of ablation within the LAPW nor the dimensions of the isolated region predicted arrhythmia-free survival LAPW isolation for catheter ablation of persistent AF. Voltage map guided LAPW isolation resulted in similar ablation efficacy regardless of LA size.
Copyright