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Comparison of Wilson central terminal and IVC indifferent electrode for unipolar mapping of idiopathic outflow tract premature ventricular contractions [Meeting Abstract]

Barbhaiya, C R; Fowler, S; Bernstein, S A; Park, D S; Holmes, D; Aizer, A; Chinitz, L A
Background: Analysis of the local unipolar electrogram aids premature ventricular contraction (PVC) localization in catheter ablation of idiopathic, outflow tract PVCs. A unipolar electrogram QS complex may be seen in the region of PVC origin, but the specificity of this finding is low. The unipolar anodal electrode utilized for PVC mapping is typically Wilson central terminal (WCT) or an indifferent electrode placed within the inferior vena cava (IVC). The optimal unipolar electrode selection for unipolar PVC mapping is unknown. Objective: To compare unipolar mapping of idiopathic outflow tract PVCs using WCT to unipolar mapping using an IVC electrode. Methods: PVC mapping and ablation was performed in 20 consecutive patients presenting for first-time ablation of idiopathic, outflow tract PVCs. The unipolar electrode utilized for initial mapping was randomly assigned and blinded to the operator. Mapping was performed using the CARTO 3 mapping system and SmartTouch RF ablation catheter (Biosense Webster, Inc.). Activation mapping and pace-mapping was performed at the discretion of the operator. Locations with a QS complex were annotated on the electroanatomic map. After a complete map was created blinded mapping was repeated with the alternate unipolar electrode prior to RF application. Results: PVCs were localized to the right ventricular outflow tract in 18 patients (90%) and to the left ventricular outflow tract in 2 patients (10%). Complete unipolar mapping could not be completed in 4 of 20 (20%) of cases due to infrequency of PVCs. In the 16 remaining patients, QS complex surface area was significantly larger with WCT than with the IVC electrode (3.11 +/- 1.8 cm2 vs. 1.3 +/- 0.8 cm2, p < 0.001). The IVC electrode QS area was completely within the WCT QS area in all cases, and the ratio of WCT QS area to IVC electrode QS area was 2.6 +/- 0.8 (range 1.8 to 4.4). The area of RF application at which PVCs were durably suppressed was within the IVC electrode QS area in all patients. Conclusion: Utilization of an indifferent IVC electrode may improve precision and specificity of unipolar mapping in catheter ablation of idiopathic, outflow tract PVCs
EMBASE:617041256
ISSN: 1556-3871
CID: 2620952

Utilization of a radiation safety time out significantly reduces radiation exposure during electrophysiology procedures [Meeting Abstract]

Aizer, A; Cheng, A V; Wu, P; Holmes, D; Fowler, S J; Bernstein, S A; Park, D S; Wagner, S R; Barbhaiya, C R; Chinitz, L A
Background: Pre-procedure time outs are integral to medicine to improve quality and safety. We hypothesized that a radiation safety time out for EP procedures would reduce radiation exposure levels for patients and staff. Objective: To design, implement and assess the effect of a radiation safety time out on radiation exposure in the EP lab. Methods: Baseline data on all adult EP procedures were collected for 6 months prior to implementation of the radiation safety time out. Upon implementation of the time out, data were collected prospectively with analyses to be performed every 3 months for up to 12 months. The primary endpoint was mean dose area product (DAP). Secondary endpoints were reference dose, fluoroscopy time, use of additional shielding, and use of alternative imaging. Results: The study was halted after three months. In total, 592 cases prior to the time out and 448 cases during implementation of the time out were included. Use of the time out resulted in a 22% reduction in the DAP (p = 0.013). The mean reference dose was also reduced by 26%. The use of additional radiation shields and ultrasound imaging for venous access increased significantly during the time out period. These differences remained significant when adjusted for BMI, proceduralist, and procedure type. There was no increase in procedure time or complications with the time out (Table). Conclusion: Implementation of a radiation safety time out significantly reduces radiation exposure during EP procedures. EP laboratories, as well as other areas of medicine that use fluoroscopy, should strongly consider the use of radiation safety time outs to reduce radiation exposures and improve safety. (Table presented)
EMBASE:617042238
ISSN: 1556-3871
CID: 2620902

Cavotricuspid isthmus (CTI) ablation for organization of persistent atrial fibrillation (AF): A randomized controlled trial [Meeting Abstract]

Aizer, A; Wu, P B; Holmes, D; Fowler, S J; Bernstein, S A; Park, D S; Barbhaiya, C R; Chinitz, L A
Introduction: LA ablation for persistent AF that achieves organization to atrial tachycardia (AT) or sinus rhythm (SR) predicts greater long term ablation success. However, extensive LA ablation increases the risks of recurrent AT, adverse atrial remodeling and procedural complications. Preclinical and observational studies suggest that right atrial ablation may reduce AF risk. We hypothesized that CTI ablation may reduce the extent of LA ablation required to achieve organization of persistent AF. Methods: Persistent AF patients (n=107) were randomized to two arms (CTI-first or CTI-last) in a single center, prospective, single blind study. Excluding the CTI ablation, stepwise linear LA ablation was performed in a prespecified order. The primary endpoint was the percentage of patients who organized to AT or SR. The secondary endpoint was number of steps to organization. Results: CTI ablation first versus last during AF ablation did not significantly alter the percentage of patients who organized (Table). Among those who organized, the number of steps to organization did not differ between the two arms. No significant differences were found when patients were stratified by LA size or AF duration. Conclusions: CTI ablation does not alter the extent of LA ablation needed to achieve organization of AF. The utility of right atrial ablation for persistent AF ablation remains unclear. (Table presented)
EMBASE:72283298
ISSN: 1556-3871
CID: 2150982

Resumption of AVN conduction in post-TAVR patients who receive PPM [Meeting Abstract]

Subnani, K; Love, C J; Holmes, D; Aizer, A; Fowler, S J; Bernstein, S A; Park, D S; Barbhaiya, C R; Chinitz, L A
Introduction: Transcatheter aortic valve replacement (TAVR) is becoming a widely accepted alternative treatment for patients with symptomatic aortic stenosis who are at high risk for surgical aortic valve replacement. A common complication of the procedure is the development of conduction defects requiring permanent pacemaker (PPM) implantation. It has been noted that in some patients, the conduction block is not permanent. Determine the incidence and predictors of resuming intrinsic conduction in patients that receive PPM implantation after TAVR. Methods: A retrospective chart review of patients undergoing TAVR at New York University Langone Medical Center was undertaken. Extracted data included patient demographics, pre-TAVR electrocardiogram, procedural, echocardiographic, catheterization, and device interrogation data. Evaluation of device interrogations done at one month follow-up or earlier to look for resumption of intrinsic conduction. Results: There were a total number of 451 patients who were status-post TAVR in our registry at NYU. Of the 451, 45 patients received a permanent pacemaker placement for complete heart block; 9.9% 45/451. The majority of patients were implanted within 48hrs post TAVR. Device follow-up information at 1 month or earlier was available for 33 of the 45 patients who received PPM. 5 patients who were recently implanted are still pending follow-up. 3 patients expired after implantation and 4 were lost to follow-up. Of the 33 patients, 14 (42%) patients had resumption of AV nodal conduction at 1 month follow-up. 19 patients (57%) remained dependent. Conclusions: 42% of patients who received a permanent pacemaker for complete heart block after TAVR had resumption of conduction. This suggests that many patients may not require long term PPM post TAVR. Patients that remained dependent had a higher incidence of preexisting RBBB and LAFB, however a lack thereof does not preclude an increased risk. These data suggest that waiting longer than 48 hours for resumption of AV nodal conduction would avoid unnecessary implantation in patients who develop complete heart block post TAVR
EMBASE:72283155
ISSN: 1556-3871
CID: 2150992

Use of contact-force sensing radiofrequency ablation catheters for stepwise linear ablation of non-paroxysmal atrial fibrillation ablation does not improve outcomes [Meeting Abstract]

Knotts, R J; Bookstall, K E; Torbey, E; Bernstein, S A; Park, D S; Fowler, S J; Holmes, D; Aizer, A; Barbhaiya, C R; Chinitz, L A
Introduction: Large clinical trials have recently demonstrated stepwise linear ablation for non-paroxysmal atrial fibrillation (NPAF) to be inferior to pulmonary vein isolation alone. It is unknown whether the unfavorable outcomes observed in these trials can be attributed to the pro-arrhythmic effects of incomplete ablation lines. We hypothesized that improved lesion quality related to use of contact-force sensing (CFS) ablation catheters would improve procedural outcomes. Methods: We prospectively analyzed procedural outcomes of 74 consecutive patients with NPAF undergoing first-time radiofrequency catheter ablation with a CFS catheter (Smart Touch, Biosense Webster) using a step-wise approach (Group 1). The clinical outcomes of these patients were compared with 74 consecutive patients with NPAF who underwent catheter ablation between September 2013 and June 2014 with a non-contact force sense radiofrequency ablation catheter (Group 2) at a single tertiary care medical center. Arrhythmia recurrence was assessed using 2-week event monitors at 3-month intervals following index ablation. Results: Baseline characteristics of Group 1 and Group 2 were similar, although in Group 1 there was a greater prevalence of patients with persistent NPAF lasting for 6-months or longer prior to initial ablation (43% vs 21%, p=0.071). The recurrence rate at 1 year as estimated by the Kaplan-Meier method was not significantly different between Group 1 and Group 2 (25.7% vs 29.7%, p=0.582). The presenting recurrent arrhythmia was most frequently atrial tachycardia (AT) in both groups (Group 1: n=19, AT 68.4% and AF 31.6% vs Group 2: n=22, AT 59.1% and AF 40.9%). A similar proportion of patients in both groups underwent repeat ablation (Group 1: 17.6% vs Group 2: 13.5%, p=0.496). Conclusions: Utilization of a CFS ablation catheter was not associated with improved clinical outcomes for stepwise catheter ablation for NPAF. The optimal strategy for NPAF ablation using a contact-force sensing catheter remains undefined
EMBASE:72283716
ISSN: 1556-3871
CID: 2150972

Three-Dimensional Transesophageal Echocardiography to Facilitate Transseptal Puncture and Left Atrial Appendage Occlusion via Upper Extremity Venous Access

Aizer, Anthony; Young, Wilson; Saric, Muhamed; Holmes, Douglas; Fowler, Steven; Chinitz, Larry
PMID: 26286309
ISSN: 1941-3084
CID: 1732232

Effect of Obstructive Sleep Apnea Treatment on Atrial Fibrillation Recurrence: A Meta-Analysis

Shukla, Ashish; Aizer, Anthony; Holmes, Douglas; Fowler, Steven; Park, David S; Bernstein, Scott; Bernstein, Neil; Chinitz, Larry
OBJECTIVES/OBJECTIVE:This study aimed to evaluate the cumulative effect of treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) on atrial fibrillation (AF) recurrence. BACKGROUND:OSA is a known predictor for onset and recurrence of AF. The effect of treatment with CPAP on AF recurrence has been evaluated in small studies with varied outcomes. METHODS:We searched MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Trials Register for relevant studies. Evaluation of AF recurrence in CPAP users and nonusers in patients with OSA was the primary outcome evaluated in this study. The secondary outcome was evaluation of AF recurrence in CPAP users and nonusers after pulmonary vein isolation (PVI). RESULTS: = 0%). The beneficial effect of CPAP use was statistically significant in both groups of patients: those who underwent catheter ablation with PVI and those who did not undergo ablation and were managed medically. No other study covariates had any significant association with these outcomes of AF reduction. CONCLUSIONS:The use of CPAP is associated with significant reduction in recurrence of AF in patients with OSA. This effect remains consistent and similar across patient populations irrespective of whether they undergo PVI.
PMID: 29759338
ISSN: 2405-5018
CID: 3114672

Hemostasis of Left Atrial Appendage Bleed With Lariat Device

Hussain, Amena; Saric, Muhamed; Bernstein, Scott; Holmes, Douglas; Chinitz, Larry
New devices designed for minimally invasive closure of the left atrial appendage (LAA) may be a viable alternative for patients in whom anticoagulation is considered high risk. The Lariat (Sentreheart, Redwood City, CA), which is currently FDA-approved for percutaneous closure of tissue, requires both trans-septal puncture and epicardial access. However it requires no anticoagulation after the procedure. Here we describe a case of effusion and tamponade during a Lariat procedure with successful completion of the case and resolution of the effusion.
PMCID:4217304
PMID: 25408569
ISSN: 0972-6292
CID: 1355892

Atrial fibrillation ablation in patients with known sludge in the left atrial appendage

Hajjiri, Mohammed; Bernstein, Scott; Saric, Muhamed; Benenstein, Ricardo; Aizer, Anthony; Dym, Glenn; Fowler, Steven; Holmes, Douglas; Bernstein, Neil; Mascarenhas, Mark; Park, David; Chinitz, Larry
PURPOSE: Transesophageal echocardiography (TEE) is routinely used to assess for thrombus in the left atrium (LA) and left atrial appendage (LAA) in patients undergoing atrial fibrillation (AF) ablation. However, little is known about the outcome of AF ablation in patients with documented LAA sludge. We hypothesize that AF ablation can be performed safely in a proportion of patients with sludge in the LAA and may have a significant benefit for these patients. METHODS: We performed a retrospective analysis of all patients undergoing AF ablation at New York University Langone Medical Center (NYULMC) from January 1st 2011 to June 30, 2013. Patients with sludge found on their TEE immediately prior to AF ablation were identified and followed for stroke, AF recurrence, procedural complications, major bleeding, or death. RESULTS: Among 1,076 patients who underwent AF ablation, 8 patients (mean age 69 +/- 13 years; 75 % men) with sludge were identified. Patients with sludge in their LAA had no incidence of early or late occurrence of stroke during mean follow-up of 10 months. One patient had a left groin hematoma, and two patients had atrial tachycardias that needed a repeat ablation. TEE at the time of repeat ablation demonstrated the presence of spontaneous echo contrast (smoke) and resolution of sludge. There were no deaths. CONCLUSION: In a cohort of eight patients with LAA sludge who underwent AF ablation, no significant thromboembolic events occurred during or after the procedure. AF ablation can be performed safely and may be beneficial in these patients. Larger studies are warranted to better determine the most appropriate management route.
PMID: 24752792
ISSN: 1383-875x
CID: 909162

The Role of Multimodality Imaging in Percutaneous Left Atrial Appendage Suture Ligation with the LARIAT Device

Laura, Diana M; Chinitz, Larry A; Aizer, Anthony; Holmes, Douglas S; Benenstein, Ricardo; Freedberg, Robin S; Kim, Eugene E; Saric, Muhamed
Atrial fibrillation (AF), the most common cardiac arrhythmia, is a significant cause of embolic stroke. Although systemic anticoagulation is the primary strategy for preventing the thromboembolic complications of AF, anticoagulants carry major bleeding risks, and many patients have contraindications to their use. Because thromboembolism typically arises from a clot in the left atrial appendage (LAA), local therapeutic alternatives to systemic anticoagulation involving surgical or percutaneous exclusion of the LAA have been developed. Surgical exclusion of the LAA is typically performed only as an adjunct to other cardiac surgeries, thus limiting the number of eligible patients. Furthermore, surgical exclusion of the LAA is frequently incomplete, and thromboembolism may still occur. Percutaneous LAA exclusion includes two approaches: transseptal delivery of an occlusion device to the LAA and epicardial suture ligation of the LAA, the LARIAT procedure. In the LARIAT procedure, a pretied snare is placed around the epicardial surface of the LAA orifice via pericardial access. Proper snare placement is achieved with epicardial and endocardial magnet-tipped guidewires. The endocardial wire is advanced transvenously to the LAA apex after transseptal puncture. The epicardial wire, introduced into the pericardial space, achieves end-to-end union with the endocardial wire at the LAA apex. The snare is then placed over the LAA, tightened, and sutured. On the basis of early clinical experience, the LARIAT procedure has a high success rate of LAA exclusion with low risk for complications. The authors describe the indispensable role of real-time transesophageal echocardiography in the guidance of LAA epicardial suture ligation with the LARIAT device.
PMID: 24874974
ISSN: 0894-7317
CID: 1018862