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ICD shocks and complications in patients with inherited arrhythmia syndromes

Siskin, Matthew; Cerrone, Marina; Shokr, Mohamed; Aizer, Anthony; Barbhaiya, Chirag; Dai, Matthew; Bernstein, Scott; Holmes, Douglas; Knotts, Robert; Park, David S; Spinelli, Michael; Chinitz, Larry A; Jankelson, Lior
Background/UNASSIGNED:There is limited information on the long-term outcomes of ICDs in patients with inherited arrhythmia syndromes. Methods/UNASSIGNED:Prospective registry study of inherited arrhythmia patients with an ICD. Incidence of therapies and complications were measured as 5-year cumulative incidence proportions and analyzed with the Kaplan-Meier method. Incidence was compared by device indication, diagnosis type and device type. Cox-regression analysis was used to identify predictors of appropriate shock and device complication. Results/UNASSIGNED:123 patients with a mean follow up of 6.4 ± 4.8 years were included. The incidence of first appropriate shock was 56.52% vs 24.44%, p < 0.05 for cardiomyopathy and channelopathy patients, despite similar ejection fraction (61% vs 60%, p = 0.6). The incidence of first inappropriate shock was 13.46% vs 56.25%, p < 0.01 for single vs. multi-lead devices. The incidence of first lead complication was higher for multi-lead vs. single lead devices, 43.75% vs. 17.31%, p = 0.04. Patients with an ICD for secondary prevention were more likely to receive an appropriate shock than those with primary prevention indication (HR 2.21, CI 1.07-4.56, p = 0.03). Multi-lead devices were associated with higher risk of inappropriate shock (HR 3.99, CI 1.27-12.52, p = 0.02), with similar appropriate shock risk compared to single lead devices. In 26.5% of patients with dual chamber devices, atrial sensing or pacing was not utilized. Conclusion/UNASSIGNED:The rate of appropriate therapies and ICD complications in patients with inherited arrhythmia is high, particularly in cardiomyopathies with multi-lead devices. Risk-benefit ratio should be carefully considered when assessing the indication and type of device in this population.
PMCID:8569698
PMID: 34765721
ISSN: 2352-9067
CID: 5050742

High-power, short-duration ablation for atrial fibrillation: Pros and cons

Knotts, Robert J; Barbhaiya, Chirag R
This article reviews and compares the rationale and evidence supporting high-power, short-duration radiofrequency (RF) ablation with those of conventional-power, conventional-duration RF ablation for atrial fibrillation (AF). The pros and cons of each approach, biophysics of ablation, pre-clinical studies informing clinical utilization, and the accumulated clinical evidence are presented. Both conventional-power, conventional-duration RF ablation and high-power, short-duration ablation are similarly safe, and effective approaches for AF ablation. Theoretical advantages of high-power, short-duration ablation, including greater procedure efficiency and limited conductive heating of collateral structures, must be weighed against the narrower safety margin related to rapid energy delivery during high power ablation.
PMID: 34332664
ISSN: 1873-1740
CID: 4988452

Electrocardiographic Risk Stratification in COVID-19 Patients

Chorin, Ehud; Dai, Matthew; Kogan, Edward; Wadhwani, Lalit; Shulman, Eric; Nadeau-Routhier, Charles; Knotts, Robert; Bar-Cohen, Roi; Barbhaiya, Chirag; Aizer, Anthony; Holmes, Douglas; Bernstein, Scott; Spinelli, Michael; Park, David; Chinitz, Larry; Jankelson, Lior
Background: The COVID-19 pandemic has resulted in worldwide morbidity at unprecedented scale. Troponin elevation is a frequent laboratory finding in hospitalized patients with the disease, and may reflect direct vascular injury or non-specific supply-demand imbalance. In this work, we assessed the correlation between different ranges of Troponin elevation, Electrocardiographic (ECG) abnormalities, and mortality. Methods: We retrospectively studied 204 consecutive patients hospitalized at NYU Langone Health with COVID-19. Serial ECG tracings were evaluated in conjunction with laboratory data including Troponin. Mortality was analyzed in respect to the degree of Troponin elevation and the presence of ECG changes including ST elevation, ST depression or T wave inversion. Results: Mortality increased in parallel with increase in Troponin elevation groups and reached 60% when Troponin was >1 ng/ml. In patients with mild Troponin rise (0.05-1.00 ng/ml) the presence of ECG abnormality and particularly T wave inversions resulted in significantly greater mortality. Conclusion: ECG repolarization abnormalities may represent a marker of clinical severity in patients with mild elevation in Troponin values. This finding can be used to enhance risk stratification in patients hospitalized with COVID-19.
PMCID:7884321
PMID: 33604358
ISSN: 2297-055x
CID: 4787212

Multiple Procedure Outcomes for Non-Paroxysmal Atrial Fibrillation: Left Atrial Posterior Wall Isolation versus Stepwise Ablation

Barbhaiya, Chirag R; Knotts, Robert J; Beccarino, Nicholas; Vargas-Pelaez, Alvaro F; Jankelson, Lior; Bernstein, Scott; Park, David; Holmes, Douglas; Aizer, Anthony; Chinitz, Larry A
OBJECTIVE:To compare multiple-procedure catheter ablation outcomes of a stepwise approach versus left atrial posterior wall isolation (LA PWI) in patients undergoing non-paroxysmal atrial fibrillation (NPAF) ablation. BACKGROUND:Unfavorable outcomes for stepwise ablation of NPAF in large clinical trials may be attributable to pro-arrhythmic effects of incomplete ablation lines. It is unknown if a more extensive initial ablation strategy results in improved outcomes following multiple ablation procedures. METHODS:222 consecutive patients with NPAF underwent first-time ablation using a contact-force sensing ablation catheter utilizing either a stepwise (Group 1, n=111) or LA PWI (Group 2, n=111) approach. The duration of follow-up was 36 months. The primary endpoint was freedom from atrial arrhythmia >30s. Secondary endpoints were freedom from persistent arrhythmia, repeat ablation, and recurrent arrhythmia after repeat ablation. RESULTS:There was similar freedom from atrial arrhythmias after index ablation for both stepwise and LA PWI groups at 36 months (60% vs. 69%, p=0.1). The stepwise group was more likely to present with persistent recurrent arrhythmia (29% vs 14%, p=0.005) and more likely to undergo second catheter ablation (32% vs. 12%, p<0.001) compared to LA PWI patients. Recurrent arrhythmia after repeat ablation was more likely in the stepwise group compared to the LA PWI group (15% vs 4%, p=0.003). CONCLUSIONS:Compared to a stepwise approach, LA PWI for patients with NPAF resulted in a similar incidence of any atrial arrhythmia, lower incidence of persistent arrhythmia, and fewer repeat ablations. Results for repeat ablation were not improved with a more extensive initial approach. This article is protected by copyright. All rights reserved.
PMID: 33022816
ISSN: 1540-8167
CID: 4626822

Reply: Electrical Weapons and Electrophysiology

Barbhaiya, Chirag R; Moskowitz, Craig; Duraiswami, Harish; Jankelson, Lior; Knotts, Robert J; Bernstein, Scott; Park, David; Holmes, Douglas; Aizer, Anthony; Chinitz, Larry A
PMCID:8299239
PMID: 34317106
ISSN: 2666-0849
CID: 4949432

QT Interval Prolongation and Torsade De Pointes in Patients with COVID-19 treated with Hydroxychloroquine/Azithromycin

Chorin, Ehud; Wadhwani, Lalit; Magnani, Silvia; Dai, Matthew; Shulman, Eric; Nadeau-Routhier, Charles; Knotts, Robert; Bar-Cohen, Roi; Kogan, Edward; Barbhaiya, Chirag; Aizer, Anthony; Holmes, Douglas; Bernstein, Scott; Spinelli, Michael; Park, David S; Stefano, Carugo; Chinitz, Larry A; Jankelson, Lior
BACKGROUND:There is no known effective therapy for patients with COVID-19. Initial reports suggesting the potential benefit of Hydroxychloroquine/Azithromycin (HY/AZ) have resulted in massive adoption of this combination worldwide. However, while the true efficacy of this regimen is unknown, initial reports have raised concerns regarding the potential risk of QT prolongation and induction of torsade de pointes (TdP). OBJECTIVE:to assess the change in QTc interval and arrhythmic events in patients with COVID-19 treated with HY/AZ METHODS: This is a retrospective study of 251 patients from two centers, diagnosed with COVID-19 and treated with HY/AZ. We reviewed ECG tracings from baseline and until 3 days after completion of therapy to determine the progression of QTc and incidence of arrhythmia and mortality. RESULTS:QTc prolonged in parallel with increasing drug exposure and incompletely shortened after its completion. Extreme new QTc prolongation to > 500 ms, a known marker of high risk for TdP had developed in 23% of patients. One patient developed polymorphic ventricular tachycardia (VT) suspected as TdP, requiring emergent cardioversion. Seven patients required premature termination of therapy. The baseline QTc of patients exhibiting extreme QTc prolongation was normal. CONCLUSION/CONCLUSIONS:The combination of HY/AZ significantly prolongs the QTc in patients with COVID-19. This prolongation may be responsible for life threating arrhythmia in the form of TdP. This risk mandates careful consideration of HY/AZ therapy in lights of its unproven efficacy. Strict QTc monitoring should be performed if the regimen is given.
PMCID:7214283
PMID: 32407884
ISSN: 1556-3871
CID: 4431542

Inappropriate ICD Shock as a Result of TASER Discharge [Case Report]

Barbhaiya, Chirag R; Moskowitz, Craig; Duraiswami, Harish; Jankelson, Lior; Knotts, Robert J; Bernstein, Scott; Park, David; Holmes, Douglas; Aizer, Anthony; Chinitz, Larry A
Conducted energy weapon (commonly known as TASER) discharge in patients with implantable cardioverter-defibrillators is known to cause electromagnetic interference and inappropriate ventricular fibrillation sensing without delivery of implantable cardioverter-defibrillators therapy during conducted energy weapon application. We report the first known case of conducted energy weapon discharge resulting in inappropriate implantable cardioverter-defibrillators therapy. (Level of Difficulty: Beginner.).
PMCID:8311712
PMID: 34317440
ISSN: 2666-0849
CID: 4949472

Contact-force radiofrequency ablation of non-paroxysmal atrial fibrillation: improved outcomes with increased experience

Barbhaiya, Chirag R; Knotts, Robert J; Bockstall, Katy; Bernstein, Scott; Park, David; Holmes, Douglas; Aizer, Anthony; Chinitz, Larry A
INTRODUCTION/BACKGROUND:Clinical trials have failed to reliably show improved outcomes with utilization of contact-force sensing (CFS) radiofrequency (RF) ablation catheters. It is unknown whether the unfavorable outcomes observed in these trials are attributable to inexperience with CFS technology. OBJECTIVES/OBJECTIVE:To compare catheter ablation outcomes of stepwise linear ablation with versus without CFS technology and to assess the impact of operator experience with CFS technology on procedural outcomes. METHODS:Clinical outcomes were evaluated in 228 consecutive NPAF patients undergoing first-time left atrial ablation using a stepwise linear approach. Arrhythmia recurrence was assessed using 2-week event monitors at 3-month intervals following index ablation. RESULTS:A total of 228 patients were included in our study. There was no statistically significant difference in risk of recurrent atrial arrhythmias at 12 and 24 months between CFS and non-CFS patients (p = 0.5 and p = 0.169). The time to recurrence of atrial arrhythmias at 24 months in the second half of CFS patients was significantly lower when compared to both the first half of CFS patients (p = 0.002) and non-CFS patients (p = 0.005). CONCLUSION/CONCLUSIONS:While there was no difference in overall outcomes between CFS and non-CFS ablation using a stepwise linear approach in patients with NPAF, procedural efficacy of the second half of CFS patients was significantly improved compared to both the first half of CFS patients and all non-CFS patients. Lack of benefit seen in clinical trials using CFS technology may be related to operator inexperience with CFS ablation catheters at the time of the trials.
PMID: 31707533
ISSN: 1572-8595
CID: 4184742

Esophageal Temperature Dynamics During High Power Short Duration Posterior Wall Ablation

Barbhaiya, Chirag R; Kogan, Edward V; Jankelson, Lior; Knotts, Robert J; Spinelli, Michael; Bernstein, Scott; Park, David; Aizer, Anthony; Chinitz, Larry A; Holmes, Douglas
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.
PMID: 31978595
ISSN: 1556-3871
CID: 4273622

Simultaneous pace-ablate during CARTO-guided pulmonary vein isolation with a contact-force sensing radiofrequency ablation catheter

Barbhaiya, Chirag R; Aizer, Anthony; Knotts, Robert; Bernstein, Scott; Park, David; Holmes, Douglas; Chinitz, Larry A
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.
PMID: 30264289
ISSN: 1572-8595
CID: 3314572