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Introduction: Hybrid epicardial and endocardial ablation has been proven to be an effective method for attaining rhythm control in persistent atrial fibrillation where anti-arrhythmic drug therapy and lone catheter ablation has been disappointing. We present mid-term findings on the safety and effectiveness of hybrid ablation in persistent atrial fibrillation. Method(s): Between 2017 and 2019, nineteen patients with persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation with pulmonary vein isolation, posterior left atrial box lesion and left atrial appendage exclusion with Atriclip. They subsequently underwent endocardial mapping three months later. Any gaps from epicardial ablation were re-ablated. All patients were followed up prospectively. Result(s): Mean age of patients was 59.8+/-6.8 years. Median time of duration of atrial fibrillation preoperatively was 24 months. The average number of failed DCRs was 2.1+/-1.1. Average left atrial volume index was 55.45+/-11.5mL/m2. Average LVEF was 50.8+/-7.3%. At a mean follow-up of 395 days post hybrid ablation, all patients were in sinus rhythm at their most recent follow-up. 21% of patients had a recurrence of atrial arrhythmias. One patient had a minor complication of a left sided pleural effusion after the epicardial ablation. One patient had a pericardial effusion without tamponade requiring pericardiocentesis after epicardial ablation. There were no deaths, conversion to median sternotomy, strokes or pacemaker implantation. Conclusion(s): Sequential hybrid ablation for persistent atrial fibrillation is safe and effective.Copyright © 2020, CONFERENCE ABSTRACT

AIMS: The aim of this study is to provide a thorough, quantified assessment of the substernal space as the site of extravascular implantable cardioverter-defibrillator (ICD) lead placement using computed tomography (CT) scans and summarizing adverse events and defibrillation efficacy across anatomical findings. Subcutaneous ICDs are an alternative to transvenous defibrillators but have limitations related to ICD lead distance from the heart. An alternative extravascular system with substernal lead placement has the potential to provide defibrillation at lower energy and pacing therapies from a single device. METHODS AND RESULTS: A multi-centre, non-randomized, retrospective analysis of 45 patient CT scans quantitatively and qualitatively assessing bony, cardiac, vascular, and other organ structures from two human clinical studies with substernal lead placement. Univariate logistic regression was used to evaluate 15 anatomical parameters for impact on defibrillation outcome and adjusted for multiple comparisons. Adverse events were summarized. Substernal implantation was attempted or completed in 45 patients. Defibrillation testing was successful in 37 of 41 subjects (90%) using >=10 J safety margin. There were two intra-procedural adverse events in one patient, including reaction to anaesthesia and an episode of transient atrial fibrillation during ventricular fibrillation induction. Anatomical factors associated with defibrillation failure included large rib cage width, myocardium extending very posteriorly, and a low heart position in the chest (P-values <0.05), though not significant adjusting for multiple comparisons. CONCLUSION(S): Retrospective analysis demonstrates the ability to implant within the substernal space with low intra-procedural adverse events and high defibrillation efficacy despite a wide range of anatomical variability.Copyright © The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

OBJECTIVES: This study reports the sensing and arrhythmia detection performance of a novel extravascular (EV) implantable cardioverter-defibrillator (ICD) in a first-in-human pilot study. BACKGROUND: The EV ICD lead is implanted in the substernal space, resulting in novel sensing and detection challenges. It uses a programmable sensing profile with new or modified discrimination of oversensing and of ventricular tachycardia (VT) from supraventricular tachycardia (SVT). METHOD(S): Electrograms were post-processed from induced ventricular fibrillation (VF) at implant to determine virtual detection times for each programmable sensitivity and the least-sensitive safe sensitivity setting. In ambulatory patients, programmed sensitivity provided at least a twofold safety margin for detecting induced VF. Noise discrimination was stress tested, and the effects of source, posture, and lead maturation were determined on electrogram amplitude. Telemetry Holter monitors were used to quantify undersensing and oversensing. RESULT(S): In 20 patients at implant, the least-sensitive safe sensitivity for VF detection ranged from 0.1 to 0.6 mV. Seventeen patients were followed up for a total of 16.6 patient-years. Electrogram amplitudes were stable over time, but there were significant differences among postures and sensing vectors. For the primary sensing vector, the weighted oversensing and undersensing rates were 1.03% and 0.40% respectively, on a beat-to-beat basis. Oversensing did not cause inappropriate therapy in patients with in situ leads. Oversensing discriminators withheld VF detection in 4 of 5 spontaneous, sustained oversensed episodes. SVT-VT discriminators correctly classified 93% of 128 sustained SVTs in monitor zones. CONCLUSION(S): In the EV ICD pilot study, oversensing did not cause inappropriate therapy during ambulatory follow-up of stable leads.Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

Objectives: This study sought to determine the long-term outcomes of restoring sinus rhythm with catheter ablation (CA). Background(s): The CAMERA-MRI (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Heart Failure-An MRI-Guided Multicenter Randomized Controlled Trial) study demonstrated that restoration of sinus rhythm with CA significantly improved left ventricular ejection fraction (LVEF) compared with medical rate control (MRC) at 6 months in persistent atrial fibrillation and otherwise unexplained systolic heart failure. However, the long-term outcomes have not been reported. Method(s): Patients enrolled in the CAMERA-MRI study were followed for 4 years with echocardiogram and cardiac magnetic resonance. CA involved pulmonary vein isolation and posterior left atrial wall isolation in 94%. Patients crossed over to CA after 6-month study duration. Arrhythmia burden was determined with implanted cardiac monitors or cardiac devices. Result(s): Sixty-six patients (age 62 +/- 10 years, atrial fibrillation duration of 22 +/- 16 months, and LVEF 33 +/- 9%) were randomized 1:1 to CA versus MRC. Eighteen of 33 patients crossed over from MRC group to CA group. At 4.0 +/- 0.9 years, atrial fibrillation recurred in 27 patients (57%) in the CA group with a mean burden of 10.6 +/- 21.2% after 1.4 +/- 0.6 procedures. There was an absolute increase in LVEF with CA of 16.4 +/- 13.3% compared with 8.6 +/- 7.6% in MRC (p = 0.001). In the CA group, the absence of ventricular late gadolinium enhancement was associated with a greater improvement in absolute LVEF (19 +/- 13% vs. 10 +/- 11% in the late gadolinium enhancement-positive group; p = 0.04) and LVEF normalization in 19 patients (58%) versus 4 patients (18%) in the late gadolinium enhancement-positive group (p = 0.008) at 4.0 +/- 0.9 years follow-up. Conclusion(s): CA is superior to MRC in improving LVEF in the long term in patients with atrial fibrillation and systolic heart failure. The greatest recov

Cardiac pacemakers are one of the most frequently encountered cardiac devices seen on chest imaging. They may include single or dual chamber pacemakers, automated implantable cardioverter defibrillators (AICD), biventricular pacemakers used for cardiac resynchronisation therapy (CRT), wireless CRT, leadless pacemakers, and subcutaneous implantable cardioverter defibrillators (SICD). This review aims to provide an up-to-date review on current implantable pacemaker and defibrillator devices.Copyright © 2021 The Royal Australian and New Zealand College of Radiologists

Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.Copyright © 2020 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society

Cardiac pacemakers are one of the most frequently encountered cardiac devices seen on chest imaging. They may include single or dual chamber pacemakers, automated implantable cardioverter defibrillators (AICD), biventricular pacemakers used for cardiac resynchronisation therapy (CRT), wireless CRT, leadless pacemakers, and subcutaneous implantable cardioverter defibrillators (SICD). This review aims to provide an up-to-date review on current implantable pacemaker and defibrillator devices.

Introduction: Computed tomography pulmonary venogram can provide anatomic information of the left atrium, left atrial appendage and pulmonary veins that assist in planning radiofrequency catheter ablation for atrial fibrillation. Method(s): 26 patients underwent computed tomography pulmonary venograms prior to their hybrid atrial fibrillation ablation. Left atrial abnormalities, lack of left atrial appendage opacification, pulmonary vein ostial diameters and variant anatomy were recorded. Result(s): The mean pulmonary vein cross-sectional diameters were as follows: * Right superior pulmonary vein were 20.2+/-4.8mm x 17.8+/-4.3mm; * Right inferior pulmonary vein 19.6+/-3.9mm; * Left superior pulmonary vein 19.4+/-3.3mm x 16.1+/-2.9mm; and * Left inferior pulmonary veins 20.3+/-6.4mm x 16.4+/-3.5mm. There were 7 pulmonary vein variants. 3 patients had a common left pulmonary vein with a mean cross-sectional diameter of 33+/-2.6mm x 25.3+/-4 mm. 4 patients had right middle pulmonary veins with a mean cross-sectional diameter of 9+/-1.4mm x 8.5+/-1mm. There were no left atrial abnormalities. The left atrial appendages were well opacified. Conclusion(s): The pulmonary vein characteristics and variant anatomy were obtained. 29% of patients had variant anatomy, which is similar to the documented rates in the literature, with the most common variant being the right middle pulmonary vein.Copyright © 2020

Purpose: Since the introduction of the Biotronik Linox S/SD leads in 2006, there have been multiple reports of premature lead failure. The purpose of this study was to investigate the longevity of the Linox S/SD leads and to identify the possible predictors of lead failure in a single tertiary implant center. Method(s): We retrospectively reviewed patients who underwent implantation of Linox S/SD leads or Sorin Vigila 1CR/2CR leads (the same Linox S/SD leads marketed by Sorin) at our center. The cumulative lead survival was estimated using the Kaplan-Meier curve, and variables associated with lead failure were assessed by Cox proportional hazard model. Result(s): A total of 187 patients (154 (82%) male) underwent Linox S/SD or Vigila 1CR/2CR implantation between 2007 and 2013. During follow-up with a median time of 75 months, nine lead failures were identified (4.8%). The mean and median times from lead implantation to lead failure were 70.7 +/- 21 months and 64 (45-111) months, respectively. The cumulative survival probability for the Linox S/SD at 5 years was 97.1% and at 12 years was 90.3%. Non-physiological high-rate sensing was the most common type of lead failure in patients. In two-thirds of these patients, this led to inappropriate shock. We did not find any significant relationships between patients' clinical and procedural characteristics and lead failure. Conclusion(s): At our center, the 5-year lead survival of the Linox S/SD has been better than reports from other centers. The majority of lead failures presented as non-physiological high-rate sensing with subsequent inappropriate therapy.Copyright © 2020, Springer Science+Business Media, LLC, part of Springer Nature.

BACKGROUND: Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear. METHOD(S): We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up. RESULT(S): Of 140 patients who underwent randomization (85% men; mean [+/-SD] age, 62+/-9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8+/-7.7 to 2.1+/-3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4+/-6.9 to 13.2+/-6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P=0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P=0.01). CONCLUSION(S): Abstinence from alcohol red

Background: Prior studies suggest increased rates of noise on the Tendril (St Jude Medical/Abbott, St. Paul, MN, USA) pacemaker lead. We aim to assess the incidence of lead noise in the Tendril and 5076 (Medtronic PLC, Minneapolis, MN, USA) pacemaker leads in our cohort and in the process assess the utility of remote monitoring for identifying lead malfunction. Method(s): Deidentified, multi-centre, prospectively collected observational cohort data was obtained to assess the incidence of noise on the Tendril and 5076 pacemaker leads. Result(s): 148 Tendril and 737 CapSureFix Novus 5076 (Medtronic, MN, USA) pacemaker leads were remotely monitored. Incidence of noise on the Tendril was 8% and 0.27% on the CapSureFix Novus. Conclusion(s): Rates of noise in the Tendril lead are higher than a market competitor. Remote monitoring is useful in detecting this concerning anomaly.Copyright © 2019

Introduction: Hybrid epicardial and endocardial ablation has been proven to be an effective method for attaining rhythm control in persistent atrial fibrillation where anti-arrhythmic drug therapy and lone catheter ablation has been disappointing. We present mid-term findings on the safety and effectiveness of hybrid ablation in persistent atrial fibrillation. Method(s): Between 2017 and 2019, nineteen patients with persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation with pulmonary vein isolation, posterior left atrial box lesion and left atrial appendage exclusion with Atriclip. They subsequently underwent endocardial mapping three months later. Any gaps from epicardial ablation were re-ablated. All patients were followed up prospectively. Result(s): Mean age of patients was 59.8+/-6.8 years. Median time of duration of atrial fibrillation preoperatively was 24 months. The average number of failed DCRs was 2.1+/-1.1. Average left atrial volume index was 55.45+/-11.5mL/m2. Average LVEF was 50.8+/-7.3%. At a mean follow-up of 395 days post hybrid ablation, all patients were in sinus rhythm at their most recent follow-up. 21% of patients had a recurrence of atrial arrhythmias. One patient had a minor complication of a left sided pleural effusion after the epicardial ablation. One patient had a pericardial effusion without tamponade requiring pericardiocentesis after epicardial ablation. There were no deaths, conversion to median sternotomy, strokes or pacemaker implantation. Conclusion(s): Sequential hybrid ablation for persistent atrial fibrillation is safe and effective.Copyright © 2020

Objectives: The aim of this study was to evaluate the safety and performance of an extravascular (EV) implantable cardioverter-defibrillator (ICD). Background(s): Limitations of existing transvenous and subcutaneous ICD systems include lead reliability and morbidity issues associated with ICD lead implantation in the vasculature or lack of pacing therapies (e.g., antitachycardia pacing) in subcutaneous systems. The EV defibrillator uses a novel substernal lead placement to address these limitations. Method(s): This was a prospective, nonrandomized, chronic pilot study conducted at 4 centers in Australia and New Zealand. Participants were 21 patients referred for ICD implantation. Patients received EV ICD systems. Data collection included major systemic and procedural adverse events, defibrillation testing at implantation, and sensing and pacing thresholds. Result(s): Among 20 patients who underwent successful implantation, the median defibrillation threshold was 15 J, and 90% passed defibrillation testing with a >=10-J safety margin. Mean R-wave amplitude was 3.4 +/- 2.0 mV, mean ventricular fibrillation amplitude was 2.8 +/- 1.7 mV, and pacing was successful in 95% at <=10 V. There were no intraprocedural complications. Two patients have undergone elective chronic system removal since hospital discharge. In the 15 patients presently implanted, the systems are stable in long-term follow-up. Conclusion(s): This first-in-human evaluation of an EV ICD demonstrated the feasibility of substernal lead placement, defibrillation, and pacing with a chronically implanted system. There were no acute major complications, and pacing, defibrillation, and sensing performance at implantation were successful in most patients. (Extravascular ICD Pilot Study [EV ICD]; NCT03608670)Copyright © 2020 The Authors

BACKGROUND Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear. METHODS We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up. RESULTS Of 140 patients who underwent randomization (85% men; mean [+/-SD] age, 62+/-9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8+/-7.7 to 2.1+/-3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4+/-6.9 to 13.2+/-6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P = 0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P = 0.01). CONCLUSIONS Abstinence from alcohol reduced a

Introduction : Medical therapy for attaining rhythm control in longstanding persistent atrial fibrillation (AF) has been suboptimal. A novel hybrid thoracoscopic epicardial ablation and endocardial ablation has shown promising results in case series. We present mid-term findings on the safety and the effectiveness of hybrid epicardial/endocardial ablation for persistent and longstanding persistent atrial fibrillation. Methods : Between 2017 and 2018, ten patients with persistent and longstanding persistent atrial fibrillation underwent totally thoracoscopic radiofrequency ablation procedure with pulmonary vein isolation, box lesion and left atrial appendage exclusion. They subsequently underwent endocardial mapping with the Rhythmia system and catheter ablation three months later. Any gaps from epicardial ablation were re-ablated. All patients were prospectively followed up. Result : All patients were male and the mean age was 59.3 +/- 6.8 years. 30% of patients had persistent AF and 70% long standing persistent AF. Mean duration of AF preoperatively was 33 +/- 20.5 months. Mean left atrial volume was 51.5 +/- 9.8 mL/m2 Median duration of follow up was 321 days and in this period there were no deaths, conversion to median sternotomy, systemic thromboembolic events or pacemaker implantation. One patient required admission for management of a post-operative left sided pleural effusion. All patients have remained in sinus rhythm with two patients successfully weaned off oral anticoagulants and anti-arrhythmic drugs. One patient had recurrence of atrial fibrillation due to thyrotoxicosis. One patient required repeat endocardial ablation for mitral annular atrial flutter. Conclusion : Sequential hybrid ablation for longstanding persistent AF may be a safe and effective procedure for persistent and longstanding persistent AF in select patients.

Pacemakers can be directly involved in initiating or sustaining different forms of arrhythmia. These can cause symptoms such as dyspnea, palpitations, and decom-pensated heart failure. Early detection of these arrhythmias and optimal pacemaker programming is pivotal. The aim of this review article is to summarize the different types of pacemaker-mediated arrhythmias, their predisposing factors, and mechanisms of prevention or termination.Copyright © 2018 The Authors.

Background: Failure of the Biotronik Linox/Sorin Vigila implantable cardioverter-defibrillator leads has been reported at rates above other ICD leads. The aim of this study was to assess failure rate in these leads implanted in our centre. Method(s): We performed a retrospective analysis of all implantations of Linox/Vigila leads over the last 12 years at our centre. All patients with a Linox family ICD Lead or Vigilla lead implanted at our center were identified and all clinical data and device interrogations including a new device check were considered. Result(s): A total of 205 patients [169 (82.4%) men] had one of these leads (166 Linox family leads and 39 Vigila leads) implanted at our center between 2007 till 2015. 164 (80%) of implantations had been because of a secondary prevention indication and 140 (68.3%) leads had been implanted in right ventricular apex. Cephalic access had been used in 116 (56.9%) patients. Of these, 12 patients (5.9%) had lead failure. In four patients, lead fracture was the reason for lead failure, while noise and inappropriate shock was the issue in 4 patients and sensing/pacing problems in two patients. Conclusion(s): In our patients with a Linox family or Sorin Vigila lead, the failure rate was 5.9%.Copyright © 2019

We describe a 56-year-old male with transposition of the great arteries and Mustard repair, superior vena cava obstruction, atrial fibrillation, and progressive deterioration of his epicardial lead performance. We were successful in deploying of Micra (Medtronic, Minneapolis, MN, USA) at the septo-apical area of his nonsystemic ventricle in a stable position with satisfactory pacing and sensing thresholds.Copyright © 2018 Wiley Periodicals, Inc.

Aim: To investigate the impact of alcohol abstinence in atrial fibrillation. Method(s): We undertook a randomised controlled trial at 6 hospitals. Adults consuming >=10 standard drinks/week (1 SD ~ 12 g alcohol) with a history of paroxysmal or persistent AF were assigned 1:1 to alcohol abstinence or usual consumption. Primary endpoints at 6 months were time to AF recurrence and AF burden Results: 140 patients (age 62 +/- 9 yrs, 63% PAF, intake 17 +/- 7 SDs/week) were randomised to Abstinence (n = 70) or Control (n = 70). Recurrent AF was documented in 37 patients in the Abstinence arm and 51 patients in the Control arm (52.9% vs 72.9%; p = 0.01). The Abstinence arm had longer AF-free survival (log-rank p < 0.01) and lower AF burden (median burden 0.5%, IQR 0-3% vs 1.2%, IQR 0-10%; p = 0.01). At 6 months, the Abstinence arm had lower moderate-severe AF symptoms (10.1% vs 32.4%; p = 0.002), DELTAweight (-2.7 +/- 3.3 vs +0.8 +/- 3.0 kg; p < 0.01) and DELTAsystolic blood pressure (-12.4 +/- 12.8 vs -1.0 +/- 12.5 mmHg; p = 0.02). Conclusion(s): Significant reduction in alcohol intake should be part of the lifestyle intervention in moderate drinkers with AF. [Figure presented]Copyright © 2019

Objectives: To determine permanent pacemaker (PPM) dependency following transcatheter aortic valve replacement (TAVR) with the LotusTM valve system (Boston Scientific), and the impact of PPM implantation on long-term morbidity and mortality. Background(s): Conduction abnormalities are among the most common complications following TAVR. Limited studies have assessed pacing dependency following TAVR. Method(s): Consecutive patients (n = 166) with severe aortic stenosis who underwent TAVR with the Lotus valve system were prospectively recruited from a single-center. PPMs were implanted according to standard clinical criteria. Patients were followed in-hospital and at 1, 3, 6, and 12 months to determine pacemaker dependency and clinical outcomes. Result(s): Fourteen patients with a pre-existing PPM (8%) were excluded with the remaining 152 patients aged 83.6 +/- 5.6 years and 46% male. PPMs were implanted 3.8 +/- 4 days post-TAVR in 38/152 patients (25%). Indication for PPM was complete heart block in 29 (76%) of patients. At 30-day and one-year follow up, 57% and 38% of patients were pacemaker dependent, respectively. The mean ventricular pacing percentage decreased in the first three months after PPM implantation and remained relatively stable after that. Conclusion(s): Only 38% of Lotus recipients who require a PPM following TAVR with the Lotus valve remain pacing dependent at one year.Copyright © 2018 Wiley Periodicals, Inc.

Background: Patients with atrial fibrillation (AF) receiving timely, multidisciplinary care (MDC) have reduced morbidity and mortality. AF guideline-indicated MDC incorporates early assessment and patient education with medical therapy to improve health outcomes. Aim(s): We established a Nurse Led MDC clinic within our tertiary hospital cardiology service to provide early assessment of AF patients, guideline based management and patient education. Goals included seeing patients within six weeks of referral, triaging their on-going care and providing them with a single point of contact within our complex hospital system. Method(s): From December 2016 referred patients with a diagnosis of AF have attended a Nurse Led, electrophysiologist-supported clinic for assessment, education and therapy optimisation. Data was collected on the referral source, access times and AF subtype. Patients attend a follow-up visit within three months to assess their management strategy and can contact the AF nurse during business hours. Result(s): 65 referrals were made to our dedicated service. Referral sources were predominantly the Emergency Department (60%) and General Practitioners (28%). First presentation AF made up 60% of cases. These patients were previously referred as low priority to general cardiology outpatients, waiting 4-6 months for appointments. Through this new model of care, average access times for AF patients was reduced to 4 weeks. Conclusion(s): A Nurse Led, MDC Clinic for AF patients significantly reduces patient access times preventing delays in assessment, optimisation of therapy and patient education. Further research is needed to evaluate the clinic's impact on patient symptoms, patient satisfaction and hospital readmis-sions.

Objectives: To determine permanent pacemaker (PPM) dependency following Transcatheter Aortic Valve Replacement (TAVR) with the LotusTM valve system (Boston Scientific), and the impact of PPM implantation on long-term morbidity and mortality. Background(s): Conduction abnormalities are the most common complication following TAVR. Limited studies have assessed pacing dependency following TAVR. Method(s): Consecutive patients (n=166) with severe aortic stenosis who underwent TAVR with the Lotus valve system were prospectively recruited from a single-centre. PPMs were implanted according to standard clinical criteria. Patients were followed in-hospital and at 1, 3, 6 and 12 months to determine pacemaker dependency and clinical outcomes. Result(s): 14 patients with a pre-existing PPM (8%) were excluded with the remaining 152 patients aged 83.6 +/- 5.6 years and 46% male. PPMs were implanted 3.8 +/-4 days post-TAVR in 38/152 patients (25%). Indication for PPM was complete heart block in 29 (76%) of patients. At 30-day and 1-year follow up, 57% and 38% of patients were pacemaker dependent, respectively. The mean ventricular pacing percentage decreased in the first three months after PPM implantation and remained relatively stable after that. Conclusion(s): Only 38% of Lotus recipients who require a PPM following TAVR with the Lotus valve remained pacing dependent at one year.

We discuss a 46-year-old man with history of hypertension and inferior wall myocardial infarction and mild left ventricular dysfunction who presented with aborted sudden cardiac death due to episodes of ventricular tachyarrhythmia detected by a Reveal-LINQ which had been implanted one year prior to presentation.Copyright © 2017 Indian Heart Rhythm Society

Background Anticoagulant and antiplatelet therapy are recommended following WATCHMAN implantation (45 days and 6 months) to reduce the risk of embolic events. These patients are often also at high risk of recurrent bleeding complications. We aimed to assess the safety of reduced duration of treatment with anticoagulant and antiplatelet therapy in the early post implant period. Methods This was a retrospective cohort study assessing the duration of antiplatelet and anticoagulant therapy in 47 consecutive patients following WATCHMAN implant. The primary outcome was rate of major bleeding, stroke and systemic embolic complications. The secondary endpoints were rate of device thrombus and peri-device leak >4 mm as assessed by transoesophogeal echocardiography. Results Forty-seven patients were followed up for a mean of 2.4+/-1.7 years (111.4 total patient-years). The rate of stroke was 1.8/100 patient-years (two events) and the rate of major bleeding complication was 8.9/100 patient-years. Three patients had peri-device leak >4 mm and no patients had device thrombus visualised. 70.2% of patients had discontinued anticoagulation at 45 days, 89.4% had discontinued dual antiplatelet therapy at 90 days. Seven patients were not on any form of anticoagulant or antiplatelet at five months. Comparison of probability of survival free from stroke by time of cessation of anticoagulant and antiplatelet therapy demonstrated no significant differences (p-value for log rank test 0.238 and 0.820). Conclusion Following WATCHMAN implant shortened periods of anticoagulants and antiplatelets may be considered, particularly in the context of high bleeding risk.Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background: Electrophysiology studies/ablations (EPS) and pacemaker/defibrillator implants (PPM) can be prolonged procedures associated with increased pain and discomfort for patients. The safety and efficacy of patient controlled sedation (PCS) with propofol in this setting is unknown. Method(s): Between November 2014 and February 2015, 33 consecutive patients undergoing elective cardiac rhythm management procedures (CRM), were sedated using PCS (28 EPS, 5 PPM). Patient characteristics, procedure details, adverse events (hypotension, desaturation<92%, over sedation, disinhibition, crossover to alternative form of sedation, airway obstruction) and patient satisfaction (assessed using a 9 point visual scale) were recorded. In the 4 months preceding the introduction of PCS 100 patients undergoing elective CRM with nurse-controlled sedation (NCS) had the same data collected (51 PPM, 49 EPS). Summary statistics were compared between the two cohorts using means (t-test) and proportions as appropriate. Result(s): There was a trend towards higher patient satisfaction scores with both sedation (8.1 vs 7.6, p=0.09) and analgesia (8.1 vs 7.6, p=0.07) in the PCS group. Looking at the EPS group separately corrected for differences in patient age and procedure duration with similar differences in satisfaction scores. Rates of adverse events were similar in both groups (p=0.26) with three events recorded in the PCS group (2 disinhibition, 1 crossover) and four in the NCS group (3 desaturations, 1 hypotension). (Figure presented) Conclusion(s): Our initial experience with PCS suggests that it is a safe form of sedation for CRM procedures and may lead to greater patient comfort and satisfaction.

Introduction: Cardiac resynchronisation therapy (CRT) is an established therapy for symptomatic patients with advanced heart failure. However, traditional left ventricular lead placement may not always be technically feasible via the coronary sinus approach. Left ventricular (LV) endocardial lead implantation via a transseptal atrial approach may be a potential alternative. Purpose(s): We sought to review the feasibility and clinical outcomes in patients undergoing LV lead implantations in a single-centre, tertiary, Australian institution. Endpoints included: technical success, peri-procedural complication rates, percent LV pacing load, change in New York Heart Association (NYHA) class and change in LV ejection fraction (LVEF). Method(s): and Results: Between August 2015 and December 2016, four patients underwent endocardial LV lead implantation (3 males, mean age 71 +/-5 years). All patients had previously failed LV lead placement via the coronary sinus. Mean pre-procedural LVEF was 24 +/-8%, mean QRS duration 161+/- 19ms and baseline NYHA was III (n=3) and IV (n=1). All patients had existing indications for therapeutic anticoagulation and were anticoagulated with warfarin (3 for atrial fibrillation, 1 for mechanical aortic valve). Warfarin was withheld for 3 days prior to the procedure. Mean international normalized ratio (INR) at the time of the procedure was 1.6+/-0.3. LV access was via an inferior approach, using femoral transseptal access, with a snare from superior subclavian venous access providing access to the left atrium. The lead was then inserted via the deflectable guiding sheath into the lateral LV endocardial wall. Successful implantation was achieved in all patients. One patient had a thromboembolic complication (non disabling stroke) post procedure, despite an INR of 2.1 at the time. That patient subsequently died from progressive heart failure within a month of the procedure. The 3 remaining patients have a mean follow up of 10 +/-7 months. The me

Aim: To report on initial Australian Experience with Subcutaneous ICDs (S-ICD) Background: Several trials have demonstrated mortality benefit for implantable cardiac defibrillators (ICDs). However; there is a significant incidence of trans venous lead related complications. Subcutaneous-ICD(S-ICD) have been now approved for use in Australia; these device consist of a tri-polar parasternal lead (12-French) connected to a pulse generator; thus potentially avoiding deleterious effects of trans-venous lead implantation. Method(s): Data was prospectively collected for all S-ICDs implanted by Monash Heart doctors. Patients needing ICD without pacing indication were selected at the discretion of operators. All patients had post implant exercise stress tests (30 day) to evaluate ventricular sensing. Results & Discussion: 11 S-ICDs were implanted by Monash Heart doctors during December 2014-March 2016 with average age of patients being 46 years. Indication was primary prevention (5/11) & secondary prevention (6/11). Primary vector was the most common sensing vector for majority of patients. One patient experienced inappropriate shock with primary vector (sensing related) and his sensing vector was changed to secondary vector. One device failure was seen; with the device not responding to interrogation at one month follow up. This patient got a replacement device and initial reports from manufacturer suggest piezoelectric crystal malfunction. Conclusion(s): S-ICD is a feasible option for patients requiring implantable cardiac defibrillators without indication for trans-venous pacing.

Introduction: Globally, the number of cardiac device implantations is rising [1-3], and the percentage of device related infections also seems to be rising [1,2]. Device related infections are one of the most severe complications of device implantation [4]. Evidence on reducing device related infections is limited and most guidelines are based on empirical data [1]. Antibiotic use including dose, route and length of antibiotic course widely varies and is generally based on local protocols [1]. Objective(s): Our objective was to compare patients who received single dose IV antibiotic at the time of cardiac device implantation to those who received multiple doses to see if there was a difference in device related infection. Method(s): We surveryed 400 patients who underwent cardiac device implantation at Monash Medical Centre, Clayton, who were subsequently followed up in our pacemaker clinic for their one month check-up. At this time their wounds were assessed and they completed a questionnaire relating to their wound and infection. Result(s): Preliminary results after analysing 188 out of 400 patients showed a non-significant trend towards increased pocket infections and endocarditis in patients who only received single dose antibiotic therapy (p=0.058). There was no difference in rates of superficial infections (p=0.850) or total infections (p=0.219), although the numbers were small. Conclusion(s): Preliminary data from this study is concerning that single dose IV antibiotic without oral has a trend towards increased rates of deep device infection (pocket infection and endocarditis), further data is needed to look into this further.