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BACKGROUND: Compared with medical therapy, catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) improves cardiovascular outcomes. Risk scores (CAAP-AF and APPLE) have been developed to predict the likelihood of AF recurrence after ablation, have not been validated specifically in patients with AF and HF. METHODS: We analyzed baseline characteristics, risk scores, and rates of AF recurrence 12 months post-ablation in a cohort of 230 consecutive patients with AF and HF undergoing PVI in the Duke Center for Atrial Fibrillation registry from 2009–2013. RESULTS: During a follow-up period of 12 months, 76 of 230 (33%) patients with HF experienced recurrent AF after ablation. The median APPLE and CAAP-AF scores were 1.5 [(Q1, Q3): (1.0, 2.0)] and 4.0 [(Q1, Q3): (3.0, 5.0)], respectively and were not different from those patients with and without recurrent AF. Freedom from AF was not different according to APPLE and CAAP-AF scores. Discrimination for recurrent AF with the CAAP-AF score was modest with a C-statistic of 0.60 (95% CI 0.52 – 0.67). Discrimination with the APPLE score was similarly modest, with a c-statistic of 0.54 (95% CI: 0.47 – 0.62). CONCLUSIONS: Validated predictive risk scores for recurrent AF after catheter ablation exhibit limited predictive ability in cohorts of AF and HF. Additional tools are needed to facilitate risk stratification and patient selection for AF ablation in patients with concomitant HF.

Background Preprocedural multidetector computed tomography (MDCT) may identify patients at risk for mechanical complications during lead extraction. Methods To describe the use and feasibility of computed tomography scanning for preprocedural planning of lead extraction, we conducted a retrospective study of high-risk patients, who underwent electrocardiogram (ECG)-gated MDCT before planned lead extraction between January 1, 2012, and March 30, 2013. Results Among 30 patients the mean age was 63 ± 15 years, 60% were male, and 20% had prior sternotomy. Most devices were left sided (93%) and 24 had implantable defibrillators (80%). Indications for extraction included lead malfunction (n = 15; 50%), class I lead advisories (n = 11; 37%), and infection (n = 10; 33%). Overall, there were 65 leads extracted (mean 2.1 leads per patient). One extraction procedure was deferred due to MDCT evidence of significant myocardial perforation with the lead tip > 1 cm beyond the epicardium (n = 1, 3%). MDCT suggestion of lead adherence to central venous structures (n = 13, 43%) was associated with significantly longer laser times (88 ± 71 seconds vs 30 ± 37 seconds, P = 0.02) and larger sheath size (14.9 ± 1.3 vs 13.5 ± 1.2 French, P = 0.02). MDCT evidence of central venous occlusion or stenosis was not associated with increased laser times. Excluding the patient with MDCT evidence of significant perforation, clinical success was achieved in all patients (n = 29/29). Conclusions ECG-gated MDCT scanning before lead extraction may facilitate the identification of significant perforation and patients at high risk for mechanical complication.

Background Proper positioning of the left ventricular (LV) lead improves clinical outcomes and survival in patients receiving cardiac resynchronization therapy (CRT). Techniques of LV lead insertion using contrast injection and a telescoping system of delivery catheters to support advancement of the lead into the target branch may allow more efficient, targeted lead placement. We sought to evaluate the impact of an LV lead implant approach using telescoping-support catheters (group TS) on success rate, lead location, and procedural time compared to standard over-the-wire implant techniques (group OTW). Methods Four hundred thirty-seven consecutive patients undergoing CRT implantation were divided into group TS (n = 105) or group OTW (n = 332) based upon a review of the operative technique used for LV lead implantation. The primary outcome was success of LV lead implantation at the index procedure. Secondary endpoints included optimal positioning of the LV lead and reduction in procedural fluoroscopy time. Results Failed LV lead placement was lower (1.9% vs 8.1%, P = 0.02) and optimal lead positioning was achieved more often for group TS than group OTW (87% vs 75%, P = 0.01). In addition, there were significantly shorter fluoroscopy times for group TS versus group OTW (29.6 minutes vs 41.9 minutes, P < 0.01). Conclusion A CRT-implant approach using contrast injection and a telescoping-support catheter system results in fewer failed LV lead implants, improved LV lead location, and shorter procedure times.