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Introduction: Little is known about very early atrial fibrillation (AF) ablation after first AF detection. Methods: We evaluated patients with AF ablation <4 months from newly diagnosed paroxysmal AF (NEWPaAF) and newly diagnosed persistent AF (NEWPeAF). We compared the two patient populations and compared ablation outcomes to those undergoing later ablation. Results: Ablation was done <4 months from AF diagnosis in 353 patients (135 = paroxysmal, 218 = persistent). Early ablation outcome was best for NEWPaAF versus NEWPeAF for initial (p = 0.030) but not final (p = 0.102) ablation. Despite recent AF diagnosis in both groups, they were clinically quite different. NEWPaAF patients were younger (64.3 ± 13.0 vs. 67.3 ± 10.9, p = 0.0020), failed fewer drugs (0.39 vs. 0.60, p = 0.007), had smaller LA size (4.12 ± 0.58 vs. 4.48 ± 0.59 cm, p < 0.0001), lower BMI (28.8 ± 5.0 vs. 30.3 ± 6.0, p = 0.016), and less CAD (3.7% vs. 11.5%, p = 0.007), cardiomyopathies (2.2% vs. 22.9%, p = 0.0001), hypertension (46.7% vs. 67.4%, p < 0.0001), diabetes (8.1% vs. 17.4%, p = 0.011) and sleep apnea (20.0% vs. 30.3%, p = 0.031). For NEWPaAF, early ablation AF‐free outcome was no better than later ablation (p = 0.314). For NEWPeAF, AF‐free outcomes were better for early ablation than later ablation (p < 0.0001). Delaying ablation allowed more strokes/TIAs in both AF types (paroxysmal p = 0.014, persistent p < 0.0001). Conclusions: Patients presenting for early ablation after newly diagnosed persistent AF have more pre‐existing comorbidities and worse initial ablation outcomes than patients with NEWPaAF. For NEWPaAF, there was no advantage to early ablation, as long as the AF remained paroxysmal. For NEWPeAF, early ablation gave better outcomes than later ablation and they should undergo early ablation. For both AF types, waiting was associated with more neurologic events, suggesting all patients should consider earlier ablation. [ABSTRACT FROM AUTHOR]

Introduction: Vascular access is required for most cardiac electrophysiology procedures. Over the past 2 decades, ultrasound guidance has increased in utilization as the primary method for assisting operators in gaining access to cardiac implantable electronic device (CIED) implantation. Methods: Ultrasound guidance using a technique that includes both short‐axis and long‐axis views combined with a twisting needle motion after maximal tenting provides an extremely safe and reproducible technique for vascular access for all CIED procedures. Results and Conclusions: In this manuscript and accompanying videos, a step‐by‐step guide is explained for optimal ultrasound‐guided visualization and needle maneuver technique to maximize safety and efficiency for vascular access in all CIED procedures. [ABSTRACT FROM AUTHOR]

Introduction: Single‐center observational studies have shown promising results with fragmented electrogram (FE)‐guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE‐guided GP ablation in patients with VMB performed by first‐time operators and those of a single high‐volume operator. Methods and Results: This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high‐volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty‐seven consecutive patients with VMB who underwent FE‐guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p =.022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p <.001). Over a mean follow‐up duration of 8.0 ± 3 months (range 2–24 months), none of the patients suffered from syncope. Conclusion: This multi‐center pilot study shows for the first time the feasibility of FE‐guided GP ablation across a large group of procedure‐naïve operators. [ABSTRACT FROM AUTHOR]

Background: Standard treatment for locally advanced esophageal cancer usually includes a combination of chemotherapy, radiation, and surgery. In squamous cell carcinoma (SCC), recent studies have indicated that esophagectomy after chemoradiation does not significantly improve survival but may reduce recurrence at the cost of treatment‐related mortality. This study aims to evaluate the cost‐effectiveness of chemoradiation with and without esophagectomy. Methods: We developed a decision tree and Markov model to compare chemoradiation therapy alone (CRT) versus chemoradiation plus surgery (CRT+S) in a cohort of 57‐year‐old male patients with esophageal SCC, over 25 years. We used information on survival, cancer recurrence, and side effects from a Cochrane meta‐analysis of two randomized trials. Societal utility values and costs of cancer care (2017, USD) were from medical literature. To test robustness, we conducted deterministic (DSA) and probabilistic sensitivity analyses (PSA). Results: In our base scenario, CRT resulted in less cost for more quality‐adjusted life years (QALYs) compared to CRT+S ($154 082 for 1.32 QALYs/patient versus $165 035 for 1.30 QALYs/patient, respectively). In DSA, changes resulted in scenarios where CRT+S is cost‐effective at thresholds between $100 000‐$150 000/QALY. In PSA, CRT+S was dominant 17.9% and cost‐effective at willingness‐to‐pay of $150 000/QALY 38.9% of the time, and CRT was dominant 30.6% and cost‐effective 61.1% of the time. This indicates that while CRT would be preferred most of the time, variation in parameters may change cost‐effectiveness outcomes. Conclusions: Our results suggest that more data is needed regarding the clinical benefits of CRT+S for treatment of localized esophageal SCC, although CRT should be cautiously preferred. [ABSTRACT FROM AUTHOR]

Background Radiofrequency (RF) technology has improved detection of retained surgical sponges with a reported 100% sensitivity and specificity. However, the potential for interactions of the RF signals emitted by the detection system with cardiac implantable electronic devices (CIEDs) or temporary pacemakers may limit its use in those patients with these devices. This study investigated whether RF detection technology causes interference or clinically significant changes in the programmed settings of implanted pacemakers and defibrillators or temporary epicardial pacemakers. Methods Fifty patients who were scheduled either for CIED removal or placement of a temporary epicardial pacemaker (at the time of open heart surgery) were recruited for this study. Device settings and measurements from separate interrogations before and after scanning with the RF detection system were compared. For the temporary pacemakers, we observed for any changes in hemodynamics or signs of pacing interference. Results Twenty (40%) pacemakers, 20 (40%) implantable cardioverter defibrillators, and 10 (20%) temporary pacemakers were analyzed in this study. During scanning, no signal interference was detected in any permanent device, and there were no significant changes in programmed settings after scanning with the RF detection system. However, pacing inhibition was detected with temporary pacing systems when programmed to a synchronous mode (DDD). Conclusions RF detection technology can be safely used to scan for retained surgical sponges in patients with permanent CIEDs and temporary pacemakers set to asynchronous mode. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to compare a unique zip-type adjustable coaptive tape-based skin closure device to traditional subcuticular sutures in three domains: time, cosmesis, and wound closure-related outcomes in cardiac implantable electronic device (CIED) procedures. Methods A total of 40 patients were enrolled in a prospective randomized controlled trial to assess time to wound closure, as well as cosmesis and wound closure-related outcomes. Results The adjustable coaptive tape-based skin closure device had shorter overall closure time (78 ± 6.6 seconds vs 216 ± 21.5 seconds; P < 0.001) and mean closure time per centimeter (18.0 ± 2.0 s/cm vs 50.1 ± 6.7 s/cm; P < 0.001) versus sutures, with less intersurgeon and interpatient variability with the use of adjustable coaptive device versus sutures (P < 0.001). There was no difference between groups in postoperative pain or scar cosmesis during the follow-up period. Neither group had any closure-related adverse events. Conclusions The adjustable coaptive tape-based skin closure device demonstrated shorter closure times with less variability when compared to sutures. It is a safe and acceptable alternative to sutures for skin closure following CIED implantation. [ABSTRACT FROM AUTHOR]

Ultrasound-Guided Lead Placement. Introduction: Ultrasound guidance is widely recommended to reduce the risk of complications during central venous catheter placement. However, ultrasound guidance is not commonly utilized for implanting leads for cardiac rhythm management devices. Methods and Results: We describe our technique of ultrasound-guided pacemaker implantation, including a novel pull-through technique that allows percutaneous guidewire insertion prior to the first incision. We review the literature and recent advances in ultrasound imaging technology that may facilitate the adoption of ultrasound guidance. Conclusions: Ultrasound guidance provides a safe and rapid technique for extrathoracic subclavian or axillary venous lead placement. (J Cardiovasc Electrophysiol, Vol. 24, pp. 370-374, March 2013) [ABSTRACT FROM AUTHOR]