Faculty Bibliography

OBJECTIVES/OBJECTIVE:This study sought to determine whether a radiation safety time-out reduces radiation exposure in electrophysiology procedures. BACKGROUND:Time-outs are integral to improving quality and safety. The authors hypothesized that a radiation safety time-out would reduce radiation exposure levels for patients and the health care team members. METHODS:The study was performed at the New York University Langone Health Electrophysiology Lab. Baseline data were collected for 6 months prior to the time-out. On implementation of the time-out, data were collected prospectively with analyses to be performed every 3 months. The primary endpoint was dose area product. The secondary endpoints included reference point dose, fluoroscopy time, use of additional shielding, and use of alternative imaging such as intracardiac and intravascular ultrasound. RESULTS:, representing a 21% reduction (p = 0.007). The median reference point dose prior to time-out was 163 mGy, and during the time-out was 122 mGy (p = 0.011). The use of sterile disposable protective shields and ultrasound imaging for access increased significantly during the time-out. CONCLUSIONS:A radiation safety time-out significantly reduces radiation exposure in electrophysiology procedures. Electrophysiology laboratories, as well as other areas of cardiovascular medicine using fluoroscopy, should strongly consider the use of radiation safety time-outs to reduce radiation exposure and improve safety.

Background: Increased catheter stability during AF ablation is associated with higher ablation success rates. Rapid cardiac pacing and high frequency jet ventilation (HFJV) have both been independently shown to improve catheter stability. Simultaneous modulation of cardiac and respiratory motion has not been previously studied.
Objective(s): To study the effects of modulating heart rate and respiratory rate simultaneously on catheter stability.
Method(s): Forty paroxysmal AF patients were randomized to four study conditions. Ablation lesions were created at 15 prespecified locations. Twenty patients received atrial pacing (500 msec) during the first half of each lesion; twenty patients were paced during the second half of each lesion. Within each group, half received HFJV and half received standard ventilation. Contact force (CF) variability, defined as CF standard deviation, was compared between study groups.
Result(s): Compared to sinus rhythm and standard ventilation, rapid pacing (5.45 g vs. 5.86 g; p=0.006) and HFJV (5.10 g; p=0.003) each significantly reduced mean CF standard deviation. Simultaneous pacing and HFJV produced even greater reduction of mean CF standard deviation (4.29 g; p<0.001) (Figure). Pacing and HFJV alone had similar effects on mean CF variability (p=0.2).
Conclusion(s): Rapid pacing and HFJV synergistically improve catheter stability during AF ablation. Simultaneous pacing with HFJV further optimizes catheter stability over pacing or HFJV alone and may improve ablation outcomes. [Figure presented]
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Background: Despite the increased prevalence of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM), the efficacy of radiofrequency ablation (RFA) has been characterized over limited follow-up intervals (~1 year). Several large meta-analyses note that patients with HCM have substantially higher rates of arrhythmia recurrence after RFA, compared to patients without HCM. The implication of confirmed HCM mutations on ablation efficacy has similarly only been assessed in small-scale studies.
Objective(s): To assess arrhythmia recurrence after RFA in patients with HCM and paroxysmal AF (PAAF) or persistent AF (PEAF) as well as its relation to their genetic background and LVOT gradient.
Method(s): Arrhythmia recurrence after RFA was assessed in 66 HCM patients and compared to 343 patients without HCM. AF recurrence was defined as AF on EKG or >30s of AF on ICD/pacemaker interrogation or on monitoring devices after a 3-month blanking period. Kaplan-Meier analysis was performed to compare arrhythmia recurrence rate and timing.
Result(s): The EF of HCM patients was higher than that of the non-HCM patients in both the PAAF and PEAF groups (65.5 and 63.0% vs 61.4 and 53.3%, respectively, p<0.001); within the HCM group, the clinical characteristics of the genetically (+) HCM group (n=14) did not differ from those of the genetically (-) group (n=12). Arrhythmia recurrence at 1 year in PAAF and PEAF was not significantly different between HCM and non-HCM patients (18% vs 11%, p=0.2, and 33% vs 26%, p=1), nor was mean time to arrhythmia recurrence (PAAF 193+/-48 vs 181+/-59 days, p=0.8, and PEAF 175+/-58 vs 168+/-20 days, p=0.6). Recurrence rates over the entire follow-up period of the HCM patients were 54 and 85% in the PAAF and PEAF groups (1076+/-187 and 1050+/- 201 days of follow-up), respectively. Amongst HCM patients with LVOT gradients >70mmHg (PAAF, n = 8, and PEAF, n = 3) longer-term rates of arrhythmia recurrence were similar at 88% and 67% (p=0.9).
Conclusion(s): Arrhythmia recurrence at 1 year following AF ablation in HCM patients is similar to that of non-HCM AF patients regardless of the type of AF. Absolute rates of atrial arrhythmia recurrence in HCM patients at >3 years post ablation are considerable. Confirmed HCM mutations and severe LVOT gradients do not modify the outcome of AF ablation.
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Background: Left ventricular outflow tract (LVOT) obstruction is associated with adverse outcomes in hypertrophic cardiomyopathy (HCM). AV sequential pacing has not demonstrated benefit for patients with medication-refractory LVOT obstruction in prospective, randomized clinical trials, although these trials did not include transthoracic echocardiogram (TTE) guided optimization or concomitant pharmacotherapy with disopyramide.
Objective(s): To evaluate efficacy of a standardized TTE guided AV optimization protocol for patients with persistent LVOT obstruction despite AV sequential pacing for reduction in LVOT gradient.
Method(s): Outcomes of 20 consecutive HCM patients with medication refractory LVOT gradients who were not surgical candidates and underwent AV sequential pacing from 8/2014 to 6/2017 were analyzed. ECG guided AV intervals were determined by the implanting cardiac electrophysiologist at the time of implant. Patients with incomplete response to initial settings underwent Doppler TTE guided AV optimization.
Result(s): All patients received maximally tolerated disopyramide and beta or calcium channel blockade. Following initial implant, 8 of 20 (40%) of patients had complete elimination of LVOT gradient with, and 12 of 20 (60%) had incomplete response and underwent TTE guided optimization. Compared to initial ECG guided programming, the TTE optimized sensed AV delays were shorter in all patients (mean reduction 51 +/- 48ms). Following TTE guided AV optimization, 9 of 12 patients had elimination of LVOT gradient, and 3 of 12 patients had 82.6 +/- 5.2% reduction in LVOT gradient. Patients undergoing TTE optimization had significant reduction in NYHA heart failure class (1.0 +/- 0 vs. 2.2 +/- 0.7, p=0.004).
Conclusion(s): TTE guided AV optimization shows promise as a means of improving outcomes in patients with incomplete response to medical therapy including disopyramide and AV sequential pacing for reduction of LVOT gradient in HCM.
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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.
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Background: Implantable loop recorder (ILR) based monitoring of patients with LQTS allows enhanced arrhythmia surveillance and can help distinguish life-threatening from benign arrhythmias.
Objective(s): We present a case of a child with LQTS and wide complex tachycardia detected by ILR.
Result(s): An asymptomatic 12 year old with LQT2 syndrome, positive for a G648S hERG mutation, with baseline QTc of 510-550ms despite maximally tolerated Nadolol (Figure 1A) was followed in our inherited arrhythmia center. His affected mother has had multiple syncopal events related to polymorphic ventricular tachycardia (VT) and appropriate ICD shocks. We elected to implant him with ILR to allow longitudinal monitoring and early detection of arrhythmia. He presented 6 months later with 2 alerts for asymptomatic polymorphic, wide complex tachycardia at ~200 bpm during sleeping (Figure 1B). Electrophysiology study (EPS) was performed to determine etiology of the arrhythmia. Dual AV node physiology was present. Sinus tachycardia at 200 bpm with left bundle branch block (LBBB) morphology was induced with Isoproterenol and atrio-fascicular pathway was excluded. Respiratory changes resulted in the tachycardia appearing as polymorphic on the ILR during the EPS.
Conclusion(s): This is the first reported case of sinus tachycardia with LBBB aberrancy in a child with LQTS. Pseudopolymorphic wide complex tachycardia was the result of aberrancy and respiratory artifact. Combined ILR monitoring and EP study provided a correct diagnosis, thus avoiding further interventions. [Figure presented]
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Background: The rapid increase in the number and complexity of electrophysiology (EP) procedures performed annually requires improved strategies to safely enhance post procedural monitoring and early discharge.
Objective(s): To determine if a wearable device that continuously and non-invasively measures vital signs and hemodynamic parameters can predict post-procedure cardiovascular decompensation.
Method(s): Investigator initiated, prospective study of 21 patients receiving either atrial fibrillation ablation (N=16) or device implantation (N=5). Patients were monitored for the post-procedure time periods ranging from 8 to18 hours with two techniques: 1) sporadic measurements with a conventional vital sign monitor; and 2) continuous measurements with toSense's CoVaTM Monitoring System, an FDA-cleared wearable device measuring stroke volume (SV), cardiac output (CO), thoracic fluid index (TFI), heart rate (HR), and respiration rate (RR). CoVaTM-generated data were wirelessly analyzed to established markers of decompensation, defined as decline in systolic blood pressure of >20mmHg over 5 minutes or SpO2 values < 90%. Decompensation index (DI), a normalized index defined as: DI = mean{(norm d[HR]/dt) + (norm d[HRV]/dt) + (norm d[SV]/dt) + (norm d[RR]/dt) + (norm [TI]/dt)} was used to predict decompensation events.
Result(s): Patients continuously monitored for >8 hours with CoVaTM, who were also sporadically measured at least 5 times with the vital sign monitor (N=11) were analyzed. Agreement of the two parameters measured by both devices-HR and RR-was: DELTAHR = 6.5+/-0.3 bpm; DELTARR = 3.8+/-0.8 breaths/min. 55% of patients (N=6) experienced brief decompensation events. The vital sign monitor made sporadic measurements every 95+/-21.3 minutes. Using DI, CoVaTM predicted 78% of the total patient decompensations, with the average prediction being 22+/-23 minutes in advance.
Conclusion(s): Continuous measurements with a wearable device may detect post-procedure decompensation in patients receiving electrophysiology procedures or device implantations with greater accuracy and better temporal resolution as compared to sporadic measurements with conventional vital sign monitors.
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PURPOSE/OBJECTIVE:Elimination of pace-capture along pulmonary vein isolation (PVI) lesion sets reduces atrial fibrillation (AF) recurrence in catheter ablation of paroxysmal AF. Pacing from the RF ablation electrode during RF application is prevented within the CARTO electroanatomic mapping system (Biosense Webster, Inc.) due to theoretical safety considerations. We evaluated a method of pacing the distal ablation electrode during RF application in the CARTO system, thus avoiding repeated activation and inactivation of the pacing channel and facilitating immediate recognition of pace-capture loss. We investigated the safety, feasibility, and utility of simultaneous pace-ablate (SPA) during AF ablation with the CARTO-3 system and a contact-force sensing RF ablation catheter. METHODS:Safety of feasibility of SPA was evaluated in 250 patients undergoing first-time AF ablation. Frequency and regional distribution of pace-capture following PVI was evaluated in a cohort of 50 consecutive patients undergoing catheter ablation of paroxysmal AF. RESULTS:SPA was successfully performed in all 250 patients without adverse event. At least one pace-capture site was noted in 22 of 50 PAF patients (44%), and pace-capture following PVI was most common at anterior and superior left atrial sites. There were 2.0 ± 3.3 RF applications during pacing via the distal ablation electrode per patient, and all lesions sets were successfully rendered unexcitable. CONCLUSIONS:Pace-capture along the completed PVI lesion set remains common despite utilization of contact-force sensing RF ablation catheters and automated lesion annotation. Simultaneous pace-ablate in AF ablation using the CARTO system may be safely used to render atrial lesion sets unexcitable.

Background: Unfavorable outcomes for stepwise linear ablation of non-paroxysmal atrial fbrillation (NPAF) in clinical trials may be attributable to pro-arrhythmic effects of incomplete ablation lines. It is unknown if recurrent arrhythmia following stepwise linear ablation is more likely to be successfully ablated compared to recurrent arrhythmia following a more limited initial procedure The optimal ablation strategy for catheter ablation of NPAF using a contact-force sensing (CFS) radiofrequency ablation (RFA) catheter remains unclear. Objective: To compare 2-procedure outcomes of stepwise linear RFA to left atrial posterior wall isolation in patients undergoing NPAF ablation using a CFS RFA catheter. Methods: We compared clinical outcomes of two cohorts of 100 consecutive NPAF patients undergoing frst-time RFA using a CFS RFA catheter. Group 1: stepwise linear ablation (July 2014-July 2015); Group 2: left atrial posterior wall isolation (October 2015-June 2016). Arrhythmia recurrence was assessed using 2-week event monitors at 3-month intervals following ablation procedures. Results: Baseline characteristics of the two groups were similar. Mean follow-up time was 656 +/- 361 days for Group 1 and 436 +/- 228 days for Group 2. At 24-month follow up, Kaplan-Meier estimated single procedure arrhythmia free survival was signifcantly greater in Group 2 compared to Group 1 (76% vs 59%, respectively; p = 0.01), primarily driven by a higher rate of recurrence of atrial tachycardia (12% vs 35%, respectively; p < 0.001). Among patients with recurrent arrhythmia after a single procedure, Group 2 patients were less likely to require repeat ablation compared to Group 1 (6/24 vs 34/41, respectively; p < 0.001) and less likely to recur after repeat ablation (1/6 vs 13/34, respectively; p = 0.001). Conclusion: Compared to stepwise linear ablation, LA posterior wall isolation for catheter ablation of NPAF resulted in a lower incidence of recurrent arrhythmia at 2 years, a lower likelihood of requiring repeat ablation amongst patients with recurrence, and a lower likelihood of recurrence following a second ablation