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Aims In parallel with increasing implantation rates and patients' longer life expectancy, the need for transvenous lead extraction (TLE) as a specialized procedure has shown a significant growth over years. Herein, we aimed to present our initial experience in TLE by using a novel TightRail™ Rotating Mechanical Dilator Sheath. Methods and results Between October 2014 and March 2015, a total of 42 leads in 23 patients were removed at our tertiary referral centre. All of the extracted leads were >12 months old and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the TightRail™ Mechanical Dilator Sheath (Spectranetics Corporation) with the rotational cutting force only. Indications for lead removal included cardiac device infection in 12 (52.2%) cases, lead malfunction in the 10 (43.5%) cases, and upgrade to cardiac resynchronization therapy-defibrillator (CRT-D) in the remaining 1 case (4.3%). The extracted devices were pacemaker in 10 (43.4%) cases, implantable cardioverter-defibrillator (ICD) in 7 (30.4%) cases, and CRT in the remaining 6 (26.0%) subjects. Among 42 leads, 10 (23.8%) were right ventricular, 14 (33.3%) were atrial, 13 (31.0%) were defibrilator, and 5 (11.9%) were coronary sinus electrodes. The median time from implantation was 72 (18–216) months. Complete procedural success with TightRail™ system alone was achieved in 22 (95.7%) patients (41/42 leads) and overall clinical success was 100%. One right ventricular lead was completely removed with the help of femoral snare. All the patients were discharged uneventfully without any complication. Conclusion Our preliminary data with small sample size show that TightRail™ Mechanical Dilator Sheath is a new useful tool for chronically implanted pacemaker (PM)/ICD leads. Continued investigation including large patient cohort is required to evaluate success and complication rates in comparison to other tools and techniques.

Aims The second-generation cryoballoon (Arctic Front Advance™) (Arc-Adv-CB) has a redesigned injection system which distributes the refrigerant homogenously to the frontal balloon surface. The aim of this study was to compare the efficacy and safety of the Arc-Adv-CB and its predecessor (Arctic Front™) (Arc-CB) in patients who underwent pulmonary vein isolation (PVI) for atrial fibrillation (AF). Methods and results Three hundred and six patients (55.35 ± 10.60 years, 47.05% male) were included in the study. A total of 1205 pulmonary veins were attempted for PVI with either Arc-CB or Arc-Adv-CB. The follow-up durations were 30 (23–38) and 10 (8–13) months in Arc-CB and Arc-Adv-CB groups, respectively ( P < 0.001). When the blanking period was considered, freedom from AF after a single ablation procedure was 68.53 and 90.83% in patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively. The most frequent complication was transient phrenic nerve palsy (PNP) which occurred in five(2.54%) and nine(8.26%) of patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively ( P = 0.040). Left atrial (LA) diameter (hazard ratio, HR: 3.552, 95% CI: 2.034–6.201, P < 0.001), smoking history (HR:1.643, 95% CI: 1.011–2.671, P = 0.045), persistent AF (HR:1.725, 95% CI: 1.021–2.915, P = 0.041), duration of AF (HR:1.039, 95% CI: 1.000–1.080, P = 0.047), and early AF recurrence (HR:2.399, 95% CI: 1.443–3.989, P < 0.001) were associated with increased late AF recurrence. On the other hand, intraprocedural vagal reactions (HR: 0.550, 95% CI: 0.331–0.915, P = 0.021) and Arc-Adv-CB use (HR: 0.441, 95% CI: 0.225–0.866, P = 0.017) were associated with lower late AF recurrence. Left atrial diameter (HR: 3.072, 95% CI: 1.646–5.732, P < 0.001), early AF recurrence (HR: 1.906, 95% CI: 1.103–3.291, P = 0.021), and Arc-Adv-CB use (HR: 0.472, 95% CI: 0.239–0.931, P = 0.030) were independent predictors for late AF recurrence. Conclusion Our study has shown that Arc-Adv-CB use is associated with lower late AF recurrences at the cost of an increased risk for PNP.

Aims Ablation for atrial fibrillation (AF) has been suggested to be associated with ‘reverse left atrial remodelling’. Reduction in left atrial volume index (LAVIR) is regarded as a determinant of reverse remodelling following pulmonary vein isolation (PVI). However, there is paucity on data about the predictors for LAVIR after PVI. In this study, we aimed to investigate predictors of LAVIR at 12 months in AF patients undergoing cryoballoon-based PVI. Methods and results Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s), who were scheduled for cryoballoon-based AF ablation procedure per the recent consensus recommendations, were enrolled and followed-up for 12 months in this prospective observational study. Left atrial volume was derived using the biplane area–length method. A total of 160 patients (54.25 ± 7.66 years, 44.40% female) were involved in the study. Reduction in left atrial volume index occurred in 120 patients. Age [hazard ratio (HR): 0.901, 95% confidence interval (CI): 0.828–0.981, P = 0.017], hypertension (HR: 0.151, 95% CI: 0.048–0.471, P = 0.001), mild mitral regurgitation (MR) (HR: 5.327, 95% CI: 1.489–19.058, P = 0.010), and AF recurrence (HR: 0.017, 95% CI: 0.005–0.065, P < 0.001) were found to be independent predictors for LAVIR. Conclusion To the best of our knowledge, this is the largest study in the literature investigating the predictors of LAVIR following AF ablation. According to this data, younger patients without hypertension or moderate MR are most likely to experience LAVIR following ablation.

Aims Atrial fibrosis has been found to be associated with recurrent atrial fibrillation (AF) following catheter ablation. Autoantibodies against M2-muscarinic receptors (anti-M2-R) may play a role in the development of AF by inducing left atrial (LA) fibrosis. In this study, we aim to compare anti-M2-R levels between paroxysmal lone AF patients and healthy control subjects and to investigate the relationship between pre-ablation anti-M2-R level, LA fibrosis quantified by delayed enhancement magnetic resonance imaging (DE-MRI), and AF recurrence following cryoablation. Methods and results Thirty-one patients with paroxysmal lone AF (53.4 ± 8.0 years, 61% male), who underwent cryoballoon-based ablation, along with 31 healthy control subjects were included. Enzyme-linked immunosorbent assay tests to measure serum anti-M2-R levels were performed in both groups and DE-MRI was done to quantify LA fibrosis prior to the ablation in the patients. Anti-M2-R levels were higher in the study population when compared with control subjects [212.4 (103.2–655.5) vs. 73.0 (39.5–299.1) ng/mL, P < 0.001]. Anti-M2-R level predicted moderate-extensive LA fibrosis independent of other measures [odds ratio: 1.26 (95% confidence interval (CI): 1.04–1.53), P = 0.017]. At a mean follow-up of 35.2 ± 3.5 months, nine patients (29.0%) had AF recurrence. In the Cox regression model including pre-ablation anti-M2-R level, LA diameter, LA volume index, and moderate-extensive LA fibrosis, only moderate-extensive LA fibrosis predicted late AF recurrence independent of other measures [hazard ratio: 29.41 (95% CI: 3.52–250.00), P = 0.002]. Conclusion Serum anti-M2-R levels may be associated with the severity of LA fibrosis and may be implicated in the pathophysiology of AF recurrence following cryoablation. Detection of anti-M2-R levels may help select appropriate patients for the procedure.

Aims The association between premature ovarian failure (POF) and cardiovascular diseases has been investigated in a few studies, but none have looked at ventricular repolarization abnormalities in these patients. In this study, we aimed to evaluate the ventricular repolarization by QT dynamicity in patients with POF. Methods and results We enrolled 26 female patients (mean age 37.5 ± 10.1 years) with primary POF and 31 healthy female subjects (mean age 37.5 ± 9.0 years). The linear regression slopes of the QT interval measured to the apex and to the end of the T-wave plotted against RR intervals (QTapex/RR and QTend/RR slopes, respectively) were calculated from 24 h Holter recordings using a standard algorithm. QTapex/RR and QTend/RR slopes were more steeper in the POF patients in contrary to healthy control subjects (QTapex/RR = 0.184 ± 0.022 vs. 0.131 ± 0.019, P < 0.001; QTend/RR = 0.164 ± 0.021 vs. 0.128 ± 0.018, P < 0.001). Pearson's correlation analyses revealed a stronger negative correlation between oestradiol (E2) and QTapex/RR ( r = –0.715, P < 0.001). There was also a moderate negative correlation between E2 and QTend/RR ( r = –0.537, P < 0.001). Serum follicle-stimulating hormone level was positively correlated with QTapex/RR ( r = 0.681, P < 0.001) and QTend/RR ( r = 0.531, P < 0.001). Conclusions Our study results suggest that QT dynamicity is impaired in patients with POF despite the absence of overt cardiovascular involvement. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired ventricular repolarization in patients with POF.

Aims The growing problem with endocardial lead infections and lead malfunctions has increased the interest in percutaneous lead removal technology. In this report, we present our initial experience in percutaneous lead extraction with a novel hand-powered sheath, the Evolution mechanical dilator sheath. Methods and results During 13 months between June 2009 and July 2010, 41 leads in 23 patients were removed. All of the extracted leads were >12 months old, and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the Evolution mechanical dilator sheath (Cook Medical) with the rotational cutting force only, without laser or radiofrequency energy. Indications for lead removal included cardiac device infection in 7 (30.4%) cases, lead malfunction in the 15 (65.2%) cases, and lead displacement in the remaining 1 case (4.4%). In 14 (60.9%) cases, the extracted device was a pacemaker, and implantable cardioverter defibrillators (ICD) in 9 (39.1%) of them. Among 41 leads, 25 (60.9%) were right ventricular, 14 (34%) were atrial, and 2 (4.8%) were coronary sinus electrode. The median time from the preceding procedure was 74 months (25–180 months). Complete procedural success with Evolution system alone was achieved in 19 (82%) patients (35 leads). Four leads were completely removed with snaring and in two leads, partial success was achieved with a remaining ventricular tip smaller than 1.5 cm. Clinical success was 100%, and all of the patients discharged uneventfully without a major complication. Conclusions Our experience confirms that the mechanical technique with Evolution system is an effective first-line method for chronically implanted pacemaker/ICD leads. Continued investigation is required to evaluate success and complication rates in comparison with other techniques.