Faculty Bibliography

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

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)

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

OBJECTIVES/OBJECTIVE:This study sought to assess the incidence, operator demographics, clinical characteristics, procedural factors, and prognosis of esophageal perforation and fistula after atrial fibrillation ablation. BACKGROUND:Esophageal injury is a feared complication of atrial fibrillation ablation. METHODS:An Internet-based global survey soliciting anonymous information regarding esophageal perforation and fistula was emailed to 3,080 physicians. Detailed information regarding physician, patient, and procedural characteristics related to esophageal perforation with or without fistula was collected. RESULTS:; p = 0.03), and lower left ventricular ejection fraction (55.1 ± 9.1% vs. 61.7 ± 5.4%; p = 0.04). Among analyzed patients, atrial-esophageal fistula was seen in 72%, pericardial-esophageal fistula in 14%, and esophageal perforation without fistula in 14%. Mortality was 79% with atrial-esophageal fistula and 13% in esophageal perforation without atrial-esophageal fistula. CONCLUSIONS:Esophageal perforation is rare but continues to occur with multiple catheter types despite esophageal monitoring during ablation. The prognosis of esophageal perforation is substantially improved if diagnosed and treated before development of atrial-esophageal fistula. An early surgical approach to esophageal perforation should be strongly considered regardless of evidence of fistula.

BACKGROUND: Arrhythmias in cardiac amyloidosis (CA) result in significant comorbidity and mortality but have not been well characterized. OBJECTIVE: The purpose of this study was to define intracardiac conduction, atrial arrhythmia substrate, and ablation outcomes in a group of advanced CA patients referred for electrophysiologic study. METHODS: Electrophysiologic study with or without catheter ablation was performed in 18 CA patients. Findings and catheter ablation outcomes were compared to age- and gender-matched non-CA patients undergoing catheter ablation of persistent atrial fibrillation (AF). RESULTS: Supraventricular tachycardias were seen in all 18 CA patients (1 AV nodal reentrant tachycardia, 17 persistent atrial tachycardia [AT]/AF). The HV interval was prolonged (>55 ms) in all CA patients, including 6 with normal QRS duration (